MH Recorded class lecture pt 1 Legal Aspects, Documentation, and Forensic Principles in Psychiatric Nursing
Legal and Ethical Frameworks in Psychiatric Nursing
Picking Up Slide 14 Content: The session resumes from slide 14, following a discussion on expressing information regarding legal aspects. This includes previous coverage of exceptions to the rules regarding patient confidentiality, specifically the "duty to warn."
Definitions of Torts:
Tort: A tort is defined as any wrongful act—whether intentional or accidental—that results in injury to another person.
Intentional Tort: This is a willful act where the perpetrator intentionally meant to cause the outcome. Examples include assaulting a patient, falsely holding them (false imprisonment), invading their privacy, or committing defamation through slander or libel.
Unintentional Tort: These are unintended acts against another person that cause harm, specifically referring to neglect and malpractice.
Legal Nuances by State Jurisdictions: Definitions for terms like assault, battery, and false imprisonment vary from state to state. Healthcare providers must understand the specific legal definitions applicable in their state to avoid liability.
Avoiding False Imprisonment: To prevent charges of false imprisonment (holding a patient illegally or against their will), healthcare workers must ensure that all legal paperwork is intact.
1013 Forms: It is vital to have the physical, signed "1013" paperwork. This document must follow the patient, especially during transfers from an Emergency Room (ER) to a psychiatric facility, and must be placed in the patient's chart.
Scenario Example: If a patient has been officially discharged and has their paperwork, and a nurse pulls them back into the facility as they are leaving without a legal reason, this could be considered false imprisonment.
Assault and Battery Definitions:
Assault: This is an action where an individual touches or pushes another without the right or the will to be touched. It involves the act itself (e.g., pushing a patient).
Battery: This occurs when the assaultive action results in an actual injury to the person.
Proving Negligence and Professional Standards
Five Elements of Negligence: To prove a nurse or healthcare individual is negligent, the following five criteria must be established:
Duty: It must be proven that the nurse was assigned to the patient and had a specific responsibility for their care.
Breach of Duty: It must be proven that the nurse did not do what they were supposed to do.
Actual Cause (Cause and Effect): Evaluated by asking, "If it were not for what the nurse did or failed to do, would the injury still have occurred?"
Proximate Cause (Legal Cause): Determined by whether the event was foreseeable.
Foreseeability Example: If a nurse raises the head of a bed and the patient chokes because they had an unknown allergy to iodine or a pre-existing medical issue they never disclosed, the nurse could not have foreseen the outcome, affecting the proximate cause.
Damages: There must be evidence of actual harm or physical injury to the patient.
Regulation of Nursing Practice:
State Board of Nursing: This organization regulates and manages the standards of nursing care. It is the primary body that upholds nursing laws in a state (e.g., Georgia State Board of Nursing).
American Nurses Association (ANA): The ANA focuses on promoting professionalism, excellence in care, and best practices. It acts as an advocate for changes in federal law and provides educational opportunities and professional conferences.
The Issue of "Fake Nurses": There have been instances of individuals practicing with fraudulent licenses. The State Board of Nursing maintains lists of these individuals, and it is considered the responsibility of the nursing community to report them if identified.
Reporting and Intervention Duties
Mandatory Reporting: Nurses have a duty to intervene and report any incompetence, impairment, or criminal activity observed in the workplace.
Handling Impaired Coworkers:
If a coworker is visibly impaired (e.g., inebriated), they must be removed from the position and sent home immediately.
Liability Warning: A nurse on duty must NOT drive an impaired coworker home. Furthermore, the nurse should not allow the impaired individual to drive themselves, as the nurse could be held liable if a fatal accident occurs. The best course of action is to call an ambulance or the police to handle the transport.
Supervisory Hierarchies: In many psychiatric settings, the Registered Nurse (RN) serves as the immediate supervisor for Licensed Practical Nurses (LPNs), Mental Health Assistants (MHAs), techs, and Certified Nursing Assistants (CNAs).
Reporting Protocol:
Document the incident clearly and accurately.
Notify the immediate supervisor.
If a supervisor is unavailable, the nurse must intervene directly to protect the patients (e.g., taking the medication room keys from an inebriated staff member).
Documentation Integrity and Record Ownership
Factual Documentation: All notes must be factual, accurate, and complete. If a patient speaks, their statements should be placed in quotation marks (verbatim). Documents should be devoid of personal bias or language that could incriminate the nurse.
Patient Access to Records:
Records belong to the institution, and patients generally cannot review them while still admitted.
Upon discharge, patients have a legal right to request and receive their medical records through the medical records department, regardless of whether the records pertain to mental health.
Privacy and Safety: Nurses should be mindful that patients can see their names on records. In psychiatric units, badges often only display the first name to maintain a degree of privacy, though full names can often be found via public State Board of Nursing license searches.
Electronic Documentation Rules:
Security: Never allow anyone to document under your login. Always log out or lock the computer when leaving a station.
Errors: Falsification or documenting on the wrong patient profile can lead to termination.
Corrections: Different facilities have different rules for correcting errors (e.g., a single line through paper errors with the word "error," or using digital addendums without deleting the original mistake).
The Role of Documentation in Quality Assurance (QA) and Risk Management:
Documentation is used to track patient progress and justify the plan of care.
Reimbursement: Insurance companies use documentation to determine if a patient's stay should be covered. If a patient has a behavioral issue but it isn't documented, the insurance will assume it didn't happen and may deny further coverage.
Forensic Nursing and Competency
Forensic Nursing Role: This involves the intersection of nursing science and the legal system. Forensic nurses may act as witnesses, providing opinions based on nursing standards in court cases.
Determining Competency: Forensic assessments determine if an individual is competent to stand trial.
Insanity Claims: Individuals found "criminally insane" often receive the maximum time for their crime in a secure facility rather than a standard prison. They are followed by the forensic state system for life and must comply with mandated medication regimens.
Intermittent Recidivism Case Study: A patient who killed her 7-year-old daughter (stating the child was "too beautiful for this world") was eventually able to function in society, earning degrees and working. However, she would stop her medications due to stress, leading to re-hospitalization, particularly around the anniversary of her daughter’s death.
Safety and Violence in Psychiatric Settings
Safe Milieu: The primary goal of the nurse is to maintain a safe environment. Violence is a known risk in psychiatric settings due to unpredictable patient behavior.
Communication as Safety: Nurses must communicate threats or changes in patient behavior to the next shift.
Example: A patient might ask a nurse about their car color or parking spot to target them after discharge. This information must be shared among staff to prevent harm.
New Legislation: New laws now allow patients to be charged for assaulting or spitting on a nurse, providing healthcare workers with similar legal protections to police officers.
Managing Threats: Common threats include spitting. Nurses are advised to maintain personal space, noting that some psychiatric medications cause "dry mouth," which may limit how far a patient can actually spit.
Questions & Discussion
Question: Is assault the actual action?
Response: Yes, assault is the action, such as pushing someone, or touching someone when you have no right to do so.
Question: Do patients have access to your last name?
Response: Yes. While badges might only show a first name, anyone can look up a professional license on the State Board of Nursing website using first and last names.
Question: What are the different codes used in the facility?
Response:
Code Blue: Someone is not breathing (medical emergency).
Code Yellow/Code Violent: Indicates a psychiatric emergency or behavioral escalation.
Double Code Violent: Used if a patient has a weapon.
Code Adam / Code Strong / Show of Force: Sometimes used to call for staff presence without alerting the patient, which might cause further escalation.
Silent Codes: Internally calling for specific staff (e.g., calling for all "Myrons" for male staff or "Ann Judas" for female staff) to handle sensitive situations like a patient being undressed during a fight.
End of Session: The class is instructed to take a break until 09:10, after which they will cover chapters 4, 5, 8, and 9.