OBRA and Legal Ethical Issues
Omnibus Budget Reconciliation Act of 1987 (OBRA)
Goal: To improve the quality of life for residents in nursing facilities.
Regulations Focus On:
Resident rights
Restorative care
Psychosocial care
Preventive care to maintain maximum physician and mental wellness of residents.
Nurse Aide Training and Competency Evaluation Program (NATCEP)
The facility MUST assure that nurse aides complete an approved NATCEP.
The first 16 hours of training must be completed prior to any direct contact with a resident.
After the initial 16 hours, Nurse Aides (NA) can perform ONLY those skills for which they have been trained and deemed proficient by their instructor.
An approved NATCEP must consist of at least 100 clock hours total, broken down as follows:
60 hours classroom training
40 hours clinical training
The NA must successfully complete the training program to qualify for the state certification test.
State Test Requirements
The state certification test includes:
A written or oral exam consisting of 70 questions
A skills test consisting of 5 randomly selected skills
The NA must pass both the skills and written tests to be placed on the registry.
Each NA has 3 opportunities to pass each test, and must meet competency within 2 years of their completion date.
Each person on the registry must keep the department informed of their current address and telephone number.
NA Certification expires 24 months after entry in the registry. To continue certification, NAs must submit verification of paid employment prior to the expiration date.
NAs are required to complete 24 hours of in-service education every 2 years.
A finding of abuse, neglect, or misappropriation of resident property may be entered into the registry, resulting in no employment as a NA in LTC facilities.
Ethics and Laws in Nursing Facilities
Ethics: Defined as knowledge of right and wrong, detailing what people should do. An ethical person possesses a sense of duty and responsibility towards others.
Example: Ethical judgments guide actions and decisions in a professional environment.
Laws: Established to dictate what people must do. Laws are commonly rooted in ethical principles and have penalties for noncompliance.
Ethical Dilemmas
Examples include:
Witnessing a co-worker speak rudely to a resident
Reporting a care mistake
Pro-life vs. Pro-choice issues
Religious mandates impacting medical decisions (e.g., blood transfusions)
Teen right to privacy concerns (e.g., STI, mental health, pregnancy).
Legal Issues
Examples include:
Reporting abuse or neglect
Adhering to HIPAA guidelines
Issues concerning impaired work status (e.g., alcohol, drugs)
Committing abuse or neglect
Theft of resident property.
Compliance and Training Under OBRA
State Inspections: Conducted to ensure compliance with regulations, with penalties for noncompliance.
Nurse Aide Training Regulations: NAs must be placed on the Nurse Aide Registry within 4 months of their hire date.
State Registry Requirements:
The Health and Human Services Commission (HHSC) does not recertify NAs listed on the Employee Misconduct Registry (EMR) or those convicted of a criminal offense.
Legal and Ethical Behaviors
Key behaviors include:
Being honest at all times
Protecting the resident/patient privacy
Reporting abuse or neglect
Following the care plan and assignments
Reporting any mistakes promptly
Not performing tasks outside of one’s scope of practice
Following the chain of command
Documenting observations and incidents appropriately and promptly
Adhering to safety and infection control rules
Avoiding acceptance of gifts or tips.
Scope of Practice
Defines the tasks that healthcare providers are legally allowed to perform as per state or federal law. Regulations may vary by state.
Nursing Assistants are NOT licensed healthcare providers; all tasks are assigned by licensed healthcare personnel.
Chain of Command
Describes the line of authority, ensuring residents receive proper health care. There is always a supervisor to report incidents or accidents to, starting with the immediate supervisor.
Liability
A legal term signifying that an individual can be held responsible for causing harm to someone else.
Basic Nursing Skills
Essential skills include understanding vital signs, providing personal care, observing and reporting changes in resident conditions, rehabilitative skills, and conducting required resident assessments.
A comprehensive resident health status assessment must be documented on a 52-page document, which is to be completed within 14 days of admission and updated yearly, with reviews every three months or upon major changes.
Confidentiality and Privacy Protection
Key practices include:
Verifying the identity of callers
Not discussing residents in public
Being discreet when interacting with resident family members
Avoiding bringing family or friends to meet residents
Protecting computer screens and logging out after use
NEVER sharing information on public or social media
Ensuring documents are not left exposed and shredding any documents containing PHI (Protected Health Information).
Patient Relationships
Avoid becoming personally or sexually involved with residents or their families.
Minimum Data Set (MDS)
A key assessment tool to address:
Mental health and social service needs
Care for cognitively impaired residents.
HIPAA - Health Insurance Portability and Accountability Act
Important rules for maintaining privacy and security of health information:
Listening to messages in a private area
Handling patient information appropriately on social media platforms, such as avoiding posting rude comments, discussing company information, or sharing confidential patient health information.
Advanced Directives
Definition: Legal documents that allow individuals to express their wishes regarding medical care if they are unable to make those decisions themselves.
Living Will: Outlines desired or undesired medical treatment at the end of life (for terminal conditions).
Durable Power of Attorney for Health Care: Designates a person to make medical decisions on one's behalf if unable to do so.
DNR (Do Not Resuscitate): A physician’s order to refrain from performing CPR in the event of cardiac or respiratory arrest.
POLST (Physician's Orders for Life-Sustaining Treatment): Specifies desired treatments for seriously ill patients.
Social Media and Professional Conduct
Prohibited Uses of Social Media:
Discussing confidential patient information
Harassing or discriminatory remarks
Sharing inappropriate comments or conduct that violates HIPAA laws.
Who Can You Talk To?
Members of the patient's care team
Staff assigned to the patient
Physicians involved in the patient's care
Therapists associated with the patient's care
Family members as approved by the patient
Your supervisor.