Can You Refuse A Patient Assignment

live4today, RN · Jul 16, 2005

A nurse can refuse to accept a patient that she/he is not trained to handle appropriately. If you accept the care of a patient out of your training level, and something bad happens to the patient while in your care then you are at fault. :)

blueheaven · Jul 16, 2005

Refusing to care for a patient that you are not comfortable caring for is one thing but unless you document it (in our facility, the union provides forms for this) on an incident report and document that you talked to your immediate supervisor about the situation. In your situation, having the supervisor to notify the chief of staff of the situation and see if he would step in and "pink slip" this patient to an acute psych facility.

elkpark · Jul 16, 2005

I, too, wonder why this client wasn't transferred to a psych facility under petition for involuntary commitment -- I've been a psych nurse for 20 years, and have never heard of a disposition like the one you describe.

Yes, you have the right to refuse a patient assignment if you truly believe that you are unable to provide safe care for the patient, either because of the workload or because you lack the skills/knowledge to provide for the patient's needs. However, were you really unable to provide safe care to him, or did you just not want that kind of patient on a med-surg floor? I agree it was an inappropriate admission, but I'm not sure you would be covered under your Nurse Practice Act if your rationale for refusal was that admitting him to the unit might put others in danger. Did anyone higher up than the staff nurses talk to the admitting doc about what other possibilities had been considered, and staff concerns about having that patient on the med-surg unit?

I agree that inappropriate admissions to your floor are a medical staff issue -- your hospital must (is required by CMS to) have a medical staff peer review process that could look at this situation and make a determination about whether the physician involved handled the situation appropriately. Nursing leadership at your hospital can take this situation to the medical staff and request a review.

I'm sure this man is not the only client who has ever presented to your ED with psych needs; what is your hospital's process (is there a process) for getting psych evaluations does and determining appropriate disposition? If there isn't one, there needs to be ... Either the hospital administration or the medical staff could/should develop such a policy (hint -- it would not involve admitting acute psych patients to a med-surg floor with a phony dx like "recurrent HAs" ... :) )

GigLs2u · Jul 16, 2005

In Texas, there is protection in the Nurse Practice Act but you must claim it before you accept the assignment.

I am sorry I can not think of the exact phrase but once you claim it and cite the area under the NPA then there is paper work directly related to this claim. Next, certain people in administration have to meet and come up with their decision. Then if they demand you work under those conditions the hospital/facility is accepting ALL liability for anything errors you commit during that shift.

The facility can always fire you even if your claim is valid.

My cousin has taken this stance at her hospital at least 3 times. She currently works in the emergency room but was a manager there for almost 20 years so she is well informed.

I, too, wonder why this client wasn't transferred to a psych facility under petition for involuntary commitment -- I've been a psych nurse for 20 years, and have never heard of a disposition like the one you describe.
Yes, you have the right to refuse a patient assignment if you truly believe that you are unable to provide safe care for the patient, either because of the workload or because you lack the skills/knowledge to provide for the patient's needs. However, were you really unable to provide safe care to him, or did you just not want that kind of patient on a med-surg floor? I agree it was an inappropriate admission, but I'm not sure you would be covered under your Nurse Practice Act if your rationale for refusal was that admitting him to the unit might put others in danger. Did anyone higher up than the staff nurses talk to the admitting doc about what other possibilities had been considered, and staff concerns about having that patient on the med-surg unit?
I agree that inappropriate admissions to your floor are a medical staff issue -- your hospital must (is required by CMS to) have a medical staff peer review process that could look at this situation and make a determination about whether the physician involved handled the situation appropriately. Nursing leadership at your hospital can take this situation to the medical staff and request a review.
I'm sure this man is not the only client who has ever presented to your ED with psych needs; what is your hospital's process (is there a process) for getting psych evaluations does and determining appropriate disposition? If there isn't one, there needs to be ... Either the hospital administration or the medical staff could/should develop such a policy (hint -- it would not involve admitting acute psych patients to a med-surg floor with a phony dx like "recurrent HAs" ... :) )

gladtobeOB · Jul 18, 2005

Thanks, for the responses. This patient was evaluated by a Crisis worker who further infuriated him and made a bad situation even worse. They tried to get the pt into numerous faciltities but was turned down or said they had no beds. The pt would have had a dual dx being bipolar and a drug addict and many facilities do not accept that type of patient according to the crisis worker. There is from what I have been told going to be a Root/Cause analysis done on this so this won't be the last thing I hear from this situation.

My point with accepting this pt was his homicidal ideations, anger, drug abuse and possibly harming himself, staff or pts/residents and then I would be responsible in some way for his actions, no security or police involvement in the hospital. To me just my opinion when some threatens to kill they should be taken to jail no matter what the threat and charged not putting innocent people in danger because the dr doesn't want trouble and was really trying to the pt help.

I had no trouble with the pt but the whole idea of the what could have and still can happen from such threats. Like I said before to many details to type but I want to know for future knowledge my rights under the nurse practice act and what legal ramifcation if any could have happened if staff or pts were injured because of his actions etc

elkpark · Jul 18, 2005

What about your state hospital? In my state, there are four (each "covering" a different region of the state), and they are the disposition "of last resort" -- meaning, they don't have the option of refusing to take people like the man you describe. I can understand private, community hospital psych units turning someone like that down, but your state has to have some place for people like that to go for appropriate treatment (not your med-surg unit!!!! :uhoh3: )

I understand that, once the "crisis worker" threw in the towel (don't get me started on the kind of people who are allowed to be making these kind of decisions in EDs after hours -- some are v. good, and some are okay, but some are real bozos ...), the doc was between a rock and a hard place (couldn't just release the guy onto the street, and told no place for him to go), but your state has to have some state mental health system that can take people when all else fails ...

Is the hospital's RCA including input from your local mental health center about what resources are available in situations like this, and what went wrong on their end? 'Cause if I ran your hospital, I would sure be calling them up and demanding to know what they suggested we do the next time someone was raising cain in the ED. Best wishes --

GigLs2u · Jul 19, 2005

I am curious what your supervisor has to say. What was his/her response at the time? What is his/her expection for the next them?

First, I will address duty by giving you a real case facts and ruling. A patient in a rural area presented to the local ER with chest tightness. The nurse triaged/assessed including vital signs. She informed the ER physician about the patient, his complaint and her assessment. He told her to send the patient to the other hospital 20 minutes away because they can better handle cardiac problems. The nurse emphasized she felt the patient should be seen. The physician refused to see the patient. The nurse informed the patient and family member and helped him back into their car for the drive to the next hospital. The patient died in route.

The court ruled:

1) The hospital is there for the community and thus has a duty to the people who go there for medical help.

2) Employees (e.g.; the nurse) have a duty to people who present for help in the emergency room by virtue of employment in the hospital.

3) The doctor was not an employee of the hospital.

4) Doctors do not have a duty to patients. They have the choice to decide which patients they will or will not accept.

5) The hospital and nurse were neglient in their duty to this patient.

In addition, to losing the civil law suit the Board of Nurse Examiners found the nurse neglient in her duties and revoked her nursing license.

Now I will address what you may not know related to patients expressing homocidal threats. A mental health warrant can be sought for such individuals. Whoever is in charge in the emergency room should know how this is done in your area. If they don't then he/she should find out. If they are too lazy to do it, then maybe you should to protect yourself.

Where I am this is done by the police department. Anyone can call the police and say Joe Doe is threatening to kill me. Most often it is a family member who calls the police and sayes: My son, Joe, is threatening to kill me. He is manic-depressive and takes street drugs. I think he needs to be evaluated because he is treatening to kill me. When the police come there is paperwork the caller has to complete to facilitate the mental health warrant with evaluation. The individual is kept in jail until placed in a psychiatric facility.

I have worked in PICU, psychiatric intensive care. We got patients from over 200 miles away because they did not have beds in the area they were picked up so no beds available makes me wonder. I have even moved lons of people a day earlier than plan to get such patients.

Good Luck!

Joy

Thanks, for the responses. This patient was evaluated by a Crisis worker who further infuriated him and made a bad situation even worse. They tried to get the pt into numerous faciltities but was turned down or said they had no beds. The pt would have had a dual dx being bipolar and a drug addict and many facilities do not accept that type of patient according to the crisis worker. There is from what I have been told going to be a Root/Cause analysis done on this so this won't be the last thing I hear from this situation.
My point with accepting this pt was his homicidal ideations, anger, drug abuse and possibly harming himself, staff or pts/residents and then I would be responsible in some way for his actions, no security or police involvement in the hospital. To me just my opinion when some threatens to kill they should be taken to jail no matter what the threat and charged not putting innocent people in danger because the dr doesn't want trouble and was really trying to the pt help.
I had no trouble with the pt but the whole idea of the what could have and still can happen from such threats. Like I said before to many details to type but I want to know for future knowledge my rights under the nurse practice act and what legal ramifcation if any could have happened if staff or pts were injured because of his actions etc

luanne123 · Jul 21, 2005

I am curious what your supervisor has to say. What was his/her response at the time? What is his/her expection for the next them?
First, I will address duty by giving you a real case facts and ruling. A patient in a rural area presented to the local ER with chest tightness. The nurse triaged/assessed including vital signs. She informed the ER physician about the patient, his complaint and her assessment. He told her to send the patient to the other hospital 20 minutes away because they can better handle cardiac problems. The nurse emphasized she felt the patient should be seen. The physician refused to see the patient. The nurse informed the patient and family member and helped him back into their car for the drive to the next hospital. The patient died in route.
The court ruled:
1) The hospital is there for the community and thus has a duty to the people who go there for medical help.
2) Employees (e.g.; the nurse) have a duty to people who present for help in the emergency room by virtue of employment in the hospital.
3) The doctor was not an employee of the hospital.
4) Doctors do not have a duty to patients. They have the choice to decide which patients they will or will not accept.
5) The hospital and nurse were neglient in their duty to this patient.
In addition, to losing the civil law suit the Board of Nurse Examiners found the nurse neglient in her duties and revoked her nursing license.
Now I will address what you may not know related to patients expressing homocidal threats. A mental health warrant can be sought for such individuals. Whoever is in charge in the emergency room should know how this is done in your area. If they don't then he/she should find out. If they are too lazy to do it, then maybe you should to protect yourself.
Where I am this is done by the police department. Anyone can call the police and say Joe Doe is threatening to kill me. Most often it is a family member who calls the police and sayes: My son, Joe, is threatening to kill me. He is manic-depressive and takes street drugs. I think he needs to be evaluated because he is treatening to kill me. When the police come there is paperwork the caller has to complete to facilitate the mental health warrant with evaluation. The individual is kept in jail until placed in a psychiatric facility.
I have worked in PICU, psychiatric intensive care. We got patients from over 200 miles away because they did not have beds in the area they were picked up so no beds available makes me wonder. I have even moved lons of people a day earlier than plan to get such patients.
Good Luck!
Joy

Wow, I'm sorry you had to experience that. I'm surprised they didn't keep the patient in the ER with a 1:1 (including security) until placement was found at a psych facility. What kind of attending admitted the patient?

Luanne

msoregon · Apr 24, 2009

I am a nurse. I am confused and utterly frightened at the court's decision in the ruling that you mentioned.

1) How is an ER doctor not an employee of the hospital?

2) What was the nurse supposed to do in this case? She was supposed to ignore the doctor's order to send the pt to anther hospital and do what? She can't treat him herself. Time was of the essence. In this case, I would have contacted my nursing supervisor. What else could this nurse have done?

3) Why do doctors not have a duty to patients? If he works in the ER and is the only ER doctor available, how does he not have a duty to the patients there? If the problem is out of his area of expertise, how is it wrong for him to send the pt somewhere that can better take care of him? I thought hospitals did this. They send pts to hospitals better equipped to take care of their needs. What was the doctor in this case supposed to do?

I am more concerned with the question of what was Right for this nurse to do in this case, since the court decided what the nurse did was wrong.

Thank you.

TuTonka · Apr 29, 2009

Supervisors and Chiefs of Staff are people that handle these things. But where I come from the ER Dr. is Hired by the Hospital and therefore responsible to care for these pts. If the Dr felt he could be cared for better elsewhere the transfer would have taken place after the pt was stablize and sent by ambulance. I am truly saddened by stuff such as this and I send my sympathy to the nurse involved.

TuTonka

patwil73 · Apr 29, 2009

Had An Incident Last Week Where I Work, Small Hospital With Nursing Home Included In Which A Man Well Known To This Facilty Came In Seeking Psychiatric Help. (we Do Not Have The Capacity Or Doctors To Care For This Specialty). He Had Homicidal Ideations In The Er, Hx Of Being Bipolar, Hopped On Every Known Drug But Heroin. Stated In Er He Would Kill Everyone There In Er If Cops Were To Become Involved. So As The Story Goes He Was Admitted To The Floor Dx Recurrent Headache(which Obvously Had Since He Was So Jacked On Drugs) And Homicidial Ideations To The General Med/surg Floor For A 1:1.
Many Other Things Happened To Long To Write But What I Am Wondering Is If I Could Under The Nursing Practice Act Refused To Accept This Patient Under My Care With Such Statements And With The Potential To Harm Everyone That May Have Been In That Hospital At The Given Time?
Your Advise Would Be Greatly Appreciated.

My first instinct on reading this is that you could certainly try to refuse the assignment but i doubt you would get very far. As a med-Surg nurse you should be able to deal with a patient with a recurrent headache. Also you should have had at least some pysch training (it is mandated that you ask about thoughts of suicide or self-harm here at our hospital). So essentially you are treating his pain, monitoring his detox, and assessing for underlying symptoms that could cause headache - stroke, meningitis, etc.

If such a patient had been admitted at my facility I would have had a quick talk at the start with him - essentially emphasizing the fact that if he threatened anyone here I would call the police. If he threatened to hurt anyone here because I call the police i will restrain him and then call the police. You can't let crazy dictate your treatment or limit your options - it never works out.

Finally I am betting, since my ER has tried this a time or two, that since no beds were available in surrounding psych units that the ER did not want to be stuck with this patient they came up with a handy medical diagnosis to get him admitted - I have had them say we want to admit with hypokalemia (K is 3.2) simply because they don't want to watch him themselves.

Hope this helps

Pat