3/23/15. ROME MCGUIGAN, P.C. Attorneys at Law MARY ALICE MOORE LEONHARDT, ESQ., BSN NURSE ATTORNEY

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1 Attorneys at Law MARY ALICE MOORE LEONHARDT, ESQ., BSN NURSE ATTORNEY Healthcare, Special Needs and Elder Law Department Today s Presentation # Background for Legal Practice as a School Nurse # Declaratory Rulings and Guidelines issued by the Board of Examiners for Nursing # Recent Changes in APRN Scope of Practice # Mandatory Reporting Today s Presentation # Medication Storage and Administration # Recent Developments in School Athletics # Documentation # Emancipated Minors # Student Identification 1

2 Today s Presentation # Complaint, Investigation and Disciplinary Proceedings # Case Studies Background # State Board of Education (SBE) regulations # Regulations of Connecticut State Agencies ( Regs. ) generally require at minimum:! Licensed RN! 1 year full-time employment as RN w/in 5 years! Academic preparation in specified areas Background # LPNs cannot be school nurses, but can assist! Administer meds if: # Training in med administration, # Training and supervised experience in pharmacology, or # Supervised experience! See Regs a-3 # Unlicensed individuals can also assist! No regulations or guidelines re: qualifications 2

3 Declaratory Rulings and Guidelines! Board of Examiners for Nursing periodically issues! Feb. 7, Declaratory Ruling re: Role of the LPN! April 5, Declaratory Ruling re: Delegation by Licensed Nurses to Unlicensed Assistive Personnel! Dec. 20, Statement on the use of Controlled Substances for the Treatment of Pain Declaratory Rulings and Guidelines! March 1, 1995 (as modified March 6, 2002) - Patient Abandonment Guidelines adopted by the Board! Dec. 1, Guidelines issued for Use of Medical Protocols Recent Changes in APRN Scope of Practice! Independent Practice # Public Act No (eff. July 2014) Permits APRNs to practice entirely independently of physicians and consulting physicians # Qualifications: # Licensed and practicing in collaboration with physician for at least 3 years and 2,000 hours # Previously: # APRNs had to work in collaboration with a physician, including having a written agreement regarding the APRN s prescriptive authority 3

4 Recent Changes in APRN Scope of Practice! New laws regarding Continuing Education # APRNs applying for licensure renewal must include at least one contact hour of training or education in each of the following topics: # Infectious diseases, including, but not limited to, acquired immune deficiency syndrome and human immunodeficiency virus, # Risk management, # Sexual assault, # Domestic violence, # Cultural competency, and # Substance abuse Mandatory Reporting! Children # Oral report must be made ASAP, but no later than 12 hours after suspect abuse/neglect has occurred # Applies to suspected maltreatment of any kind, regardless of identity of alleged perpetrator # Also applies to LPNs and possibly other assistants # Penalties? # Participation in an educational and training program # Fine of > $500 but < $2,500 # Likely report to state Department of Public Health Mandatory Reporting! Children (cont d) # W/in 48 hours of oral report, must submit written report to DCF and person in charge of school # Specific requirements for written report # State law protects from discharge, discrimination or retaliation by employer for reporting! See C.G.S. 17a-101, 17a-101a through 17a-101e 4

5 Mandatory Reporting! Persons with Disabilities # Report to Office of Protection and Advocacy for Persons with Disabilities # Oral report must be made ASAP, but no later than 72 hours after suspect abuse/neglect has occurred # Applies to suspected maltreatment of any kind, regardless of identity of alleged perpetrator # Also applies to LPNs and possibly other assistants Mandatory Reporting! Persons with Disabilities (cont d) # W/in 5 days of initial report, must file written report # Penalties? # Fine of $500 or less # Likely report to state Department of Public Health # Specific requirements for written report! See C.G.S. 46a-11b Mandatory Reporting! Other reporting requirements: # Elderly (see C.G.S. 17b-451) # Residents of Long-Term Care Facilities (see C.G.S. 17b-407) 5

6 # Failure to store and/or administer medications properly are two of the biggest issues leading to licensure problems # "Error" means:! failure to do any of the following as ordered: # administer a medication to a student; # administer medication within the time designated by the prescribing practitioner; # administer the specific medication prescribed for a student; # administer the correct dosage of medication; # administer medication by the proper route; and/or # administer the medication according to generally accepted standards of practice; or,! administration of a medication to a student which is not ordered, or which is not authorized in writing by the parent or guardian of such student. # Each district s BOE determines if permitted # If BOE permits, it establishes written policies and procedures # At a minimum, no medication may be administered without:! written order of an authorized prescriber; and! written authorization of the student's parent or guardian (unless student emancipated). # Prescribed medication shall be administered to and taken by only the person for whom the prescription has been written. # Self administration (if approved by BOE)! Nurse s role in? # Evaluate the situation and determine if it is safe and appropriate # Document this in the student s health record # Develop a plan for general supervision! See Regs a-4 6

7 # Handling, storage and disposal (Regs a-5)! Accept only proper delivery! Develop administration plan! Specific storage requirements! Access only permitted by authorized staff! Specific removal and destruction requirements! No more than a 45 day supply permitted! Storage only if current written order # Documentation & record keeping (Regs a-6)! Medication administration record (MAR) has very specific requirements! MAR must be filed in cumulative health record! Only school nurse can obtain verbal order (which must be received in writing w/in 3 days)! Errors each BOE shall have a policy regarding notification and documentation of errors # Report must be completed using accident/incident report form # Any error must be documented in cumulative health record # Supervision (Regs a-7)! The school nurse is responsible for general supervision of administration of medications in the schools to which that nurse is assigned.! There are a number of more specific supervision requirements. 7

8 Developments in School Athletics # 2 laws in 2014! Concussions and Sudden Cardiac Arrest # Both require school to receive written consent of parents/guardians (unless emancipated minor) # Concussion How does it affect nurses?! Nurses are considered a qualified school employee who may be required to notify a parent/guardian when a student removed from play for a concussion or suspected concussion Developments in School Athletics # Sudden Cardiac Arrest How does it affect nurses?! Requires coaches to immediately remove from athletic activities a student who shows warning signs of immediate cardiac arrest, and to bar such student from resuming participation until receiving written clearance from CT licensed doctor! Nurse may be involved in assessment and removal of student from activity! Nurse may be involved in the determination regarding whether to permit student to return to activity Documentation # Failure to document and failure to document properly are common issues # Documentation done in accordance with district s documentation policy and procedures # At a minimum record must:! accurately reflect professional nursing practice;! provide a means to communicate with other health care professionals and families;! provides a vehicle for quality assurance; and! provides support in case of legal allegations. # See Regs. 19a through 19a

9 Emancipated Minors # "Emancipation" is a legal process that gives a teenager who is 16 or older legal independence from his or her parents or guardians. # It can happen when: (a) a parent has absolutely and completely renounced all care and control of the minor child, (b) the parent has deserted the minor child, or (c) on a judge s ruling on a minor child s own petition to the superior court. Emancipated Minors # How does emancipation affect school nurses?! Former parents/guardians denied access to information/documentation (HIPAA)! DCF not responsible for emancipated minors, so reports of abuse/neglect would not go to it! Consent to treatment! Prior to administering healthcare, if student claims he/ she emancipated, school nurse should require student to present his/her emancipation order Student Identification # Strongly related to proper administration/storage of medications # School nurse must take reasonable steps to confirm identity of student prior to administering healthcare # Failure to do so may result in a HIPAA breach or, even worse, administration to wrong student # DPH has investigated these issues in the past 9

10 Department of Public Health Investigations # Petition/Complaint filed by consumer or other healthcare provider # Investigation! Third-party investigator? # Legal office?! Consent Order?! Statement of Charges? # Hearing? # Discipline? Case Studies # Lauren B. Peck, R.N. - Petition No ! Improperly obtained medication for student, and improperly administered # Lynda T. Young, R.N. - Petition No ! Failed to completely, properly and/or accurately document every time a special needs child came into the nurse s office to user inhaler Questions? 10

11 Life is 10 percent what happens to me and 90 percent how I react to it. Lou Holtz HARTFORD OFFICE 1 State Street Hartford, CT MARY ALICE MOORE LEONHARDT, ESQ., BSN Nurse Attorney mmooreleonhardt@rms-law.com STAMFORD OFFICE 1100 Summer Street Stamford, CT