faculty overview of the disciplinary process charlene ...1 overview of the disciplinary process...

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Overview of theDisciplinary Process

Utilized by the AlabamaBoard of Nursing

Satellite Conference and Live WebcastWednesday, June 10, 2009

2:00 - 4:00 p.m. Central Time

Produced by the Alabama Department of Public HealthVideo Communications and Distance Learning Division

Faculty

Charlene Cotton, MSN, RN, ABNNurse Consultant

Alabama Board of Nursing

Alice Maples, BS, JD, LLMGeneral Counsel

Alabama Board of Nursing

Important Notice• Nothing in this presentation is

intended to serve as legal advice,nor should any part of thispresentation be construed as orrelied upon as legal advice

• Licensees are encouraged to seekindividual counsel regardingquestions related to particular factsand circumstances

Introduction

• Objectives of presentation

• Overview of presentation

Objectives

• Understand the purpose andfunction of the Nurse Practice Act

• List at least three components of theNurse Practice Act

• Identify violations of the AlabamaNurse Practice Act

Objectives

• Recognize all violations to report tothe Alabama Board of Nursing

• Know when to report a violation

• Be familiar with the disciplinaryactions resulting from violations

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Purpose and Function of theAlabama Nurse Practice Act• Enacted 1915, revised 2009• Creates & defines Board of Nursing• Requires license to practice or use

professional title–Registered Nurse (1915)–Licensed Practical Nurse (1948-49)–Advanced Practice Titles•CRNA, CRNP, CNM, CNS (1995)

Components of the AlabamaNurse Practice Act

• Establishment of the Alabama Boardof Nursing

• Authority & duties of the board

• Regulation of Nursing EducationProgram

Components of the AlabamaNurse Practice Act

• Examination and licensure of nurses

• Regulation of advanced practicenurses

• Disciplinary actions againstlicensees

Nurse Practice Act and ABNAdministrative Code

• Definitions

• Standards of practice

• Disciplinary actions

• Mandatory reporting

DefinitionsStandards of Practice

• Accountability

–Answerable or responsible for action

• Delegation

–The act of authorizing a competentindividual to perform acts supportiveto registered nurses or licensedpractical nurses in selectedsituations


• Responsibility

–The charge to do something that isexpected performance

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• Standardized Procedure

–Written policies and protocolsestablishing the permissiblefunctions, activities, and level ofsupervision of RNs and LPNswithin a licensed hospital settingbeyond basic nursing educationalpreparation


• Standardized Procedure

–Require(s) approval by the chiefnursing administrator, chiefmedical officer, and chief executiveofficer as evidenced by eachsignature on the written policy(ies)and protocol(s)

– Alabama Board of Nursing Administrative Code: §610-X-2-06

Definitions - Discipline• Alabama Board of Nursing

Administrative Code §610-X-8-01

–Letter of Closure

• Letter from the Board thatnotifies the RN, LPN, or applicantfor licensure that the case hasbeen closed without discipline



–Letter of Admonishment

• Letter from the Board thataddresses the areas of concernover the reported conduct &notifies the RN, LPN, or applicantfor licensure that the case hasbeen closed without discipline



–Reprimand

• Formal censure by the Board

–Fine

•Monetary penalty imposed by theBoard



–Probation

•Monitored practice of nursingwhich permits the nurse tocontinue to practice nursingpursuant to specified conditionsas set forth by the Board

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–Suspension

• Temporary withdrawal of thelicense by Board action

–Revocation

•Withdrawal of the license byBoard action



–Voluntary Surrender

• Voluntary relinquishment of alicense that has the force andeffect of revocation

Standards of Practice• “The board may reprimand, fine,

probate, suspend, revoke, orotherwise discipline any RN or LPNupon proof the person

– Is guilty of unprofessional conductof a character likely to deceive,defraud, or injure the public inmatters pertaining to health, thatincludes but is not limited to:

Standards of Practice

• Failure to practice nursing inaccordance with the standards ofpractice adopted by the Board”

– Alabama Board of Nursing Administrative Code §610-X-8-.03(6)(b)

Overarching Standardsof Practice

• 610-X-6.02 Conduct & Accountability

–RNs and LPNs shall

•Have knowledge &understanding of the laws &rules regulating nursing

• Function within the legal scopeof nursing practice


•Be responsible & accountablefor the quality of nursing caredelivered to patients based on &limited to scope of education,demonstrated competence, &nursing experience

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•Obtain instruction & supervisionas necessary whenimplementing new or unfamiliarnursing techniques or practices

•Accept individual responsibility& accountability for judgments,actions, & nursing competency


•Collaborate with other membersof the health care team

• Practice without discriminationon the basis of age, race,religion, gender, national origin,sexual orientation, patientdiagnosis, or disability


•Respect the dignity & rights ofpatients & their significant othersincluding, but not limited to–Privacy–Protection of confidential

information, unless disclosureis required by law–Freedom from exploitation of

physical, mental, sexual, orfinancial boundaries


–Protection of real & personalproperty

•Accept individual responsibility &accountability for timely reportingof illegal, substandard, unethical,unsafe, or incompetent nursingpractice directly to the Board ofNursing

Disciplinary Actions• Code of Alabama 1975, §34-21-25 (as

amended effective March 5, 2009)

–The Board may also deny, revoke,or suspend any license issued by itor otherwise discipline a licenseeupon proof of any of the followingregarding the licensee:

Disciplinary Actions• Is guilty of fraud or deceit in

procuring or attempting toprocure a license

•Has been convicted of a felony

• Is guilty of a crime involvingmoral turpitude or of grossimmorality that would tend tobring reproach upon the nursingprofession

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Disciplinary Actions• Is unfit or incompetent due to the

use of alcohol, or is addicted tothe use of habit-forming drugs tosuch an extent as to render himor her unsafe or unreliable as alicensee

Disciplinary Actions• Is unable to practice nursing

with reasonable skill and safetyto patients by reason of illness,inebriation, excessive use ofdrugs, narcotics, alcohol,chemicals, or any othersubstance, or as a result of anymental or physical condition

Disciplinary Actions•Has been convicted of any

violation of a federal or state lawrelating to controlled substances

• Is guilty of unprofessionalconduct of a character likely todeceive, defraud, or injure thepublic in matters pertaining tohealth

Disciplinary Actions•Has willfully or repeatedly

violated this article, as definedby board rules and regulations

What Does That Mean?• The statute sets forth eight broad

types of conduct that constitutegrounds for disciplinary actionagainst a licensee

• The Alabama Board of NursingAdministrative Code further definesthose types of conduct, thusestablishing clear expectations withregard to a nurse’s conduct

Fraud in theApplication Process

• Alabama Board of NursingAdministrative Code § 610-X-8-.03

– Is guilty of fraud or deceit inprocuring or attempting to procurea license by:

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Fraud in theApplication Process• Filing false, forged or altered

documents or credentials,including required continuingeducation documentation

•Misrepresenting or falsifyingfacts in applying for originallicensure, renewal, reactivation,or reinstatement of license

Fraud in theApplication Process•Having another person appear

for a licensing or certificationexamination

Criminal Activities• Alabama Board of Nursing

Administrative Code § 610-X-8-.03

–Has been convicted of a felonyoffense

Criminal Activities–Has been convicted of, or has

entered a plea of guilt, regardlessof court disposition, to a chargedcriminal act involving moralturpitude or of gross immoralitythat would tend to bring reproachupon the nursing profession

–Such criminal acts include, but arenot limited to, offenses involving:

Criminal Activities•Drugs• Theft• Lewdness• Sexual misconduct•Abuse• Violence• Fraud•Any other conduct detrimental to the

public’s health, safety, or welfare

Criminal Activities

–Has been convicted of anyviolation of a federal or state lawrelating to controlled substances,including misdemeanor & felonyoffenses

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Alcohol & Drug Addictions• Alabama Board of Nursing

Administrative Code § 610-X-8-.03– Is unfit or incompetent due to the

use of alcohol, or is addicted to theuse of habit-forming drugs to suchan extent as to render theregistered nurse or licensedpractical nurse unsafe orunreliable that includes but is notlimited to:

Alcohol & Drug Addictions• Testing Testing positive for

alcohol and/or unauthorizedmood-altering drugs

•Misappropriation or diversion ofdrugs from the workplace.

•Obtaining an unauthorizedprescription by fraudulent meansfor self use

Alcohol & Drug Addictions•A pattern of abuse or misuse of

habit forming and/or mood-altering drugs or alcohol

• Impairment while on duty due toalcohol or the use ofunauthorized or duly authorizedprescription drugs

Alcohol & Drug Addictions•Refusal to submit to drug screen

for cause

• Submission of a diluted,adulterated, or substitutedspecimen for drug testing

Alcohol & Drug Addictions• The use of alcohol or habit

forming or mood altering drugsto the extent that medical orpsychiatric treatment,rehabilitation, or counseling ismedically determined orotherwise recommended by alegally authorized practitioner

Unprofessional Conduct• Code of Alabama 1975, § 34-21-25

permits discipline if the licensee “isguilty of unprofessional conduct of acharacter likely to deceive, defraud,or injure the public in matterspertaining to health”

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Unprofessional Conduct –Standards & Scope of Practice• Alabama Board of Nursing

Administrative Code, § 610-X-8-.03


Unprofessional Conduct –Standards & Scope of Practice• Failure to comply with the Alabama

Nurse Practice Act and rules andregulations as well as all federal,state or local laws, rules orregulations applicable to the area ofnursing practice

Unprofessional Conduct –Standards & Scope of Practice• Failure to practice nursing in

accordance with the standards ofpractice adopted by the Board

• Practice beyond the scope ofpractice as determined by, but notlimited to:

Unprofessional Conduct –Standards & Scope of Practice

–Educational preparation

–License status

–Advanced practice approval

–Collaborative practice agreements

–State and federal statutes andregulations


–State and national standardsappropriate to the type of practice

–Nursing experience

–Standardized procedures


–Knowledge, skills, and ability tomanage risks and potentialcomplications

–Required instruction andsupervision

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Scope of Practice Violation

• While functioning as a surgical scrubnurse, inserted trocar into abdomenof patient

–Surgeon was not present

Scope of Practice Violation

• Inserted External Jugular with nostandardized procedure approvedfor the facility

Scope of Practice Violation Scope of Practice Violation

• Medications without physician order

–Administered medication withoutorder and then wrote order

–Gave patient a placebo instead ofordered med

–Performed sharp debridement onpatient’s heel

Scope of Practice Violation& Diversion/Theft

• Took IV Fluid (D5LR) home fromhospital and administered to her15-year-old daughter withoutinvolvement of MD

–Daughter later airlifted to PediatricICU

Scope of Practice Violation& Diversion/Theft

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Notes Regarding PatientCare Orders

• Administrative Code § 610-X-6-.09

Patient Care Orders & theDefinition of Professional Nurse• ...executing medical regimens

including administering medicationsand treatments prescribed by alicensed or otherwise legallyauthorized physician or dentist

NPA § 34-21-1 (3a)

Patient Care Orders• Administrative Code §610-X-6-.09

– “Authorized prescriber”

• Licensed physician or dentist

•CRNP

•CNM

• LICENSED PA or SA

– Lawful order

Patient Care Orders• Administrative Code §610-X-6-.09

– CRNPs & CNM are not authorizedto order narcotic medications andother controlled substances

Verbal Orders• Administrative Code §610-X-6-.09(2)– RN or LPN may receive verbal

orders from an authorizedprescriber relayed by•Another licensed or registered

health care professional•CERTIFIED medical assistant

– Implement standing orders atdirection of authorized prescriber

Violation: Patient CareOrders & Scope of Practice

• Gave another employee an injectionof Rocephin without an order fromlicensed prescriber

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Patient Care Orders & Fraud

• Solicited MD orders for services thathad already been provided without aMD order

FAQ• Can I take orders from the Doctor’s

office manager who happens to behis wife and was a nurse?

FAQ• We are being told that all orders

have to be verbal if they have notbeen written by the MD (i.e. no morephone orders)

– Is this correct?

Intravenous (IV) Therapy byLicensed Practical Nurses

• Administrative Code 610-X-6-.11

Prohibited IV Tasksfor All LPNs

• Initiation of IV therapy in a neonate• Administration of– Solutions requiring titration– Blood or blood components– Plasma volume expanders– GP-II-B-III-A inhibitors (platelet-

aggregate inhibitors)– Hyperalimentation by routes other

than peripheral


• Administration of– IV meds for procedural sedation

or anesthesia– IV medications via push or bolus

through a central line– IV push insulin or

chemotherapeutic agents– Any other drugs deemed to be

inappropriate by the facility

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• Accessing or programming animplanted IV infusion pump

• Repair of a central venous routeaccess device

• Performance of therapeuticphlebotomy


• Accessing a central venous routeaccess device including but notlimited to

– Implanted ports

– Lines used for hemodynamicmonitoring

Restrictions or Limitations• Include but not limited to

– LPN must have at least one year’sexperience with IV therapy

– Only IV push medications definedin application allowed to beadministered by LPN

Restrictions or Limitations• Include but not limited to

– Administration of IV pushmedication ONLY throughperipheral line

– On-site supervision by RN anytime IV push medication therapyperformed by LPN

Unprofessional Conduct• Judgment, assessment,

intervention, & medicationassessment– Alabama Board of Nursing

Administrative Code § 610-X-8-.03• Is guilty of unprofessional

conduct of a character likely todeceive, defraud, or injure thepublic in matters pertaining tohealth, that includes but is notlimited to:

Unprofessional Conduct• Failure to assess & evaluate

patient’s status

• Failure to institute nursinginterventions that might berequired to stabilize a patient’scondition or to preventcomplications

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Unprofessional Conduct• Failure to–Use appropriate nursing

judgment–Administer medications &

treatments in a responsiblemanner–Demonstrate competence in

administering or carrying outpatient care

Medication Administration

• 4 year old child would not take theImodium

–The nurse crushed medication andinjected through his IV resulting incellulitis

Medication Administration• Administered Morphine 40mg IV

push instead of ordered 4 mg

Medication Administration• RN - licensed 6 months– ICU patient with pacemaker, on

ventilator, Atrial Fibrillation withmultifocal PVCs–MD ordered Solumedrol 90 mg, K-

Phos 20mmol IV & Cordarone drip–Supervisor delivered medications

to RN•Asked & was told nurse had

never given K-phos

Medication Administration–Supervisor explained vial

contained total of 45 mmol, & theordered 20 mmol was equal to 6.7cc–Nurse administered the K-Phos by

IV Push, instead of IV drip–Heart rate dropped from 90s to 40s• Ventricular fibrillation–Patient died

Documentation• Alabama Board of Nursing



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Documentation

• Failure to make entries,destroying or altering entries,charting before assessment ordelivery of care, or making falseentries in patient, employer, oremployee records

Documentation• Failure to timely, accurately,

legibly, & completely report &document on appropriate recordsa patient's status, including signs& symptoms, responses,treatments, medications, othernursing care rendered,communication of pertinentinformation to other health teammembers, & unusual occurrencesinvolving the patient

How Does the Nurse RecordPertinent Patient Data As

Proof of the Quality of CareProvided?

• New rules specific to documentationare under development

–Check the ABN website forproposed rule changes

Fraudulent Documentation• PRE-CHARTED meds given via

Nasogastric tube when the tube hadbeen pulled out by the patient andnot replaced

• PRE-CHARTED patient transferredto ICU @ 1AM– I&Os already totaled for 6AM, &

assessments had already beencharted for 3AM & 5AM

Fraudulent Documentation• Documented wound care that had

not been administered

– On August 23 family showedsupervisor dressing of patient’sbuttock which was dated August20

– Order was for the wound to beirrigated and dressing changedevery shift

Documentation Violations

• Signed control drug record withoutactually counting the controlleddrugs with a second nurse

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Patient Safety, Supervision,and Delegation

• Is guilty of unprofessional conductof a character likely to deceive,defraud, or injure the public inmatters pertaining to health, thatincludes but is not limited to:


–Directing, assigning, or providingpatient care in a manner that failsto take into consideration patientsafety


–Assigning nursing functions toothers who lack the educationalpreparation, license, credentials,competence, experience,knowledge, or physical, mental oremotional ability to perform theassigned functions


–Failure to provide adequatesupervision, management, ortraining of individuals to whomnursing functions orresponsibilities are delegated orassigned

Documentation, ImproperSupervision, & Fraud

• Wrote orders in the medicationrecord of patients when no orderhad been given by MD

• Directed other nurses to writeorders that had not been given inorder to cover up med errors

Improper Delegation

• Allowed CNA to perform nursingprocedures on patients includingflushing G tubes and changing foleycatheters

• Delegated prescribed medications tounlicensed staff because residentswere impatient

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Specialized Delegation Rules• School nurses

• SAIL program

• Alabama Department of MentalHealth Residential CommunityPrograms– Administrative Code § 610-x-6-.06 & .07 & .15

Patient Abuse,Neglect, & Exploitation


–Gross negligence in the practice ofnursing

Patient Abuse,Neglect, & Exploitation–Abandoning or neglecting patients

•A certified copy of the record ofa state or federal agency thatsubstantiated neglect of apatient shall be conclusiveevidence of patient neglect

Patient Abuse,Neglect, & Exploitation–Failure to safeguard the patient's

dignity, right to privacy, andconfidential health informationunless disclosure is required bylaw

Patient Abuse,Neglect, & Exploitation– Intentionally or negligently causing

or permitting physical, sexual,emotional, or verbal abuse ofpatient, willfully harassing orintimidating patient•Certified copy of record of a state

or federal agency substantiatingpatient abuse shall be conclusiveevidence of abuse, harassment, orintimidation of patient

Patient Abuse,Neglect, & Exploitation–Violating professional boundaries

of the nurse-patient relationshipthat includes but is not limited to:

• Sexual or inappropriate intimateconduct with a patient, patient’simmediate family member(s) orsignificant other(s)

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Patient Abuse,Neglect, & Exploitation• Emotional or financial

exploitation of the patient or thepatient’s immediate familymember(s) or significant other(s)

• Inappropriate personaldisclosure to a patient, or thepatient’s immediate familymember(s) or significant other(s)

Abuse

• Example

–Verbally abused and usedprofanity with a patient in anattempt to get the patient to returnto the other side of the patient’ssemi-private room

Professional Boundary

• Engaged in conversations withpatient which resulted in patientfamily’s agreement to pay the costsof nurse’s tuition

• Imposed religious beliefs onpatient/resident

Professional Behavior,Privacy & Confidentiality,Professional Boundary

• While working in PACU, approachedteenage patient recovering fromsurgery & inquired whether patientknew her daughter & her daughter'sboyfriend

–Patient made derogatory commentabout the boyfriend

Professional Behavior,Privacy & Confidentiality,Professional Boundary

• Nurse subsequently communicatedthat comment to her daughter whichultimately resulted in patient beingconfronted by the boyfriend uponreturning to school followingsurgery

Violation: Patient RightsPrivacy & Confidentiality

• Obtained personal information froma resident’s medical record, withoutauthorization, for a resident he wasnot caring for

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• Looking for correct DOB for fatherof his girlfriend (a CNA) becausenurse had been claiming her parents(who were unaware) on his incometaxes for years

–His tax return had been rejected


• Failed to provide privacy duringcatheterization

• Failed to provide privacy duringdressing change


• Male assistant in ER (who was alsoenrolled in nursing school)unnecessarily exposed & took visualliberties with a 23 year old femalepatient who had back, neck & leftshoulder pain following a caraccident


• Shared knowledge about a particularpatient’s medical condition with herwomen’s church group

Interaction WithCoworkers, Employers, Etc.• Alabama Board of Nursing



Interaction WithCoworkers, Employers, Etc.

• Exhibiting inappropriate orunprofessional conduct orbehavior in the workplace

• Engaging in fraud, deceit ormisrepresentation in seekingemployment, practicing, orseeking to practice that includesbut is not limited to:

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–Alteration of a temporarypermit, identification card orlicense

–Falsification of credentials

–Falsification of employmentrecords


–Presenting oneself as aregistered nurse, licensedpractical nurse, or advancedpractice nurse without Boardapproval

–Falsification of continuingeducation documents


•Commission of fraudulent acts inadvertising, insurance, or inbilling for services, that includes,but is not limited to:

–Medicare or other federalgovernment programs


–Medicaid or other stategovernment programs

–Commercial insurance orhealth plan

UnprofessionalBehavior & Conduct

• Took a 4 hour nap while on duty andcharted on a L&D patient (39 wkgestation with failed induction)

–Documented hourly assessmentsfour times during this “nap” time

–Called security employee at hishome & told him she needed 4hours of video tape to disappear

UnprofessionalBehavior & Conduct

• Involved in altercation and assaultedPCT by slapping PCT in the facetwice

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Drug Use & Impairment &Theft at Work



–Personal use of unauthorized orillegal drugs or substances orobtaining, furnishing oradministering drugs or controlledsubstances to any person, exceptas directed by a legally authorizedprescriber


–Appropriating anything of value,use or benefit, including but notlimited to:

•Any real or personal property ofthe patient, employer, or anyother person or entity

• Failing to take precautions toprevent such misappropriation


–Practicing while the mental orphysical ability to practice isimpaired by any mood-alteringdrugs or substances or by aphysical, mental, or emotionaldisorder that renders theregistered nurse or licensedpractical nurse unable to performwith reasonable skill and safety

Responsibilities to the Board


Responsibilities to the Board

–Aiding, abetting, or assisting anindividual to violate or circumventany law or rule intended to guidethe conduct of a nurse or any otherlicensed health care provider

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Responsibilities to the Board–Failure to ensure verification of

current Alabama licensure andcredentials of nursing personnelfor whom the nurse isadministratively responsible

–Failure to report illegal,substandard, unethical, unsafe orincompetent nursing practices

Discipline in Another State

• Alabama Board of NursingAdministrative Code § 610-X-8-.03


Discipline in Another State•Having a license denied,

conditionally issued,reprimanded, placed onprobation, suspended, revoked,or voluntarily surrendered inanother state, territory orcountry, or having been court-martialed or administrativelydischarged by a branch of theUnited States Armed Forces…

Discipline in Another State…for any act or conduct which

would constitute grounds fordisciplinary action in this state

–A certified copy of the recordof the agency that took suchaction shall be conclusiveevidence of the grounds fordiscipline

Diversion

• Nurse took a partial blister pack ofRisperdal 0.25 mg tablets for use bya family member

• Obtained medication (Atenolol) fromfacility for personal use

Diversion• Allowed herself to be given an

injection of Phenergan (belonging toa patient) by a nurse coworkerwithout MD order

• Shoe box in nurse’s lockercontained vials of meds, numerouspills, capsules, tablets & cards ofmeds that were discontinued and/orfor patients who had beendischarged and/or died

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Mental and PhysicalConditions and Drug Abuse• Is unable to practice nursing with

reasonable skill and safety topatients by reason of illness,inebriation, excessive use of drugs,narcotics, alcohol, chemicals, or anyother substance, or as a result ofany mental or physical condition

–This is a new provision effectiveMarch 5, 2009

Willful or Repeated Violationsof the Nurse Practice Act

• As defined by rules and regulations

–Failure to respond to official Boardcorrespondence, including but notlimited to:

•Requests for information

• Subpoenas

•Notices



–Has willfully or repeatedly violatedany provisions of a statute or rulethat includes but is not limited to:

• Practicing or seeking to practiceprofessional or practical nursingwithout a current license ortemporary permit

Willful or Repeated Violationsof the Nurse Practice Act• Impersonating an applicant for

licensure or another licensedpractitioner or permitting orallowing another person to usethe nursing license or temporarypermit

•Continued violation of statute orrule after notice by the Board

Willful or Repeated Violationsof the Nurse Practice Act• Failure to comply with any

stipulated terms and conditionsof any Board order or contract



–Failure of a RN or LPN whoprovides continuing education tocomply with continuing educationrules

–Failure to repay scholarship fundsawarded by the Board for post-baccalaureate study

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Willful or Repeated Violationsof the Nurse Practice Act–Submitted payment of any fees or

fines to the Board with a worthlesscheck, invalid credit card, or byany other method that is nothonored by the financial institution

–Poses a risk to public safety forany other reasons authorized bylaw

Mandatory Reporting• “The registered nurse and licensed

practical nurse shall. . .

–Accept individual responsibilityand accountability for timelyreporting of illegal, substandard,unethical, unsafe, or incompetentnursing practice directly to theBoard of Nursing”• Alabama Board of Nursing Administrative Code §

610-X-6-.02(10)

Mandatory Reporting• “The Board may reprimand, fine,

probate, suspend, revoke orotherwise discipline any registerednurse or licensed practical nurseupon proof that the person:– Is guilty of unprofessional conduct

of a character likely to deceive,defraud, or injure the public inmatters pertaining to health, thatincludes but is not limited to:

Mandatory Reporting

• Failure to report illegal,substandard, unethical, unsafeor incompetent nursingpractices”– Alabama Board of Nursing Administrative Code§ 610-X-8-.03(6)(y)

Statistics

• Common complaints

• Common violations

Complaints vs. Discipline

• 1147 complaints received in FY 2007

• 541 nurses disciplined in FY 2007

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FY 2007 Violations• 541 nurses disciplined in fiscal year

2007

–337 cases were settled throughinformal disposition

–66 cases went to administrativehearings

–138 licensees chose to voluntarilysurrender their licenses in the faceof pending disciplinary action

Process of Discipline• Complaint

• Investigation

• Formal charges

• Hearing

• Disposition

• Appeals

Complaints• Code of Alabama 1975, § 34-21-25–Whenever a written complaint is

made to the board that a personhas committed any of the acts orcome within any of the provisionsenumerated in subsection (b), theboard shall investigate thecomplaint and may bring an actionin its own name to hear anddetermine the complaint

Complaints• Written complaints–From coworkers, mandatory

reporters, patients and patientfamilies, board-generated,regulatory authorities

• Investigations–Complaints that state a claim on

their face are referred to an ABNinvestigator

Complaints

• Actions–Brought in the name of ABN by

executive officer

How Will You Know AComplaint Has Been Filed

Against You?

• If a complaint states a possibleviolation of the Nurse Practice Act,then you will receive a NOTICE OFINVESTIGATION letter

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Investigation• Alabama Board of Nursing

Administrative Code § 610-X-8-.04Investigation

–Upon self-disclosure or receipt of awritten complaint alleging that aregistered nurse or licensedpractical nurse has violated astatute or rule by committing…

Investigation…one or more of the actionsspecified as grounds for disciplinaryaction, the Executive Officer shallprovide for an investigation byBoard staff to determine if there issufficient evidence to warrantdisciplinary proceedings

Investigation–When an investigation discloses

that disciplinary action is notwarranted for the protection of thepublic health, safety and welfare,the investigative file shall beclosed, provided that the mattermay be reinvestigated at any timeif circumstances so warrant

Investigation• Alabama Board of Nursing

Administrative Code § 610-X-8-.05Board Action FollowingInvestigation

–The Board or its authorizeddesignee shall have the power toact on the report of theinvestigation as follows:

Investigation•Dismiss complaint

• Send a letter of admonishment tothe registered nurse or licensedpractical nurse

•Commence disciplinaryproceedings

•Accept voluntary surrender of alicense

What Happens DuringAn Investigation?

• Four investigators & two nurseconsultants

• Investigator conducts interviewswith witnesses, the licensee, and thecomplainant (if possible)

• Board subpoenas records fromemployers, hospitals, etc.

• Investigators prepare summary ofcase for review by Nurse Consultant

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What Happens DuringAn Investigation?

• Nurse Consultant looks at theconduct as found during theinvestigation to determine if, from anursing perspective, the nurse didanything wrong

• Attorney reviews investigativereports and opinion of NurseConsultant

Statement of Charges –What is Required?

• (AAPA) Code of Alabama 1975, § 41-22-12(b)

–The notice shall include

•A statement of the time, place,and nature of the hearing

Statement of Charges –What is Required?

•A statement of the legal authority& jurisdiction under which thehearing is being held

•A reference to the particularsections of the statutes andrules involved; and

•A short and plain statement ofthe matters asserted

How Will YouReceive the Charges?

• Code of Alabama 1975, § 34-21-25

–The hearing shall be held inMontgomery, Alabama. Theperson whose qualification isunder consideration shall have notless than 20 days' written notice ofthe time and place of the initialhearing…


… and the notice shall beaccompanied by a copy of thecomplaint. The notice may beserved upon the accused person byany sheriff of the State of Alabama.If the accused person is out of thestate, evades service, or cannot beserved in person…


… then service may be made bymailing, by registered or certifiedmail, the notice and a copy of thecomplaint to the accused person athis or her last known post-officeaddress in this state, and the returnshall show that service has beenmade in this manner.

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The Hearing –What Are Your Rights?

• Code of Alabama 1975, § 34-21-25

–At the hearing, the complainant,the person whose qualification isunder consideration, and any otherperson permitted by the board,shall have the right to introduce alloral or written testimony, or both…


… as the board deems relevant tothe issues involved, and the right tobe heard in person or by counsel, orboth. The board may permit thecomplaint to be amended, but noamendment shall be permittedwhich is not germane to the chargeor charges sought to be amended…


… or which materially alters thenature of any offense charged. Theboard may determine all questionsas to the sufficiency of thecomplaint, procedure, andadmissibility and weight ofevidence. If the person whosequalification…


… is under consideration is absent,the hearing may proceed in his orher absence.

–Any accused person, complainant,or other party and the board maysubpoena witnesses or pertinentrecords for the hearing, and thosesubpoenas…


…may be served by any sheriff ofthe State of Alabama. Witnessesmay be sworn by the president ofthe board or by the persondischarging the duties of thepresident. Witnesses testifying at ahearing shall upon discharge as awitness be paid…


…by the party requesting thesubpoena an amount not to exceedthe per diem expense allowed toAlabama state employees for in-state travel and the actual cost oftransportation to and from the placeof the hearing, not to exceed themileage rate…

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…allowed to Alabama stateemployees for in-state travel

–Evidence may also be taken bydeposition, and the law andpractice as to depositions in circuitcourts shall be followed in allreasonable respects.

What Happens at a Hearing?

• The Board puts on it’s evidencethrough witnesses and exhibits

–Witnesses are subject to cross-examination by the licensee orhis/her attorney

What Happens at a Hearing?

• The licensee or his/her attorney putson his/her evidence throughwitnesses and exhibits

–Witnesses are subject to cross-examination by the Board’sattorney

Are Board Members Presentat the Hearing?

• No

–The Board members do not attendthe hearings. A Hearing Officerhears the case. He then reviewsthe transcript and exhibits andissues a Recommended Findingsof Fact & Conclusions of Law & arecommendation for discipline.

Are Board Members Presentat the Hearing?

–The Board is given a copy of theHearing Officer’s Recommendation,transcript, & exhibits to review.

–The Board meets in executivesession & votes on whether toaccept, reject, or modify the HearingOfficer’s Recommendation.

Disposition• Code of Alabama 1975, § 34-21-25– If the accused person is found guilty

of the charges, the board may refuseto issue a license, may revoke orsuspend a license, or may otherwisediscipline a licensee•A revoked license may be

considered for reinstatement afterone year in accordance with boardrules

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Possible Case Dispositions• Alabama Board of Nursing

Administrative Code § 610-X-8-.09Decisions of the Board

–Based upon the evidencepresented at the administrativehearing or pursuant to informaldisposition the Board action maybe one or more of the following:

Possible Case Dispositions•Dismiss the complaint

•Reprimand the respondent

• Probate the respondent’s license

• Suspend the respondent’slicense

•Revoke the respondent’s license

Possible Case Dispositions•Deny approval of the applicant to

take the licensing examination ordeny approval of the applicantfor licensure by endorsement

•Deny renewal or reinstatement ofa license

• Impose other sanctions orrestrictions

Possible Case Dispositions• The Board may levy a fine not to

exceed $1,000.00 per violation

• The decisions of the Board shallbe in writing in the form of anOrder, a copy of which shall bemailed or delivered to therespondent or the respondent’sattorney

Possible Case Dispositions• The decisions of the Board shall

be subject to publicdissemination

•Appeals are to the Circuit Courtof Montgomery County,Montgomery, Alabama and are tobe perfected in accordance withthe Administrative Procedure Act

How Does the BoardImplement It’s Decision?

• The Board issues a Written Order,which is served on the Respondentby Certified Mail

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Appeal of the Board’s Order• (NPA) Code of Alabama 1975, § 34-

21-25–Any person whose license is

ordered suspended or revokedmay appeal to the circuit court or acourt of like jurisdiction ofMontgomery County, from anyorder of the board under thissection, within 30 days from dateof the decision of the board

Appeal of the Board’s Order

–The trial of appeals shall beconducted in like manner, asnearly as may be, as provided forin the Alabama AdministrativeProcedure Act

Appeal of the Board’s Order• (NPA) Code of Alabama 1975, § 41-

22-20

–A person who has exhausted alladministrative remedies availablewithin the agency, other thanrehearing, and who is aggrieved bya final decision in a contested caseis entitled to judicial review underthis chapter

What Happens on Appeal?

• Appeal is to the Montgomery CountyCircuit Court

• A copy of the entire record is filedwith the Court

• The Board’s attorney and thelicensee or his/her attorney writebriefs and present oral argumentregarding the case


• The Court can affirm the decision,remand the case for furtherproceedings, or reverse or modifythe decision, or grant otherappropriate relief

–Code of Alabama 1975, § 41-22-20(k)


• The licensee or the Board mayappeal the decision of the CircuitCourt to the Alabama Court of CivilAppeals

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How Does the Board HandleLarge Volumes of Cases?

• Alabama Board of NursingAdministrative Code § 610-X-8-.08Informal Disposition of ContestedCases–Complaints or controversies may

be considered & resolved by theBoard or Board designee throughalternative dispute resolution,informal conferences, meetings, orother informal means

How Does the Board HandleLarge Volumes of Cases?• Such shall be held without

prejudice to the right of theBoard thereafter to instituteformal proceedings based uponthe same or related material ifcircumstances so warrant

How Does the Board HandleLarge Volumes of Cases?

• Informal dispositions may be madeof any contested case by stipulation,agreed settlement, consent order ordefault or by another method agreedupon by the parties in writing and asapproved by the Board

How Does the ConsentOrder Process Work?

• IF your case is one that can beresolved through a Consent Order,you will be invited for an interview atthe Board office with a nurseconsultant or the chief investigator.–The nurse consultant or

investigator will go over yourconduct with you & you may beoffered a consent order


–You may read & sign the consentorder at that time or take it withyou to be returned (if you sochoose) at a later date

• If you enter into the Consent Order,you will sign the Consent Order–However, the Consent Order does

not become final unless and until itis approved by the Board


–The Board can, & sometimes does,reject Consent Orders

• If you choose not to enter into theConsent Order, or if the Boardrejects it, your case will be set for anadministrative hearing

• Some cases cannot be resolved by aconsent order & are set for anadministrative hearing without aconsent order being offered at all

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Reviewing Consent Orders• All proposed Consent Orders are

subject to review & approval by theBoard

• The Board can, & periodically does,reject the Consent Orders

– In that case, the matter may go toan administrative hearing

Reviewing Consent Orders

• The Board may discuss the ConsentOrders in executive session, butmust vote on whether to acceptthem in an open meeting

Board Order ofDisciplinary Action

• Board members vote on every Orderto discipline a nurse’s license

• Action of the Board of Nursing ispublic record

• You will be notified by US mail afterthe Board issues the order

Public Records ofDisciplinary Action

• Board ordered discipline

• All records are public

• Disciplinary action is reported toNPDB and HIPDB

• Reports that go to NPDB and HIPDBmay go to Office of InspectorGeneral (OIG)

Complying with Board Orders• Payment of fine within 30 days• Required to notify current employer

of disciplinary action• Return ABN license card as ordered• Provide documentation to the Board– Completion of Board-ordered

continuing education– Other Board-mandated activities

Probation Monitoring• Board ordered discipline with

probation

• Must be employed in your licensedcapacity to complete period ofprobation

• Time not employed in nursingdoesn’t count

• Notify Board when your job oremployment changes

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Practice Restrictions• Practice restrictions apply to all

nurses who are monitored by theBoard of Nursing

–You must have

•Consistent supervision

•Consistent work group

•Work site monitor in addition tosupervisor

Practice Restrictions• You are not allowed to

–Work alone or unsupervised

–Work in supervisory position

–Work > 80 hours in a 2 week payperiod

–Have access to or administercontrolled substances forminimum of 6 months

Complying with Probation• Submit reports to the Board– On schedule– Complete

• Employer Reports• Meet with Board staff as directed• Maintain active license• Earn 24 contact hours of approved

continuing education to meetrenewal requirements

Addiction/Chemical Dependency• Probation fine: $1000• Board approved treatment provider• Compliance with treatment

recommendations• Monitoring for 5 years– Options to complete in 3 years of

full compliance• Aftercare meetings at least 1 year• Individual counseling

Monitoring Requirements• 12 step support group meetings–3/week

• Monthly reports from nurse• Quarterly reports from counselors,

Aftercare counselors, employers• Prescription verification for ALL

medications• Identify primary healthcare

providers

Random Drug Screens• Ordered for the duration of

monitoring• Any day–Monday-Saturday, 1-4 times/month

• Board contracts with lab service• Go to a lab on “the list”• Positive screens reviewed by

medical review officer (MRO),employed by 3rd party administrator

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Treatment Program• Determines when you return to work

• Severity of problems

• Level of recovery

• Support system

• Length of time away from nursing

• Cognitive deficits

• Decision making & judgment undernormal circumstances, & under stress

Completing Probation• Comply with all specifications in

your Board order

• You will receive notice by US mail

– Keep your address up to date inBoard records

• Return the license card forprobation

• Receive “Active” license card atyour address of record

Failure to Comply

• Violation

• Statement of Charges

• Starts the disciplinary process allover again

• Consent order, or not

• Formal hearing

Summary

• You are entitled to Due Processbefore your license is disciplined

• Your license is not disciplined untilthe Board enters a final orderdisciplining you for your conduct

• The Board does not prevent youfrom working while your case isbeing investigated

faculty overview of the disciplinary process charlene ...1 overview of the disciplinary process...

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