Editing Management of Care (section)

== Legal Principles in Nursing ==

=== Sources of law that govern nursing ===
'''Statutory law''' includes the state nurse practice act. '''Regulatory or administrative law''' includes board of nursing rules and agency regulations. '''Common law''' is developed through court decisions. '''Criminal law''' addresses offenses against the state and includes acts such as diverting controlled substances or falsifying records. '''Civil law''' addresses wrongs between parties and is where most nursing liability lives.

=== Negligence and malpractice ===
'''Negligence''' is the failure to act as a reasonably prudent person would act under similar circumstances. It can be committed by anyone. '''Malpractice''' is professional negligence: the failure of a licensed professional to meet the standard of care of a reasonably prudent nurse with similar education and experience in similar circumstances.

Proving malpractice requires all of the following elements. If any one fails, the claim fails:
# '''Duty:''' a nurse-patient relationship existed, creating an obligation to provide care.
# '''Breach of duty:''' the nurse's action or omission fell below the standard of care.
# '''Causation:''' the breach directly caused the injury (proximate cause).
# '''Damages:''' actual harm resulted, whether physical, emotional, or financial.

Common allegations against nurses include medication errors, failure to assess and monitor, '''failure to rescue''' (recognizing deterioration but not escalating it), failure to follow the chain of command, patient falls, failure to use equipment safely, documentation failures, and failure to communicate a change in status to the provider.

=== Intentional torts ===
* '''Assault:''' a threat that creates a reasonable fear of harmful contact. No touching is required. Telling a patient he will be held down for an injection is assault.
* '''Battery:''' harmful or offensive contact without consent. Giving that injection over the patient's refusal is battery.
* '''False imprisonment:''' unlawfully confining a patient, including improper use of restraints or preventing a competent adult from leaving against medical advice.
* '''Invasion of privacy:''' unauthorized disclosure of patient information or exposure of the patient's body.
* '''Defamation:''' a false statement that damages reputation. '''Slander''' is spoken, '''libel''' is written.
* '''Fraud:''' willful misrepresentation, such as falsifying a record or misrepresenting credentials.

=== Restraints ===
Restraints are a last resort. Less restrictive alternatives must be tried and documented first: reorientation, bed and chair alarms, moving the patient nearer the nurses' station, involving family, toileting schedules, addressing pain, hunger, and delirium triggers, and removing lines and tubes when no longer needed.

Rules that appear repeatedly on examinations:
* A '''provider order is required'''. In an emergency an RN may initiate restraint and must obtain the order promptly per policy.
* '''PRN or standing orders for restraints are prohibited.'''
* Orders for restraint of '''violent or self-destructive''' behavior are time-limited and must be renewed within maximum intervals: 4 hours for adults 18 and older, 2 hours for ages 9 through 17, and 1 hour for children under 9 (Centers for Medicare & Medicaid Services [CMS], 2020).
* A '''face-to-face evaluation''' of the patient is required within 1 hour of initiating restraint for violent or self-destructive behavior.
* Use the '''least restrictive''' effective device, apply it so it can be released quickly, secure ties to the '''movable part of the bed frame''', never to the side rail, and use a '''quick-release knot'''.
* Monitor circulation, sensation, and skin integrity; release and provide range of motion, repositioning, toileting, and fluids per policy, commonly every 2 hours.
* Assessment, alternatives attempted, patient response, and continued need must be documented.

=== Documentation ===
The record is a clinical, legal, and billing document. Entries must be factual, objective, accurate, complete, timely, and legible, and must identify the author. Chart what was observed, what was done, and how the patient responded, not conclusions or opinions about other staff. Never chart in advance. Never chart for another person. Correct an error by drawing a single line through it, writing the correction with date, time, and initials, and leaving the original readable. Never erase, white out, or delete.

'''Incident or occurrence reports''' are internal quality and risk-management tools. The event itself and the patient's condition and treatment are documented in the medical record, but the record should '''not''' state that an incident report was completed, and the report is not filed in the chart.

=== Mandatory reporting and protective statutes ===
Nurses are '''mandatory reporters''' of suspected child abuse, elder and dependent-adult abuse, and certain communicable diseases and injuries such as gunshot and stab wounds, with specifics set by state law. Reporting requires '''reasonable suspicion''', not proof, and good-faith reporters are protected from liability. '''Good Samaritan laws''' protect a nurse who volunteers aid at the scene of an emergency, provided the nurse acts within the scope of ordinary skill, does not accept payment, and does not abandon the person once care is begun.

=== Chain of command ===
The chain of command is the formal route for escalating unresolved patient safety concerns. A representative nursing chain runs from assistive personnel to the LPN, to the RN, to the charge nurse, to the nurse manager, to the house supervisor or director, to the chief nursing officer. Provider concerns escalate from the resident or the ordering provider to the attending physician, to the department chief, and to the medical director, with risk management and the ethics committee available as parallel resources.

'''Rules for using it:''' address the concern with the person involved first when it is safe to do so, escalate one level at a time, escalate promptly rather than at the end of the shift, document each step, and '''never carry out an order the nurse believes is unsafe or incorrect'''. A nurse who follows a wrong order shares liability with the person who wrote it. The correct action is to clarify with the ordering provider and, if unresolved, escalate.