Chapter 2

1. Chapter 2 Ethical & Legal Issues

2. Seatwork • Among your tablemates, please describe the difference between ethics and laws. • Ethics is concerned with what you should and should not do. • The law is concerned with what you can and cannot do. • A law is a rule that is made by a government body. • Laws are enforced by government bodies. • Ethics deal with morals and what is the right thing to do. • Professional groups have code of ethics.

3. 2. Define the terms law, ethics, and etiquette • Ethics help us make decisions at home, in the workplace, or in the community. In healthcare, ethics guide the people giving care. For example, keeping a resident’s information confidential is ethical behavior. It is also the law. • In healthcare, laws protect those receiving care. For example, there is a law against stealing a resident’s belongings.

4. 2. Define the terms law, ethics, and etiquette Etiquette is the code of proper behavior and courtesy in a certain setting. For example, identify yourself when you answer the phone at your facility. Ask, “How may I help you?” This is proper telephone etiquette.

5. 3. Discuss examples of ethical and professional behavior • Professional and ethical behavior is vital to the safety of residents. • Remember the following guidelines for legal and ethical behavior that nursing assistants must follow: • Keep all resident and staff information confidential. • Be honest at all times. • Be trustworthy. • Do not accept gifts or tips. • Report abuse or suspected abuse of residents.

6. 3. Discuss examples of ethical and professional behavior • Guidelines for legal and ethical behavior for nursing assistants (cont’d): • Do not report to work under the influence of alcohol or drugs. • Follow all facility policies, rules, and procedures. • Do assigned tasks. Report mistakes promptly. • Be positive, professional, and tactful. • Treat all residents with respect and be empathetic. • Be patient.

7. 4. Describe a nursing assistant code of ethics • Many facilities have adopted a formal code of ethics. This helps their employees deal with issues of right and wrong. • All facility codes of ethics revolve around the idea that the resident is a valuable person who deserves ethical care.

8. Transparency 2-1: Nursing Assistant Code of Ethics • I will strive to provide and maintain the highest quality of care for my residents. I will fully recognize and follow all of the Residents’ Rights. • I will communicate well, serve on committees, and read all material as provided and required by my employer. I will attend educational in-services, and join organizations relevant to nursing assistant care. • I will show a positive attitude toward my residents, their family members, staff, and other visitors. • I will always provide privacy for my residents. I will maintain confidentiality of resident, staff, and visitor information. • I will be trustworthy and honest in all dealings with residents, staff, and visitors.

9. Transparency 2-1: Nursing Assistant Code of Ethics (cont'd) • I will strive to preserve resident safety. I will report mistakes I make, along with anything that I deem dangerous, to the right person(s). • I will have empathy for my residents, other staff, and all visitors, giving support and encouragement when needed. • I will respect all people, without regard to age, gender, ethnicity, religion, economic situation, sexual orientation, or diagnosis. • I will never abuse my residents in any way. I will always report any suspected abuse to the proper person immediately. • I will strive to have the utmost patience with all people at my facility.

10. 5. Explain the Omnibus Budget Reconciliation Act (OBRA) • Define the following terms: • OBRA (Omnibus Budget Reconciliation Act) • law passed by the federal government that includes minimum standards for nursing assistant training, staffing requirements, resident assessment instructions, and information on rights for residents. • NATCEP (Nurse Aide Training and Competency Evaluation Program) • part of the Omnibus Budget Reconciliation Act (OBRA) that sets minimum requirements for training and testing nursing assistants. • scope of practice • defines the tasks that healthcare providers are legally permitted to perform as allowed by state or federal law.

11. 5. Explain the Omnibus Budget Reconciliation Act (OBRA) • The Omnibus Budget Reconciliation Act (OBRA) was passed in 1987. It has been updated many times since then. • OBRA was written in response to reports of poor care and abuse in long-term care facilities. • Congress decided to set minimum standards of care. This included standardizing training of nursing assistants.

12. Federal and State Laws (cont’d) • The Omnibus Budget Reconciliation Act of 1987 (OBRA) is a federal law. • Its purpose is to improve the quality of life of nursing center residents. • This law sets minimum training and competency evaluation requirements for nursing assistants. • Each state must have a nursing assistant training and competency evaluation program (NATCEP).

13. 5. Explain the Omnibus Budget Reconciliation Act (OBRA) • OBRA regulations are important to the nursing assistant practice for many reasons, including the following: • Give recognition through certification and registration • Help define the nursing assistant’s scope of practice • Provide better uniformity of care • Promote educational standards

14. Federal and State Laws (cont’d) • The training program • OBRA requires at least 75 hours of instruction. (AZSBON = 120hr) • Includes classroom and at least 16 hours of supervised practical training (AZSBON = 40hr; 20hr in LTC) • Provides the knowledge and skills needed to give basic nursing care (Article 8) • Competency evaluation • Includes a written test and a skills test • OBRA allows at least 3 attempts to successfully complete the evaluation. (AZSBON = 2 attempts; if no pass, must take a refresher course)

15. Federal and State Laws (cont’d) • Nursing Assistant Registry • Official record or listing of persons who have successfully completed that state’s approved NATCEP • The registry has information about each nursing assistant. • All information stays in the registry for at least 5 years. • Any agency can access registry information. • You receive a copy of your registry information. • You can correct wrong information.

16. Federal and State Laws (cont’d) • Other OBRA requirements • Retraining and a new competency evaluation program are required for nursing assistants who have not worked for 24 months. • Agencies covered under OBRA must provide 12 hours of educational programs to nursing assistants every year. • Performance reviews also are required.

17. Certification • Each State’s NATCEP must meet OBRA requirements. • Nursing assistants can have their certification (licenses, registration) denied, revoked, or suspended. • To work in another state you must meet that state’s NATCEP requirements: • Apply to the state agency responsible for NATCEPs and the nursing assistant registry. • Your application is reviewed. • Certification (a license, registration) is granted if requirements are met.

18. Delegation • Delegate means to authorize another person to perform a nursing task in a certain situation. • The person must be competent to perform a task in a given situation.

19. Delegation (cont’d) • Who can delegate • RNs can delegate nursing tasks to LPNs/LVNs and nursing assistants. • In some states, LPNs/LVNs can delegate tasks to nursing assistants. • Delegation must protect health and safety. • Nursing assistants cannot delegate.

20. Delegation (cont’d) • The National Council of State Boards of Nursing (NCSBN) describes four steps in the delegation process. • Step 1—Assess and plan is done by the nurse. • Step 2—Communication involves the nurse and you. • Step 3—Surveillance and supervision; the nurse observes the care you give. • Step 4—Evaluation and feedback is done by the nurse.

21. Delegation (cont’d) • The NCSBN’s Five Rights of Delegation is another way to view the delegation process. • The right task • The right circumstances • The right person • The right directions and communication • The right supervision

22. Delegation (cont’d) • Your role in delegation • You must protect the person from harm. • You either agree or refuse to do a delegated task. • Accepting a task • When you agree to perform a task, you are responsible for your own actions. • You must complete the task safely. • Report to the nurse what you did and the observations you made.

23. Delegation (cont’d) • Refusing a task • The task is beyond the legal limits of your role. • The task is not in your job description. • You were not prepared to perform the task. • The task could harm the person. • The person’s condition has changed. • You do not know how to use the supplies or equipment. • Directions are not ethical or legal. • Directions are against agency policies. • Directions are unclear or incomplete. • A nurse is not available for supervision.

24. Delegation (cont’d) • Never ignore an order or a request to do something. • Tell the nurse about your concerns. • You must have sound reasons for refusing a task.

25. The Person’s Rights

26. Patient’s Rights • The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities • Adopted in April 2003 by the American Hospital Association (AHA) • Refer to handout

27. 6. Explain Residents’ Rights • Define the following terms: • Residents’ Rights • rights identified in the Omnibus Budget Reconciliation Act (OBRA) that relate to how residents must be treated while living in a long-term care facility; they provide an ethical code of conduct for healthcare workers. • Residents’ Council • a group of residents who meet regularly to discuss issues related to the long-term care facility. • misappropriation • the act of taking what belongs to someone else and using it illegally for one’s own gain.

28. Patient’s Bill of Rights

29. Residents’ Rights • Omnibus Budget Reconciliation Act (OBRA) • Passed in 1987 by the U.S. Congress • Applies to all 50 states • Requires nursing centers to provide care in a manner and in a setting that maintains or improves each person’s quality of life, health, and safety • Resident rights are a major part of OBRA

30. Residents’ Rights (cont’d) • Residents have rights relating to their everyday lives and care in a nursing center. • Some residents cannot exercise their rights due to incompetence. • A representative may act on his or her behalf. • Nursing centers must inform residents of their rights. • Residents’ rights are posted throughout the center.

31. Residents’ Rights (cont’d) Surrogacy Decision Makers Law in Arizona 36-3231 • 36-3231. Surrogate decision makers; priorities; limitations • A. If an adult patient is unable to make or communicate health care treatment decisions, a health care provider shall make a reasonable effort to locate and shall follow a health care directive. A health care provider shall also make a reasonable effort to consult with a surrogate. If the patient has a health care power of attorney that meets the requirements of section 36-3221, the patient's designated agent shall act as the patient's surrogate. However, if the court appoints a guardian for the express purpose of making health care treatment decisions, that guardian shall act as the patient's surrogate. If neither of these situations applies, the health care provider shall make reasonable efforts to contact the following individual or individuals in the indicated order of priority, who are available and willing to serve as the surrogate, who then have the authority to make health care decisions for the patient and who shall follow the patient's wishes if they are known: • 1. The patient's spouse, unless the patient and spouse are legally separated. • 2. An adult child of the patient. If the patient has more than one adult child, the health care provider shall seek the consent of a majority of the adult children who are reasonably available for consultation. • 3. A parent of the patient. • 4. If the patient is unmarried, the patient's domestic partner. • 5. A brother or sister of the patient. • 6. A close friend of the patient. For the purposes of this paragraph, "close friend" means an adult who has exhibited special care and concern for the patient, who is familiar with the patient's health care views and desires and who is willing and able to become involved in the patient's health care and to act in the patient's best interest. • B. If the health care provider cannot locate any of the people listed in subsection A of this section, the patient's attending physician may make health care treatment decisions for the patient after the physician consults with and obtains the recommendations of an institutional ethics committee. If this is not possible, the physician may make these decisions after consulting with a second physician who concurs with the physician's decision. For the purposes of this subsection, "institutional ethics committee" means a standing committee of a licensed health care institution appointed or elected to render advice concerning ethical issues involving medical treatment. http://www.azleg.state.az.us/ars/36/03231.htm

32. Competency Defined • competent • adj. 1) in general, able to act in the circumstances, including the ability to perform a job or occupation, or to reason or make decisions. 2) in wills, trusts and contracts, sufficiently mentally able to understand and execute a document. To be competent to make a will a person must understand what a will is, what he/she owns (although forgetting a few items among many does not show incompetency), and who are relatives who would normally inherit ("the natural objects of his/her bounty") such as children and spouse (although forgetting a child in a will is not automatic proof of lack of competency, since it may be intentional or the child has been long gone). 3) in criminal law, sufficiently mentally able to stand trial, if he/she understands the proceedings and can rationally deal with his/her lawyer. This is often broadly interpreted by psychiatrists whose testimony may persuade a court that a party is too psychotic to be tried. If the court finds incompetency then the defendant may be sent to a state mental facility until such time as he/she regains sanity. At that time a trial may be held, but this is rare. 4) in evidence, "competent" means "relevant" and/or "material". Lawyers often make the objection to evidence: "incompetent, irrelevant and immaterial" to cover all bases. (See: evidence) http://legal-dictionary.thefreedictionary.com/Competent

33. Right to Information • Access to all records about the person • Medical record • Contracts • Incident reports (never documented in the patient’s chart) • Financial records • The person has the right to be fully informed of his or her health condition. • The person must also have information about his or her doctor.

34. Refusing Treatment • The person has the right to refuse treatment. • A person refusing treatment cannot be treated against his or her wishes. • Advance directives are part of the right to refuse treatment. • Living wills • Instructions about life support • Report treatment refusal to the nurse. • The person’s care plan may be changed.

35. Privacy and Confidentiality • Residents have the right to personal privacy. • Staff must provide care in a manner that maintains privacy of the person’s body. • The residents have the right to visit with others in private. • Residents have the right to make phone calls in private. • The right to privacy Health Insurance Portability and Accountability Act – HIPPA standards • Student HIPPA Violation YouTube: https://youtu.be/yhjhZ_unHy0 • Rite Aid Settlement: https://youtu.be/HuRyh1kh9KY • HIPPA • Who is covered • What information is protected • Refer to Handout

36. 11. Explain HIPAA and related terms • Define the following terms: • HIPAA (Health Insurance Portability and Accountability Act) • a federal law that sets standards for protecting the privacy of patients’ health information. • protected health information (PHI) • information that can be used to identify a person and relates to the patient’s past, present, or future physical or mental condition, including any health care that patient has had, or payment for that health care. • invasion of privacy • a violation of the right to be left alone and the right to control personal information.

37. 11. Explain HIPAA and related terms • The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996. This law sets standards for protecting the privacy of patients’ health information. • It identifies certain protected health information (PHI) that must remain confidential.

38. 11. Explain HIPAA and related terms • HITECH (Health Information Technology for Economic and Clinical Health) became law at the end of 2009. It is a way to expand the protection of electronic health records (EHR). • The HITECH Act increases civil and criminal penalties for sharing PHI and expands the ability to enforce these penalties.

39. 11. Explain HIPAA and related terms • Remember these ways that NAs can keep PHI confidential: • Do not give out health information on the phone except to approved staff members. • Do not give personal information to visitors. • Do not share medical records with anyone other than the care team. • Do not discuss residents in public areas. • Do not bring family or friends to the facility. • Double-check fax numbers and use cover sheets. • Return charts to proper place after use. • Dispose of personal notes regarding resident care prior to leaving work for the day.

40. 11. Explain HIPAA and related terms • Ways that NAs can keep PHI confidential (cont’d): • Log out and exit web browser when finished with computer work. • Do not include private information in e-mails. • Do not share resident information on any social networking site (e.g., Facebook or Twitter). • Do not takes photos of residents and share them with anyone, including via cell phones, e-mail, social networking sites, or other websites. • Give documents found with resident’s information to the nurse.

41. 11. Explain HIPAA and related terms • REMEMBER: • There are serious penalties, including fines and even prison time, for not following HIPAA guidelines.

42. HIPPA Privacy Summary

43. Personal Choice • Residents have the right to make their own choices. • Choosing their own doctors • Taking part in planning and deciding about their care and treatment • Choosing activities, schedules, and care based on their preferences • Personal choice promotes quality of life, dignity, and self-respect.

44. Grievances • Residents have the right to voice concerns, questions, and complaints about treatment or care. • Problem may involve another person. • Problem may be about care given or not given. • The center must promptly try to correct the matter. • No one can punish the person in any way for voicing the grievance.

45. Work • The person has the right to work or perform services if he or she wants to. • He or she does not work for care, care items, or other things or privileges. • Other persons need work for rehabilitation or activity reasons. • Some people like to garden, repair or build things, clean, sew, mend, or cook. • Residents volunteer or are paid for their services.

46. Taking Part in Resident Groups • The person has the right to form and take part in resident groups. They can: • Discuss concerns and suggest center improvements. • Support each other. • Plan activities. • Take part in educational activities.

47. Personal Items • Residents have the right to keep and use personal items. • Type and amount depend on space needs and the health and safety of others • Treat the person’s property with care and respect. • The center must investigate reports of lost, stolen, or damaged items. • The person’s property is protected. • Do not go through a person’s property without his or her knowledge and consent.

48. Freedom from Abuse, Mistreatment, and Neglect • Residents have the right to be free from verbal, sexual, physical, and mental abuse. They also have the right to be free from involuntary seclusion. • No one can abuse, neglect, or mistreat a resident. • Nursing centers must investigate suspected or reported cases of abuse.

49. Freedom From Restraint • Residents have the right not to have body movements restricted. • Restraints • Drugs • Restraints may be used only if required to treat the person’s medical symptoms. • Doctor’s order is needed.

50. Quality of Life • Residents have the right to quality of life. • Protecting this right promotes quality of life and shows respect for the person. • Residents must be cared for in a manner and setting that promote dignity and respect for self.