5.4 Frequent Allegations and SBON Investigations

The Nurses Service Organization (NSO) reported the three most common allegations resulting in state board investigations in 2020 were related to the categories of professional conduct, scope of practice, and documentation errors or omissions.^[1]

Professional Conduct

Common allegations related to professional conduct included drug diversion and substance abuse, professional misconduct, reciprocal actions, and wastage errors.

Drug Diversion and Substance Abuse

The most common allegations related to professional conduct for both RNs and LPN/VNs in 2020 were related to drug diversion and/or substance abuse. Examples include diverting medications for oneself or others and apparent intoxication from alcohol or drugs while on duty.

The National Council of State Boards of Nursing (NCSBN) created a brochure titled Substance Abuse Disorder in Nursing to address this common issue.^[2] Many states have programs in place to assist nurses with substance abuse, such as Wisconsin Nursing Association’s Nurses Caring for Nurses (Peer Assistance) program or New York State Nursing Association’s Statewide Peer Assistance for Nurses (SPAN) program.^[3],[4]

Professional Misconduct

Professional misconduct as defined by state regulations was the second most common allegation related to professional conduct. This category includes unprofessional conduct towards coworkers and patients, as well as allegations of falling asleep.

Sample Case A home health RN was assigned to monitor an 11-month-old child from 1900 to 0700. The child was intubated and required constant monitoring to ensure the tubing remained secure while she was in her crib. However, the child’s father found the RN sleeping and the child’s tubing unsecured. The child did not suffer harm due to the incident, but the SBON publicly reprimanded the RN, and the costs to defend the nurse exceeded $2,400.^[5]

Reciprocal Actions

The third most common professional conduct allegation was reciprocal actions. Many cases involved nurses who were trying to contend with patients who were violent or aggressive and either retaliated against the patient or responded to the patient ‘s aggression in an inappropriate or unprofessional manner.

Sample Case A patient in an inpatient behavioral health unit became agitated, pulled a phone out of the wall, and threw it. The nurse entered the room and following a brief interaction, an altercation between the patient and the nurse ensued. The nurse received a public reprimand and disciplinary actions from the SBON.^[6]

Wastage Errors

Wastage errors were the fourth most common allegation. Wastage errors occurred when nurses neglected to perform accurate medication counts or did not appropriately document proper disposal of opioids and other drugs with a high potential for abuse.

Sample Case An RN left two 15 milligram tablets of a benzodiazepine called Temazepam unattended in an area accessible to patients. The medication went missing and was apparently taken by a patient. The nurse falsely documented the Temazepam as wastage, knowing the medication was actually missing. The SBON issued a $200 fine, and expenses to defend the nurse exceeded $7,200.^[7]

Scope of Practice

Common allegations related to scope of practice include failure to maintain a minimum standard of practice and providing services beyond one’s scope of practice.

Failure to Maintain Minimum Standard of Nursing Practice

The most common allegations related to scope of practice include failure to maintain a minimum standard of nursing practice. These cases include a breach of minimum professional standards, incompetence, and negligence.

Sample Case A nurse working in home health failed to complete required patient assessments and omitted pertinent patient information in the health care record. This omission could have caused a disruption in the continuity of treatment resulting in patient harm. The SBON determined the nurse failed to exercise the degree of learning, skill, care, and experience ordinarily possessed and exercised by a competent RN. The SBON placed the nurse on probation for three years, and the expenses associated with defending the nurse exceeded $5,400.^[8]

Sample Case An RN failed to follow agency policy and procedures by neglecting to properly verify identification of two patients and omitting the review of relevant laboratory results. As a result of bypassing standard safety procedures, the RN gave an extra unit of blood to one patient that was intended for the other patient, thereby depriving that patient the extra unit of blood required based on her lab results. The SBON placed the nurse on probation for three years. However, the nurse did not comply with the terms of her probation by failing to report to the SBON when she applied for licensure in two other states. The nurse also failed to obtain approval prior to commencing employment. The nurse was ultimately ordered to surrender her license.^[9]

Sample Case A student nurse was instructed to discontinue an intravenous (IV) antibiotic for a patient with a central venous catheter. When the student discontinued the IV, she unknowingly loosened the catheter connection from the lumen luer connector. The loosened line would likely have been discovered when the line was flushed per agency policy, but the student testified she did not know she was supposed to flush the catheter line or clamp it after the medication was discontinued. Shortly thereafter, the patient became unresponsive, and a code was called. The disconnection was not discovered until the patient was transferred to the intensive care unit three hours later. The patient experienced an air embolism and died. A malpractice claim was awarded.^[10]

Provision of Services Beyond Scope of Practice

The second most common allegation related to scope of practice is provision of services beyond one’s scope of practice. This category typically involves nurses making changes to patients’ prescribed treatments or administering medication that had not been prescribed.

Sample Case An RN in the ICU was caring for a patient with extreme nausea. The nurse made several unsuccessful attempts to reach the provider for an order for Ondansetron. The nurse called the pharmacy and relayed her concern for the patient’s nausea and her inability to reach the provider. The nurse informed the pharmacist that she believed the situation was urgent and she would contact the provider for an order. The pharmacy dispensed Ondansetron and the nurse administered the medication. Although the patient did not suffer adverse effects from the medication, no order was ever received for the medication. Upon finding the RN violated the Nurse Practice Act by practicing beyond the scope of practice for an RN, the SBON publicly reprimanded the nurse and ordered her to pay a fine of $600. Expenses associated with defending the nurse exceeded $6,100.^[11]

Documentation

Over half of the allegations in 2020 regarding documentation were related to fraudulent or falsified patient care or billing records. The health care record is a legal document. It should never be altered, deleted, or falsified. Maintaining accurate and timely documentation is a primary professional responsibility of nurses.

Sample Case In a case involving a nursing student, the preceptor instructed the student to monitor the patient’s vital signs every 15 minutes for one hour and then every 30 minutes for two hours and then every hour for four hours. The student allegedly documented vital signs every 15 minutes for one hour but did not record any vital signs thereafter. When confronted by her preceptor about the incomplete record, the student stated that she “forgot to do them.” Approximately 30 minutes later, the preceptor discovered the missing vital signs were documented in the patient’s record. The preceptor asked the student about the entries, and the student replied that she “made them up.” The student later contended that she meant she charted the vital signs accurately but made up the times the vital signs were taken to match the preceptor’s instructions. The SBON considered the student was still learning but viewed documentation as a basic nursing skill. Because the student’s conduct involved dishonesty, they imposed a penalty of a one-year suspension followed by one year of probation. The expenses associated with defending the student nurse exceeded $6,900.^[12]