Ethical and Legal Issues

8 2 Ethical and Legal Issues 1. Define important words in this chapter 2. Define the terms law, ethics, and etiquette 3. Discuss examples of ethical and professional behavior 4. Describe a nursing assistant code of ethics 5. Explain the Omnibus Budget Reconciliation Act (OBRA) 6. Explain Residents Rights 7. Explain types of abuse and neglect 8. Recognize signs and symptoms of abuse and neglect 9. Describe the steps taken if a nursing assistant is suspected of abuse 10. Discuss the ombudsman s role 11. Explain HIPAA and related terms 12. Discuss The Patient Self-Determination Act (PSDA) and advance directives Supplemental Tools transparency 2-1 nursing assistant code of ethics handout 2-1 decision quiz handout 2-2 who is vulnerable to abuse or neglect? chapter 2: exam Assignments textbook reading, pp. 16-30 workbook exercises, pp. 9-15 Overview of Teaching Strategies This chapter explains the legal, ethical, and professional behavior that nursing assistants will be expected to show in the healthcare setting. A sample code of ethics for nursing assistants is presented. Students will learn about OBRA and Residents Rights, and they will learn to recognize signs of abuse and what their responsibility is if they see or suspect that a resident is being abused. Students will learn about the ombudsman s role in health care, and HIPAA and the PSDA will be explained. 1. Define important words in this chapter textbook pp. 16-17 workbook p. 9 Pronounce and define each of the key terms listed in the Learning Objective on pages 16-17. 2. Define the terms law, ethics, and etiquette textbook p. 18 workbook p. 9 Ethics Laws Criminal laws Civil law Etiquette

9 Explain the difference between laws and ethics and why both are important in health care. 3. Discuss examples of ethical and professional behavior textbook pp. 18-20 workbook p. 9 Explain that professional and ethical behavior is vital to the safety of residents. Discuss the following guidelines for behavior that nursing assistants must follow: Keep all resident and staff information confidential. Be honest at all times. Be trustworthy. Do not accept gifts or tips. Report abuse or suspected abuse of residents. Do not report to work under the influence of alcohol or drugs. Follow all facility policies, rules, and procedures. Do assigned tasks. Report mistakes promptly. Be positive, professional, and tactful. Treat all residents with respect and be empathetic. Be patient. 4. Describe a nursing assistant code of ethics textbook p. 20 workbook p. 10 and Discussion Explain that all facility codes of ethics revolve around the idea that the resident is a valuable person who deserves ethical care. Display Transparency 2-1 nursing assistant code of ethics Discuss the sample nursing assistant code of ethics on the transparency. Ask students to suggest additions or clarifications. Optional Learning Activity If your facility has a nursing assistant code of ethics, share it with students. Compare it to the example in the book. 5. Explain the Omnibus Budget Reconciliation Act (OBRA) textbook pp. 20-21 workbook p. 10 OBRA NATCEP Scope of practice Discuss the requirements of OBRA. If your state or facility requirements exceed OBRA requirements, explain the differences. Explain why OBRA regulations are important to nursing assistant practice, including the following: Give recognition through certification and registration. Help define the nursing assistant s scope of practice. Provide better uniformity of care. Promote educational standards. 6. Explain Residents Rights textbook pp. 21-23 workbook pp. 11-12 Residents Rights Residents Council Misappropriation Review the Residents Rights: Quality of life Services and activities to maintain a high level of wellness Be fully informed about rights and services

10 Participate in their own care Make independent choices Privacy and confidentiality Dignity, respect, and freedom Security of possessions Rights with transfers and discharges Right to complain Visits Distribute Handout 2-1 decision quiz Ask the students to think of six decisions they made this morning before coming to class and write them on the handout. Give the students five minutes to complete the exercise. When they are finished, make the following points: These everyday decisions may seem unimportant, even tedious, because we are so used to making them ourselves. But if for some reason (illness or injury, for example) a person is unable to make these decisions for themselves, it becomes obvious how important this kind of independence is. Ask if any members of the class have ever been in the position of being unable to make these decisions and would not mind sharing that experience with the class. Emphasize that, in a facility, it is very important for the residents to make as many decisions and choices as possible. 7. Explain types of abuse and neglect textbook pp. 23-25 workbook pp. 12-13 Define and review each of the types of abuse and neglect covered: Abuse Physical abuse Psychological abuse Verbal abuse Sexual abuse Financial abuse Assault Battery Domestic violence Workplace violence False imprisonment Involuntary seclusion Sexual harassment Substance abuse Active neglect Passive neglect Negligence Malpractice Emphasize that a nursing assistant is legally required to report any observed or suspected abuse of residents and assist residents who wish to make a complaint of abuse in every way possible. Remind students that staff must not retaliate in any way against a resident who makes a complaint. And if students witness a staff member retaliating against a resident who complained, they must report it. 8. Recognize signs and symptoms of abuse and neglect textbook pp. 25-26 workbook pp. 13-14 Pronounce and define the following key term: Mandated reporters Remind students that nursing assistants are considered mandated reporters. Emphasize that all care team members must look for signs of abuse and report them. Review signs of physical abuse: Unexplained broken bones Unexplained bruising Similar injuries that occur repeatedly Burns shaped in specific ways Bite marks or scratches Unexplained weight loss or signs of dehydration Dry, cracked, torn or bleeding skin Missing hair

11 Broken or missing teeth Blood in underwear Bruising in genital area Review signs of psychological abuse: Depression or withdrawal Mood swings Fear and anxiety, especially when a caregiver is present Lack of appetite Fear of being left alone Review signs of neglect: Sores on the body Weight loss, poor appetite, or signs of dehydration Frequent complaints of hunger or thirst Strong smell of urine Unclean body Dirty, matted, or unstyled hair Ragged or dirty fingernails Soiled clothes or bed linens or incontinence briefs not being changed Ripped or torn clothing Damaged or poorly fitting hearing aids, glasses, dentures Unanswered call lights Review other signs of abuse: Missed doctor appointments Changing doctors frequently Wearing makeup or sunglasses to hide injuries Family concern that abuse is occurring Person not taking medication Caregiver does not allow others to be alone with resident Distribute Handout 2-2 who is vulnerable to abuse or neglect? Give students time to read the handout. Discuss people who are more vulnerable to abuse or neglect than others, including: The elderly Physically ill or disabled Developmentally disabled Mentally ill or disabled People with communication problems Discuss why these people are so vulnerable and the best ways for caregivers to help them. 9. Describe the steps taken if a nursing assistant is suspected of abuse textbook p. 26 workbook p. 14 Review the steps outlined by NATCEP that follow a report of abuse by a nursing assistant: Investigation Notification Hearing Decision of hearing Appeals process Remind students that if abuse is found to have occurred, the nursing assistant is placed on the abuse registry in addition to other possible penalties. Emphasize that employers check this registry before hiring nursing assistants. 10. Discuss the ombudsman s role textbook p. 27 workbook p. 14 Pronounce and define the following key term: Ombudsman Review the typical duties of an ombudsman: Advocates for Residents Rights and quality care Educates consumers and care providers Investigates and resolves complaints Appears in court and/or legal hearings Gives information to the public Optional Learning Activity Provide students with information about the department in your state that handles elder care.

12 11. Explain HIPAA and related terms textbook pp. 27-29 workbook pp. 14-15 HIPAA Protected health information (PHI) Invasion of privacy Discuss HITECH (Health Information Technology for Economic and Clinical Health) as a way to expand the protection of electronic health records (EHR). Review the facts that it increases civil and criminal penalties for sharing PHI and expands the ability to enforce these penalties. Review ways that nursing assistants can keep PHI confidential: Do not give out health information on the phone except to approved staff members. Do not give personal information to visitors. Do not share medical records with anyone other than the care team. Do not discuss residents in public areas. Do not bring family or friends to the facility. Double-check fax numbers and use cover sheets. Return charts to proper place after use. Dispose of personal notes regarding resident care prior to leaving work for the day. Log out and exit web browser when finished with computer work. Do not include private information in e-mails. Do not share resident information on any social networking site (e.g., Facebook or Twitter). Do not takes photos of residents and share them with anyone, including via cell phones, e-mail, social networking sites, or other websites. Give documents found with resident s information to the nurse. Explain that there are serious penalties, including fines and even prison time, for not following HIPAA guidelines. 12. Discuss The Patient Self-Determination Act (PSDA) and advance directives textbook pp. 29-30 workbook p. 15 Advance directives Living will Durable power of attorney for health care DNR Optional Learning Activity Bring in copies of your state s advance directive forms to share with the class. Discuss why advance directives are important to residents of facilities and others. Chapter Review Exam distribute chapter 2: exam (appendix c, pp. 289-291) Allow students enough time to finish the test. See Appendix D for answers to the chapter exams. Answers to Chapter Review in Textbook 1. Ethics are the knowledge of what is right and wrong and help guide conduct. 2. Answers will vary. 3. Answers include: Keep all resident information confidential. Keep staff information confidential. Be honest at all times. Communicate honestly and clearly with members of the care team. Be honest when documenting resident care. Be truthful when reporting the hours you have worked. Do not take items that do not belong to you. Be trustworthy. Do not accept tips or gifts from residents or their family members or friends. Report abuse or suspected abuse of residents. Do not report to work under the influence of alcohol or drugs. Follow all facility policies, rules, and procedures. Document care you give accurately and promptly. Do your assigned tasks. If you make a mistake, report it promptly to the nurse. Be

13 positive and professional. Be tactful. Treat all residents with respect and be empathetic. Be patient. Examples will vary. 4. Answers include: I will strive to provide and maintain the highest quality of care for my residents. I will fully recognize and follow all of the Residents Rights. I will communicate well, serve on committees, and read all material as provided and required by my employer. I will attend educational in-services and join organizations relevant to nursing assistant care. I will show a positive attitude toward my residents, staff, family members, and other visitors. I will always provide privacy for my residents. I will maintain confidentiality of resident, staff, and visitor information. I will be trustworthy and honest in all dealings with residents, staff, and visitors. I will strive to preserve resident safety. I will report mistakes I make, along with anything that I deem dangerous, to the right person(s). I will have empathy for my residents, the staff, and all visitors, giving support and encouragement when needed. I will respect all people, without regard to age, sex, ethnicity, religion, economic situation, sexual orientation, or diagnosis. I will never abuse my residents in any way. I will always report any suspected abuse to my supervisor or the proper person immediately. I will strive to have the utmost patience with all people at my facility. 5. OBRA requires that the Nurse Aide Training and Competency Evaluation Program (NAT- CEP) set minimum requirements for nursing assistants. Nursing assistants must complete at least 75 hours of training. Nursing assistants must also pass a competency evaluation (testing program) before they can be employed. The exam consists of both a written and manual portion. OBRA requires that nursing assistants attend regular in-service education. OBRA also requires that states keep a current list of nursing assistants in a state registry. In addition, OBRA identifies standards that instructors must meet in order to be a nursing assistant trainer. OBRA also increases the minimum staff requirements. It specifies services that nursing homes must provide. OBRA requires complete assessments on every resident. OBRA also identifies important rights for residents in long-term care facilities. 6. 75 hours 7. Answers include: quality of life; services and activities to maintain a high level of wellness; the right to be fully informed about rights and services; the right to participate in their own care; the right to make independent choices; the right to privacy and confidentiality; the right to security of possessions; rights with transfers and discharges; the right to complain; and the right to visits 8. Answers will vary. 9. Answers include: physical abuse, psychological abuse, verbal abuse, sexual abuse, financial abuse, assault, battery, domestic violence, workplace violence, false imprisonment, involuntary seclusion, and sexual harassment; examples will vary. 10. Active neglect is purposely harming a person physically, mentally, or emotionally by failing to give needed or correct care. Passive neglect is unintentionally harming a person physically, mentally, or emotionally by failing to give needed or correct care. 11. Answers will vary. 12. Report it to her supervisor immediately. 13. Answers include: unexplained broken bones or bruising; similar injuries that occur over and over, such as an injury shaped like a belt buckle; burns of unusual shape and in unusual locations; cigarette burns; bite marks or scratches; unexplained weight loss, signs of dehydration; dry, cracked, torn or bleeding skin; missing hair; broken or missing teeth; blood in underwear; bruising in the genital area; sexually transmitted infections; depression or withdrawal; mood swings; fear and anxiety, especially when a caregiver is present; lack of appetite; fear of being left alone; sores on the body; weight loss, poor appetite, or signs of dehydration; frequent complaints of hunger or thirst; strong smell of urine; unclean body; dirty, matted, or unstyled hair; ragged or dirty fingernails; soiled clothes or bed linens or incontinence; ripped or torn clothing; damaged or poorly-fitting hearing aids, glasses, dentures; unanswered call lights; missed doctor s appointments; changing doctors frequently; wearing makeup or sunglasses

14 to hide injuries; family concern that abuse is occurring; person does not seem to be taking his medication; or caregiver does not allow anyone to be alone with the resident 14. Answers include: The NA is immediately suspended. The NATCEP (Nurse Aide Training and Competency Evaluation Program) is notified, as well as the facility administrator and possibly APS. A full, confidential investigation is conducted. The facility will protect the resident and the person who reported the abuse from retaliation. If the investigation does not prove the claim of abuse, the NA returns to work. If the investigation shows that there might be truth to the claim, specific actions are taken. The NATCEP outlines steps that must be followed. These steps include investigation, notification, a hearing, decision of the hearing, and the appeals process. If the findings show that abuse did exist, the nursing assistant is placed on the abuse registry. This is in addition to other possible legal penalties. The abuse registry is shared with other state abuse registries. Employers check this registry before hiring nursing assistants. 19. HIPAA applies to all healthcare providers, including doctors, nurses, nursing assistants, and care team members. 20. Advance directives are legal documents that allow people to decide what kind of medical care they wish to have if they are unable to make those decisions themselves. They designate someone else to make medical decisions for a person if that person is disabled. 21. Answers include: All facilities receiving Medicare and Medicaid money must offer new residents information about their rights relating to advance directives. Residents have the right to participate in and direct healthcare decisions, the right to accept or refuse treatment, and the right to prepare an advance directive. The PSDA requires that facilities give new residents the facility s policies on handling advance directives. Each facility must ask residents what advance directives they have and obtain copies of these documents. Facilities must offer education to the staff about advance directives. 15. Answers include: visits the facility and listens to residents; decides what course of action to take if there is a problem; helps settle disputes and resolve conflicts; provides an ongoing presence in long-term care facilities; monitors care and conditions; advocates for Residents Rights and quality care; educates consumers and care providers; investigates and resolves complaints; works with investigators from the police, adult protective services, and health departments; appears in court and/or in legal hearings; and gives information to the public 16. Other care team members 17. The privacy of health information 18. Answers include: information that can be used to identify a person and relates to the patient s past, present, or future physical or mental condition; any health care that patient has had; payment for that health care; the patient s name, address, telephone number, medical record, social security number, and e-mail address