I work registry throughout Southern California. At present, I am contracted at a small community hospital. A case manager and I were wondering about a case in which a 23-year-old male was found down at home and paramedics brought him to this facility. He suffered an anoxic event and ended up in the ICU, on and off of a ventilator. There was definite brain injury and it was felt that a neurologist should have at least evaluated the case. Without a specialist to manage the neuro part of this complicated case, the patient remained at this small hospital for two weeks.

To just watch the posturing really bothered me; an EEG was never done and it was felt that he was greatly mismanaged. The primary physician said that he was too unstable for transfer. The patient eventually was transferred to a county facility, on a ventilator.

My question is, what liability falls on the RN caring for this patient? The family will probably seek legal counsel. In the end, an anoxic event is just that—permanent. A delay in having a neurologist on the case, even under these circumstances, is unacceptable. How can a facility open its ER to the community, knowing that it is not equipped to handle crises?

~A.F.

Unfortunately, this situation exists all across rural America, but the trend is toward hospital systems that do include at least one tertiary care facility accessible via air transport. As long as you perform your nursing care up to standards and notify the attending physician of any changes in patient condition, just as you would at any other hospital, you should not incur any liability with regard to your care of the patient.

Develop a rapport with the family and be open and honest when answering questions. Resist the urge to come right out and tell them to have their loved one transferred to another physician and/or facility. Theoretically, a nurse could be sued by a physician under the legal theory of tortious interference with contract if the nurse’s actions result in termination of the physician-patient relationship.

Pediatric home health
I am an RN who works in pediatric home health care, and care for special needs, physically/mentally challenged children in their own homes. My case manager and the supervisor say we are to take direction from the parent of the child whom we care for. Many times, I see cares/procedures done differently by the caregiver parent and frequently done incorrectly and substandard to what nurses are taught. I am told not to worry about how the parent does the procedures, and that I am not liable for their actions, only my own. What this means to me is that even though I gently try my best to help correct their method, if they don’t do things correctly, then I don’t have to worry about losing my license if they fail to improve their standard of care to their child. It’s difficult to overlook substandard care.

How liable am I as a licensed nurse when procedures are not up to a licensed nurse standard? How can I protect my standards in a home care setting when parents don’t do things correctly, even though they are reminded? Is the Nurse Practice Act enough to cover me?

~Nurse with nursing standards

A Nurse Practice Act is simply the law of a particular state that governs the practice of nursing for nurses in that state. You should be able to get a copy of this law and any associated regulations from your state nursing board; try its Web site. I think you are correct in continuing to re-demonstrate the correct procedure to the parent.

Document each time you have "retaught" the procedure and the parent response. Sometimes just asking the parents why they prefer to do things differently may demonstrate the need for some modifications you can all agree on. The best interests of the child will not be served if they tune you out completely.

Reclassification concerns
I am one of four nurses employed by a state facility in Indiana. We were recently informed that we will be reclassified and this includes a raise. At the same time, we were told that any raise would not come through immediately because the budget will not allow it. If the reclassifications are approved before the money becomes available, is it legal for our employer to expect us to perform the duties of the higher position without the enhanced compensation? What are our rights in this issue? Nothing from administration has been in writing.

~Lori Schutz
Evansville, Ind.

The simple answer is yes to the first question. Your employer can require just about anything of you within the law unless you have an employment contract or a union contract.

Any written (and sometimes oral) agreement between employer and employee regarding your terms of employment can be a contract; it need not be a formal notarized document.

Absent a contract or state regulation to the contrary, you have the right to terminate employment if you do not wish to perform your new job duties.