LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES NURSE RECONGITION 2010

1. LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES NURSE RECONGITION 2010 LEGAL ASPECTS OF NURSING PRACTICE May 5, 2010 Bonnie Bilitch, RN, MSN Director, Risk Management LAC+USC Healthcare Network For use by LA County Departments Use Only

2. OBJECTIVES: • Describe how a nurse can incorporate risk management principles into practice • State the four steps to be taken after an adverse event • List three reasons for disclosing adverse events to patients/surrogates • Identify members of the legal team • List three basic elements of professional negligence • Define key legal concepts involved with patient/visitor falls • Identify a nurse’s legal exposure in the development of pressure ulcers • List three aspects of the California privacy regulations that affect nursing practice

3. RISK MANAGEMENT

4. PURPOSE OF RISK MANAGEMENT To identify risk factors to decrease potential risk exposures related to the delivery of healthcare and to improve the quality of care provide by the organization. HOW RISKS ARE IDENTIFIED An effective risk management program is based on the ability of all staff to identify and report events. YOU ARE A RISK MANAGER!

5. Interpersonal Skills

6. Interpersonal Skills • First impression is crucial • Establish rapport • Communicate effectively • Listen • Follow through to fulfill expectations

7. Documentation

8. Documentation Date/Time/Signature/Title Identification of Late Entries Corrections to entries and audit trails Avoiding CYA/Blame Game Confidential reporting systems

9. Adverse Outcomes "For a list of the State mandated reportable adverse events, "Never 28's", Please contact your hospital's risk management department.

10. Adverse Events Reportable Adverse Events – State Law • “Never 28” • Effective July 1, 2007 • Hospital must report “adverse events” • State DHS will investigate • Information becomes public • Penalties for failing to report • Potential fines related to event

11. What do I do? Take care of patient Report to Risk Management Assure there is disclosure with patient/family and documentation Enter event into Patient Safety Net

12. Why disclose? “The hospital informs the patient or surrogate decision-maker about unanticipated outcomes of care, treatment, and services that relates to sentinel events considered reviewable by The Joint Commission.” TJC – Rights and Responsibilities of the Individual

13. “The facility shall inform the patient or the party responsible for the patient of the adverse event by the time the report [adverse event report to State] is made.” California Health and Safety Code - Section 1279 Why disclose?

14. Why disclose? Benefits to Patient and Caregivers: Trust/Forgiveness and timely, appropriate follow up and treatment

15. Do’s and Don’ts Don’t promise anything you can’t deliver Do offer a sincere expression of sorrow/regret for the harm experienced. Don’t word the apology as an attribution or acceptance of blame, nor as admission of liability. Do tell the truth. Don’t blame others, especially if they are not present in the discussion.

16. LITIGATION

17. Plaintiff Patient Family members The patient’s survivors Witnesses to the patient’s injuries Loss of consortium Defendant Provider Employer or principal

18. Basic Elements: 1. Violation of Standard of Care 2. Causation 3. Damages Professional Negligence

19. * Medical service providers must exercise 1. reasonable degree of skill 2. reasonable degree of knowledge 3. reasonable degree of care * ordinarily possessed and exercised by members of their profession * under similar circumstances Standard of Care

20. To recover against a health care provider based on malpractice it is necessary to prove that an alleged failure to exercise the care and skill required under the circumstances was a proximate cause of the condition about which complaint is made. In medical malpractice action, evidence must establish that in absence of defendant's negligence, there was reasonable medical probability that plaintiff would have obtained a better result. Causation

21. -Must be actual & cannot be nominal -Special or Economic Past Medical Expenses Future Medical Expenses Loss of Earnings Loss of Earning Capacity - General or Non-Economic (M.I.C.R.A.) Pain and Suffering - Punitive Damages

22. County Counsel Sedgwick CMS (Third Party Administrator) Defense Attorney Risk Management Legal Team

23. -Incident/PSN report -Claim against the County -Lawsuit is Filed with the Court -Assignment of Case to Defense Counsel -Discovery and Investigation by Counsel -Round Table and Facility Litigation Review Procedural steps

24. Defend the case and proceed with trial File motions in the Court to terminate the case Settle the case Round Table/Facility Litigation Reviews

25. FALL

26. Case Study: 82 y.o. female speaks no English to hospital for chest pain, vomiting, HTN. Pt admitted to hospital. Assessed at 0620 by RN. Resting comfortably. RN warned pt not to get out of bed without assistance and to use call light for assistance. At approximately 0630, pt fell and injured hip. FALL

27. Key concepts relating to falls: Dangerous condition Negligence FALL

28. Issues identified upon expert review Failure to respond to patient’s call for assistance Failure to ensure patient’s comprehension of instructions for using call light. Failure to check patient according to falls protocol FALL

29. SKIN

30. Reportable event to State A Stage 3 or 4 ulcer, acquired after admission, excluding progression from Stage 2 to Stage 3, if Stage 2 was recognized upon admission. An unstageable ulcer is a full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore, stage cannot be determined. Litigation on the increase Elderly/Dependent Adult Abuse claims SKIN

31. Initial Assessment Upon Admission Identification of High Risk Patients Implementation of Nursing Protocols Documentation, Documentation, Documentation SKIN

32. PATIENT PRIVACY

33. Privacy of Health Information Laws Existing laws: • Federal Health Insurance Portability and Accountability Act (HIPAA) • California Confidentiality of Medical Information Act (CMIA) CMIA: Providers of healthcare may not disclose patient medical information without the patient’s written authorization, unless the disclosure is permitted or required, through exceptions specified by CMIA.

34. New Privacy of Health Information Laws SB 541 and AB 211 • Intent: To hold providers accountable for maintaining the confidentiality of patient medical information • Effective January 1, 2009 • Facilities must self-report • Creates Office of Health Information Integrity • Establishes new fines – facility and individuals

35. New Privacy of Health Information Laws Reporting Requirements (SB 541) • Any unlawful or unauthorized access/use/disclosure of patient medical information to CDPH and the patient within 5 days of detection • Obligation applies to acute/psychiatric hospitals, SNF’s, licensed clinics, home health, hospice

36. New Privacy of Health Information Laws Penalties (SB 541) • $100 per day for failure to report • Up to $25,000 per patient • Up to $17,500 per subsequent violation of that patient’s medical information • Maximum total of $250,000 per reported event

37. New Privacy of Health Information Laws New State Agency (AB 211) • Office of Health Information Integrity to enforce CMIA • OHII will levy penalties for unauthorized access/use/disclosure of patient medical information by individuals (not facilities covered by SB 541)

38. New Privacy of Health Information Laws Individual Penalties (AB 211) • Up to $2,500 for negligent disclosure • Up to $25,000 for knowing and willful access, disclosure or use • Up to $250,000 for knowing and willful access, or use for financial gain. • Up to $250,000 anyone not permitted to receive medical info under CMIA who knowingly and willfully obtains, discloses or uses such info without patient’s authorization

39. Questions?