A State Board of Nursing (SBON) complaint can be filed against a nurse by a patient, resident, colleague, employer, and/or regulatory agency. Complaints are subsequently investigated by the SBON, with results ranging from no action against the nurse to revocation of the license to practice nursing. This case study involves a registered nurse, who was employed as the registered nurse for a home healthcare agency to provide case management and in-home nursing.
Total Incurred: Greater than $7,500
*Monetary amounts represent the legal expenses paid solely on behalf of the insured registered nurse.
Summary
Our insured registered nurse (RN) was working for a home healthcare agency. The RN had orders from a primary care provider (PCP) to provide skilled home healthcare treatment for a patient with a variety of healthcare concerns (e.g., medication management for new diagnosis of Type 2 diabetes mellitus, congestive heart failure, nutritional education and support, and monitoring vital signs and weight). The insured was scheduled to visit the patient three times a week for 30 days. Over time, the RN developed a close friendship with the patient and patient’s family and gave them her personal mobile telephone number to contact her, if needed.
The patient and family began contacting the RN with various healthcare related concerns, sometimes daily, and requests that she come to the home to assess and/or provide treatment to the patient. The RN was providing various nursing treatments and care nearly seven days a week but would only document the treatment she provided at his scheduled visits.
Over a weekend, the patient experienced an acute episode of urinary retention and sought care in a local emergency department (ED). The patient had a history of benign prostate hyperplasia (BPH) and had been taken off of his BPH medications due to his recent diagnosis of congestive heart failure. After attempting three different types of urinary catheters, the ED staff was finally successful with placing a urinary catheter into patient’s bladder. The patient was discharged from the ED with instructions to restart BPH medications and to keep the urinary catheter until he followed up with his urologist. After the patient arrived home, the family contacted the insured RN and asked if she could come to check on the patient. When the RN arrived, she suggested removing the urinary catheter placed by the ED as it didn’t appear to be draining properly. The patient and his family informed the RN about the difficulty the ED staff had with inserting the urinary catheter but agreed with trying a new catheter, if the insured thought it was necessary. The RN used supplies she kept in her car for home healthcare patients. The ED urinary catheter was removed, but when the RN attempted to insert a new catheter, resistance was encountered with advancing the catheter. After several attempts were made to advance the catheter past the resistance, the RN instructed the patient to go back to the ED.
The patient went to back to the ED and underwent an emergency transurethral resection of the prostate (TURP) procedure by a urologist. The ED staff contacted the insured RN’s employer and informed them of the RN’s actions of removing the patient’s urinary catheter and of attempting to place a new catheter without an order. The ED staff felt that the RN’s actions of removing the catheter were outside her scope of practice and caused further injury to the patient that necessitated an emergency TURP with hospitalization.
The supervisor noted that the RN provided skilled nursing care for over 90 days, despite the PCP’s for only 30 days of skilled care. There was no documentation of a request for the PCP to update the plan of care to provide additional skilled nursing services. The RN’s supervisor learned that the RN had been:
- Providing skilled nursing services without a provider’s order which included:
- Removing a urinary catheter and attempting to place a new catheter; and
- Treating a pressure injury that was not reported to the PCP.
- Failing to document all treatment provided to the patient in the healthcare information record.
- Providing meals and household supplies to the patient, which was not allowed by the employer’s policies and procedures.
- Checking the patient’s blood sugars and administering insulin injections, despite the patient being mentally and physically able to do so himself.
The employer terminated the RN and reported the termination and internal investigation findings to the SBON.
Risk Management Comments
After reviewing the e report and allegations made by the employer, the SBON alleged the following against the insured RN:
- The RN’s conduct was in violation of general duty, consisting of negligence or failure to exercise due care, including negligent delegation to or supervision of employees or other individuals, whether or not injury results (Count I).
- The RN’s conduct was a departure from, or failure to conform to, minimal standards of acceptable and prevailing practice for the health profession, whether or not actual injury to an individual occurs, and accordingly incompetence (Count II).
- The RN’s conduct evidences practicing outside the scope of a RN’s license (Count III).
- The RN’s conduct evidences a failure to keep and maintain a record for each patient for whom the RN has provided medical services, including a full and complete record of tests and examinations performed, observations made, and treatments provided (Count IV).
Resolution
The SBON dismissed Counts II, III, and IV against the RN. The SBON found sufficient evidence for Count I and placed the RN on probation for a minimum of one year, not to exceed three years. The terms of the insured’s probation included the following:
- Employer Reports:
- The nurse must provide any and all employers during the probation period with copies of the SBON consent order.
- The nurse must ensure that all employers submit a quarterly report to the SBON. The nurse’s immediate supervisor is required to submit quarterly reports to the SBON on the RN’s work performance, and, if at any time fails to comply with minimal standards of acceptable and prevailing practice or appears unable to practice with reasonable skill and safety, the supervisor must contact the SBON immediately.
- The nurse must be supervised at all times by a licensed health professional.
- Employment Change:
- The nurse must report all employment changes to the SBON within 15 days of change.
- The nurse must make all new employers aware of the SBON required reports and provide a copy of the consent order.
- Continuing Education Credits (CEUs):
- Within 180 days of the effective date of the consent order, the nurse must successfully complete 15 hours of CEUs. The course hours will not count toward the number of credit hours required for license renewal. The courses include:
- Ethics and Professionalism in Nursing
- Critical Thinking Skills in Nursing
- Clinical Documentation in Nursing
The SBON matter took almost a year to resolve, and expenses incurred to defend the insured nurse in this matter exceeded $7,500.
Risk Management Recommendations
- Know and comply with your facility’s policies, procedures and protocols. Unfamiliarity to established policies and protocols is not a defense, especially if a clinician has acknowledged receiving education on such policies and protocols.
- Ensure healthcare information record documentation is complete, objective, and consistently and accurately reflects clinical assessment and care provided as well as the patient’s responses to that care.
- Document your patient care assessments, observations, communications and actions in an objective, timely, accurate, complete, appropriate and legible manner. Home healthcare nursing documentation should specify:
- The reason skilled nursing is needed.
- Any recent new diagnosis, exacerbation, or hospitalization.
- Changes in the treatment regimen.
- Skilled assessments, actions taken, and treatments performed.
- Specific education provided (what was taught, to whom, learner comprehension, changes to the plan of care).
Disclaimer
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. This material is not for further distribution without the express consent of CNA. Copyright © 2025 CNA. All rights reserved.