As nurses, we are the front line of patient safety. These days, hospitals are run as corporations and tend to put profits ahead of patients.  We need to change this.  People come first!

Because hospitals are now run like businesses, productivity experts and personnel who are not nurses, ask us to do so much more with less.  Administration is squeezing nurses to put their patients’ lives at risk and their licenses on the line.

I am all for mandatory nurse patient ratios.  While I think it is important for nurses to have safe staffing, putting a number on the nurse-to-patient ratios can have adverse effects which protections need to be added to the legislation.  I would love to see mandatory staffing based on acuity.  The recommended staffing ratios for a medical/surgical unit is 1 to 4.  However, if you have 4 fresh postop patients, it would be impossible to take vital signs every 15 minutes on those 4 patients!

The proposed staffing ratio in critical care is 1 nurse to 2 patients.  Again, if you have a patient who is extremely unstable, that patient should be a 1 to 1.  By requiring mandatory staffing, the ratios should be a maximum meaning the most a medical/surgical nurse should have is 4 patients.

Legislation in California requires minimum staffing levels.  However, there have been some unintended adverse effects of the legislation.  For example, although there is mandatory nurse-patient staffing, many hospitals have cut support staff to balance out their budgets.  We need staffing legislation and whatever requirements are promulgated should ensure that there are no unintended side effects.

Something needs to be done to ensure that nurses are not putting their licenses on the line or putting patient lives at stake.  Our voices need to be heard and we need to fight for our profession and our patients.  I would also love to see minimum staffing at long term care facilities.

What are your experiences with safe staffing?  Do your institutions have their own mandatory staffing requirements.  Please share your thoughts with us in the comments below.

No one ever has become a nurse so that they can sit to document all the care they provided to their patients.  Yet, documentation is one of the most important parts of our practice.  As much as any of you may dislike documentation, it serves a very important purpose to protect your license and your livelihood as well as protecting you if a medical malpractice claim should arise.

One thing nurses seldom realize is that when they late chart or enter something in a record which is not timed, an attorney can get what is called “audit trails” to find the time that the entry actually was entered into the computer.

Tom Dillow, an informatics nurse and legal nurse consultant in Indianapolis, told me of a female patient on a medical surgical unit who coded in the early afternoon and ultimately died.  No rhythm strips were available from the code and, despite being on house wide telemetry, no rhythm strips were documented since the day prior to the code.

The records showed that the patient was in normal sinus rhythm shortly prior to the code, however, the attorneys were able to find that was placed in the chart 31 hours after the patient’s demise.  An audit trail was able to determine that fact.

A late entry does raise suspicion, but it must be done properly rather than fraudulently.  To stick something in the record hours after the care was performed without labeling it as a late entry is fraud.  To properly document, a late entry needs to include the date and time when you are documenting the late entry along with the time and date when the activity or assessment occurred.

If the nurse properly documented the late entry 31 hours later that the patient was in normal sinus rhythm, noting the date and time of the documentation and the date and time when she assessed the patient’s EKG as normal sinus rhythm, it still could raise suspicion.  At least with the proper late entry, it is not fraud. Even if it’s a fill in the box documentation, you can still add it is a late entry in the narrative portion.

Know your facility’s policies and procedures for late entries.  If you are asked to back chart sometime, do it properly by identifying it as a late entry rather than adding it at a later date and hoping no one will notice.  That is FRAUD.  People forget to document things in the chart but being honest about it with a proper late entry is a lot easier to explain than trying to cover something up.

What are your facility’s policies on late entries?  What would you do if your supervisor asked you to “fill in the holes” on a record and not properly identify it as a later entry?  I would love to hear your comments below.

I don’t know what it’s like in other states, but when Indiana went to electronic license renewal, they no longer sent reminders of license renewal to health care professionals. Some would get an e-mail and sometimes it would go to spam. Who knows?

Every even numbered year, by October 31st, licensed practical nurses in Indiana had to renew their licenses while registered nurses were required do so by the same date on the odd numbered years. In our office, we learn every year that somebody forgot to renew their license.

Did you know that practicing nursing without a license is a criminal offense? It also is considered to be fraud and material misrepresentation. In the former, it’s billing fraud because when a hospital bills for a room, the cost of registered nurses is included with the fee for the room.

Many nurses who say “Oops!” feel that forgetting to renew is no big deal, “I’ll just renew it now.” Not so fast there. It’s much more than that because of the other ramifications. Even if you don’t need an R.N. to do your job, if you perform any nursing type services (assessing, planning, intervening and/or evaluating), it is still a practicing nursing without a license. You can’t even sign R.N. after your name if you don’t have a license. Signing R.N. after your name when you are not licensed is also fraud and material misrepresentation.

Therefore, to counteract this, I advise that you put in your calendar, on a recurring basis, a reminder for every time your license renewal is due, just to ensure this will never happen to you.

There are different types of law.  Civil law, which guides us in the civil area of our lives.  Criminal law, which have consequences for your freedom.  There is military law which, obviously, affects those in the armed services of our country.  Lastly, there is administrative law, a subset of civil law which governs bodies such as nursing boards.

Statutes that govern administrative law are referred to as the Administrative Procedures Act (“APA”). Or in Indiana, the Indiana Orders and Procedures Act (IOPA). The rules that you have in civil or criminal law do not apply in administrative law.  For example, hearsay, which is an out-of-court statement used to prove the truth of the matter asserted, is not admissible in criminal or civil law.  A person must be in the courtroom to testify under oath and counsel has the right to cross exam the witness.  This is unlike nursing boards where any out-of-court statement, whether it’s a document, letter from a witness, etc., can be used against you.

If you have a matter before the nursing board, it is important to know the APA of your state.  Therefore, you can make sure that whatever rights you have are protected.

In Indiana, all nurses used to be given a Pre-hearing Settlement Conference.  I particularly enjoyed these because if the matter could not be settled with the attorney for the state, we likely were able to settle it after we met with the Board Member who participated in the conference.

According to Indiana’s IOPA now, the Indiana Professional Licensing Agency is no longer automatically scheduling Pre-hearing Settlement Conferences.  The accused nurse must ask if she wants one of these conferences.  So it is important that the nurse knows they must ask.

It also once used to be that a Pre-hearing Settlement Conference was confidential.  Now, these conferences are public and open to anyone who wants to listen.  Unfortunately, there are confidential matters discussed in these conferences which, as counsel for nurses, we do not want to be made public.

In Indiana, nurses do have the right to go to mediation under our state’s IOPA.  As of yet, we have not had to use this.  It leaves a matter open to a lot of questions as to considerations such as is a certified mediator needed and who will pay for the mediation?  However, this may be a good avenue if the issues are not able to be resolved.

Make sure you and your attorney are familiar with the Administrative Procedures Act to ensure that you are availing yourself to all the rights and protection that you can.