Questionable legal and ethical violations within a department??

[ednrs4life]

Hi guys..I am lost?? I recently started working in an ED in a state outside the state I have practiced in as an ED nurse for 10 years. I have witnessed many situations that quite honestly scare me, but I'm not sure if I'm overreacting or are my concerns legit?

1. Falsification of blood transfusion consent..pt alert and orientated and able to make decisions for himself. The pt definitely needed several transfusions. The pts nurse handed the patient the consent for and tells him "your blood work was low, you need blood, sign this form so I can give you blood". The patient, who now looks like a deer in headlights says "what am I signing, what are you going to do to me". The nurses response remains the same and when I tried to explain more, I was interrupted. The patient continued to ask why and for what, next thing I know the patients "live-in girlfriend" takes the pen and scribbles his name. The nurse then proceeded to administer the transfusion.

2. There is an LTC facility located inside the hospital. This patient's PCP ordered 2 units PRBC at approximately 8am. At approximately 11:30pm the transfusion had not been administered by an RN working at the LTC facility and there is no RN working in the LTC facility after 11pm. Patient (with dementia) brought to ED as "outpatient" for transfusion and monitoring. Looking at the paperwork a nurse with the LTC facility obtained a telephone consent from a person unknown to me at 8am. If I obtain telephone consent I always have a 2nd nurse speak with the person giving consent and we both sign off on the consent form, as do all other nurses I have worked with in the past.

3. Urine/pregnancy/strep tests are done in the ED. Well the tests are run in the dirty utility room, there is always each time I go in the room urine/strep swabs lying on the counter by the sink that have been sitting there for over 12 hours.

4. Patient verification..I have always printed my orders out so I had something in my hand in order to verify the patient/med/allergy. These nurses look at computer and somehow remember what meds to pull, then miraculously they are able to walk into a patients room and verify they are giving the right med to the right pt completely by memory. My preceptor even came in a pts room behind me handed me two 4mg vials of Decadron and told me the MD ordered 6mg for that patient..Oh heck no!!

The list of my concerns go on and on, but I think these are the most disturbing. My problem is, are these violations, should they be reported, or am I over-reacting. Also, I have no idea what entity to report these violations to. I have searched and searched there is nothing specific addressing these problems.

Thanks for your help

[Altra, BSN, RN]

I can understand where you're coming from, as can anyone who has worked in more than one hospital. You learn the "right way" and then go somewhere else where things are done differently - it can set off alarm bells. As for the specific situations you mentioned:

1. Terrible practice, that tends to develop when physicians are allowed to pawn off responsibility for obtaining consent onto busy nurses. But just for some perspective -- the alert & oriented patient could certainly have physically refused the transfusion, or any other care. I'm not excusing it -- just food for thought. You will not be able to single-handedly change this culture, but you can speak to a trusted charge nurse or your manager to see if they are open to initiating some conversations with physicians to obtain their own freaking consent, as they should be.

2. Hard to comment on this one without knowing the patient's situation and understanding the organizational relationship between the LTC and the rest of the hospital. As ED nurses we have to remember that things work differently outside of the ED setting -- ordered tests/procedures sometimes take days to complete. I will say that in all EDs in which I've worked, we sometimes get LTC/SNF patients for outpatient testing or procedures that they were otherwise unable to obtain for the patient. Is it right or an appropriate use of resources? No. Is it sometimes necessary to care for the patient? Yes.

3. So your dirty utility room is a pigstye. Unfortunate, but not something I'd be raising alarm bells about. Just because POC tests are left sitting there, doesn't necessarily mean you can conclude that no one resulted them at the appropriate time. They just couldn't be bothered to clean up afterward.

4. I have "miraculously" remembered what meds I need to obtain/give to my patients my whole career. I verify the patient's identity/armband per hospital policy. But if you prefer to print out orders (or utilize a COW), by all means, have at it.

Hope that you settle in to your new department - transition is always hard!

[Anonymous865]

Laws vary from state to state. In my state #1 would open the nurse and hospital up to a charge of medical battery and possibly other charges.

In my state only a physician or NP can obtain informed consent. Getting a signature on a piece of paper does not constitute informed consent. The physician or NP (not nurse) must tell the patient of the proposed treatment, the risks & benefits of the treatment, alternatives to the proposed treatment, and consequences of refusing the proposed treatment. Once that conversation has taken place, a nurse (or anyone else) can get the signature on the "consent form." The "consent form" itself is not consent. It is merely documentation that the conversation has taken place and the patient agrees with the planned treatment. The nurse who gets the signature also signs. She is signing as a witness that the patient is providing "informed consent." She is also signing as a witness that it was the patient who signed the form.

In your example, the patient clearly has not been "informed" and is clearly not the person providing consent.

For anyone else to consent for the patient, the patient must be determined to lack decision making capacity. This determination must be made by a provider and documented in the patient medical record.

In your example, it doesn't sound like that determination has been made.

The law clearly defines who can be a substitute decision maker for a patient if the patient lacks decision making capacity. If the girl friend did not have the patient's medical POA, she had no standing in law to sign for the patient.

When you sign for another person, you sign your own name. You never sign the other person's name. The girl friend likely committed forgery by signing the patient's name.

Regarding Altra's comment above that the patient "could certainly have physically refused" in my state that would not be a defense against a battery charge. The law clearly states that the patient does not have to physically resist the treatment for it to be battery.

I wonder if the organization's risk management knows that this is going on.

[Lennonninja, MSN, APRN, NP]

Our Pyxis machines are set up so that I can select a time frame, say 0800-1000 and it will highlight all of the meds due within that time. That's how I miraculously remember which meds to pull. Also, we have to scan the patient and scan all of the meds. Soon we will also be scanning the pump that the drips will be hanging on.