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 clients, as well as allegations of falling asleep.
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 clients who were violent or aggressive and either retaliated against the client or responded to the client ‘s aggression in an inappropriate or unprofessional manner.
A client 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 client 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.
An RN left two 15 milligram tablets of a benzodiazepine called Temazepam unattended in an area accessible to clients. The medication went missing and was apparently taken by a client. 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.
A nurse working in home health failed to complete required client assessments and omitted pertinent client information in the health care record. This omission could have caused a disruption in the continuity of treatment resulting in client 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]
An RN failed to follow agency policy and procedures by neglecting to properly verify identification of two clients 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 client that was intended for the other client, thereby depriving that client 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]
A student nurse was instructed to discontinue an intravenous (IV) antibiotic for a client 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 client became unresponsive, and a code was called. The disconnection was not discovered until the client was transferred to the intensive care unit three hours later. The client 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 clients’ prescribed treatments or administering medication that had not been prescribed.
An RN in the ICU was caring for a client 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 client’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 client 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 client 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.
In a case involving a nursing student, the preceptor instructed the student to monitor the client’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 client’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]
Professional Misconduct Case Study Scenario
Sarah is a registered nurse working in a busy hospital emergency department. One evening, she is assigned to care for Mr. Thompson, a 68-year-old man who was admitted with severe chest pain. The emergency department is understaffed, and Sarah is handling multiple clients at once.
During her shift, Sarah receives a call from her supervisor asking her to assist in another critical case. In her hurry to attend to the other client, Sarah administers Mr. Thompson’s medication without double-checking the doctor’s orders. Unfortunately, she administers the wrong dosage of a medication, causing Mr. Thompson’s condition to worsen significantly.
Upon realizing her mistake, Sarah panics and decides not to report the error to avoid potential disciplinary action. She adjusts Mr. Thompson’s medical record to conceal the mistake. Later, Mr. Thompson’s condition deteriorates further, requiring intensive care. An investigation reveals the medication error and the altered medical records.
- Identify the ethical and legal issues present in this case.
- How does Sarah’s behavior constitute professional misconduct?
- What are the potential consequences for Sarah, both professionally and legally?
- How might the lack of adequate staffing and supervision have contributed to this incident?
- What policies should the hospital have in place to prevent such errors and ensure proper reporting?
- How did Sarah’s actions affect Mr. Thompson’s safety and overall outcome?
- What impact might this incident have on the trust between health care professionals and clients?
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellencehttps://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- National Council State Board of Nursing. Substance abuse disorder in nursing [Brochure]. https://www.ncsbn.org/nursing-regulation/practice/substance-use-disorder.page ↵
- Wisconsin Nurses Association. (n.d.). Nurses caring for nurses (peer assistance). https://www.wisconsinnurses.org/about-wna/affiliates/nurses-caring-for-nurses-peer-assistance/ ↵
- Statewide Peer Assistance For Nurses. https://www.statewidepeerassistance.org/ ↵
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
- Nurses Service Organization (NSO) and CNA Financial Corporation. (2020). Nurse professional liability exposure claim report: 4th edition: Minimizing risk, achieving excellence. https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵