Is it appropriate for Risk Management to discipline?

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    Please survey my situation and give me your reaction. My 19yo son came to visit me at my hospital. While he was diatribing to me about how sick he was and receiving my wrath for not taking care of himself-- he passed out at my feet. I immediately dragged him onto a gurney, assessed him, got IV access with fluids, vitals and while he aroused and inquired I told him what had happened and that he was now an ED patient.
    At this point he informed me he couldn't afford an ED visit, had no insurance and would not agree to be admitted to the ED. I negotiated with him and told him the only way to avoid this was to agree to and get a "now" appointment at the local clinic (4 blocks away). His wife procured the "now" appontment, I squeezed in the last of the IV, documented the assessment and event and sent it to the Dr. with the patient.
    The Risk Manager, later, with no complaint from Dr. or patient and with the consent of my manager decided to suspend me without pay for 3 days, report me to the board of nursing for practicing outside the scope of my RN license and leave a wide open termination clause in case anything "like this" was to happen again.
    The nursing board generated no further investigation and said no disciplinary action was needed.
    I find it difficult to function with this open ended and undefined threat to my employment and do not trust a risk management office that thinks this was appropriate treatment.
  2. 25 Comments so far...

  3. 0
    OK let me get this straight. Were you already working in ER/ED when your son came to see you?

    If you were working in ED and he was there visiting you and fell out, Did you call for asistance and do admission paperwork etc. Did the attending over ED see and write orders for the interventions that you carried out?

    I mean here is my concern, if someone comes to ED because they are sick and goes through triage and is still sitting in the waiting area awaiting thier turn to be seen and passes out do you rush them into a room and begin an IV and do all the interventions you mentioned? Was he triaged? He wasn't there for treatment from your story of course being your son he is not going to sue you or the hospital obviously I would hope but from a risk management point of view this is a risky business. Ok someone comes to the hospital to visit a friend and they pass out nurses go to them and attempt to awaken them and might possibly call a code but if the person wakes up and you explain the situation and they say I don't want to go to ED you can't make them. Do you see what I am saying? Did you try to rouse him? I am so happy that the Board did not take any action against you and perhaps it was because this was your son but just think if this were Joe Public and you scoooped them up and began interventions with out the Pt having prior expectation of being treated. This could be a risk management nightmare!

    Just a different point of view maybe it willl help
  4. 0
    If a visitor passed out in the ED I would have no problem stating an IV on them. I would do vitals and assessment and all the paperwork, but if they then refused to be treated I would let them go, making sure they knew the risks and had followup. I would flag the chart for my manager as a "no charge" since they didn't actually sign in, and expect to be backed up for doing what I could to prevent further injury to the patient.

    In our ER though the nurses are able to start IV's on anyone that looks sick enough to need one and management expects the docs to back us up. The way they treated you was insane. Even if they disagreed with what you did they should have counselled you and made you promise not to do it again.

    PLUS...according to EMTALA you need to treat anyone presenting within 200 ft, so if someone falls unconcious outside the doors of the ER they are automatically a patient! In my opinion the board was right in saying there was no issue.
  5. 0
    Thanks for your feedback.
    My thought is still this: I and the facility are more liable for non-involvement of an unconscious visitor than we are for intervening and stabalizing.... even if we are then asked to stop. I have to admit that in my nearly 15 yrs this is my first case of the "visitor that became a pt." and then refused further care!! Son or not, nurses are required to act as pt.s advocate (even if unconscious) and without maicious intent-- and that was exactly what happened. I have had pts already entered into the system that refused to stay for treatment but never one that ,when conscious regained refused care even before they're entered into the system-- hence the confusion on my part when all the documentation was sent to the clinic for the immediate appt for the now stable pt!! A mistake of clerical proportions.
    Thanks again.
  6. 0
    My husband has a saying. You can beat the rap, but you can't beat the ride.
    Now in English, this cop slang means:
    Even though you were cleared, you went through hell. The ride is what you went through. You lost 3 days pay, sat through an investigation, I am sure cried a lot. Probably retaioned a Lawyer.

    I know of a kinda similar situation, just because the board was called in. This person was cleared immediately by the BON, and she successfully sued the person who made it all happen. Defamation of character and emotional distress. They settled it.

    Something to think about.
    Barbara
  7. 0
    I would say as long as you had an order to put in the IV and fluids you should be fine???

    That would be tough as the mother of 5.

    renerian
  8. 0
    Hi, iiwdn. Hope things are settling down for you.

    Wanted to learn as much as I could from your situation. Would you be so kind to clarify if in your facility a nurse may start the interventions you undertook prior to, and without, an ED doc's go-ahead, in circumstances such as this one?

    Thanks.
  9. 0
    Yes, by all means. There is a facility wide policy for RNs to initiate care based on need. Based on this, an unconscious person in the facility (at my feet), my assessment of symptomatic hypovolemia, my near 15yrs of CCA and ED experience prompted my response of immediate IV access and fluids.
    So, "suprised" is at least one of my reactions when, after a verbal warning (which seemed reasonable) I was then disciplined by the facility, turned in to the BON and left with the open-ended termination clause in my personel file (no definite actions or time limit).
    Now, I asked you, does all that make sense? What does any facility gain by treating an employees like this, is it appropriate for CQI (or Risk Manager or whatever they call themselves this year) to take it upon themselves to intiate discipline and or reporting, and what kind of probation is appropriate?
    I am still quite suprised ( though this is growing to distrust and anger at this point) and am taking into account responses from labor law, BON and medical attorneys.
    Thanks for your interest.
  10. 0
    You could not call anyone else to assist you or take over becuse it was you son?
    Another point, you said he was married, so you were not the official next of kin.
    If someone passes out, I run to take vitals, not open a line. I also check blood glucose.
    I see the risk, and I fear because you are so outraged, you don't see the big picture.
  11. 0
    I am with Barb on this one. You said your facility has a standing protocol for nurses to initiate treatment based on need but I would assume that treatment would be those considered to be within your scope of practice. Starting an IV probably didn't get you in trouble but I would guess that initiating fluids could, since fluids are basically considered to be a medication and that would fall outside your scope. I am sure you knew what you were doing based on your exp but it doesn't matter if you go outside of your scope of practice. I review med mal for a couple of ins co here that insure hospitals in this part of the US...Did an MD ever see your son or assess him? If not, that would be a risk mangers nightmare for certain. Also, if an RN goes outside her scope of practice the hospital is really under no obligation to back her up if a claim is filed..he or she is basically thrown to the wolves. Just my experience...


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