Trends and Cases in Board of Nursing Actions
Loretta D’Antonio Nurses Service Organization May 20, 2014
Objectives
•Review License Protection defense coverage
•Review license defense claims data for RNs, LPNs and APRNS
•Review complaint allegations for RNs, LPNs and APRNs
•Discuss nursing board outcomes for top allegations
•Review case studies by specialty
•Identify risk control measures to reduce complaints
NSO Policy License Defense Coverage
• “We will pay you up to the License Protection limit of liability stated on the certificate of insurance, for attorney fees incurred by you, for your investigation and defense of complaints. Such complaints must:
▫ arise from a license protection incident which occurred on or after the effective date of coverage, and before the expiration date of the policy period stated on the certificate of insurance; and
▫ be filed against you with a state or federal administrative agency, licensing or regulatory authority responsible for regulating your professional conduct.”
How it works
•Includes medical and non-medical incidents •Up to limits of $25,000 per hearing
•Incident must occur during an active policy year •Attorney hourly fee cap = $200/hr
•Nurse or APRN insured can choose their own attorney unlike a PL claim
Who can file a complaint?
•Patient
•Patient’s family member
•Colleague
•Employer
•Another regulatory panel
NSO Program
RN/LPN/LVN License Defense Claims Data
(1998 – 2013)
Licensure Incidents reported Total Paid Claims Total Legal Expense Paid Average Payment RN 7,729 2,556 8,355,272 3,269 LPN/LVN 1,805 511 1,483,005 2,902 % Paid 33.1% 28.3%If the RN did not have an NSO policy, the cost to defend the nurse before the board would have been 37% higher.
RN/LPN Incidents and Paid Claim Trends
76 303 310 343 479 579 454 569 555 624 721739 634 487516 582 1 15 60 94 138 202 175 185 189 214 190 245 208 232 216242 0 100 200 300 400 500 600 700 800 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 Reported Paid
Average Defense Expense Payment Trend
1,665 1,328 2,298 2,154 2,565 2,674 2,434 3,291 3,682 3,423 3,075 3,303 3,383 3,306 4,116 4,592 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 Average Payment
APRN Program License Defense Claims Data
(1998 – 2013)
Incidents reported Total Paid Claims Total Legal Expense Paid Average Payment 826 288 1,199,565 4,165 % Paid 34.9%If the APRN did not have an NSO policy providing license defense coverage, the cost to defend the nurse before the board would have been 62% higher.
APRN Incidents and Paid Claim Trends
1 5 16 14 18 44 42 41 55 56 69 73 83 67 79 87 95 1 4 7 6 15 6 25 17 17 27 35 36 26 35 39 -20 0 20 40 60 80 100 120 '97'98'99 '00'01'02'03 '04'05'06'07'08 '09'10'11'12 '13 Reported Paid
APRN Average Payment Trend
2,320 1,043 2,145 3,562 3,100 1,824 3,149 4,302 3,599 3,728 4,538 4,976 4,259 5,254 4,935 0 1,000 2,000 3,000 4,000 5,000 6,000 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 '13 Average Payment
NSO Program - Top allegations by licensure
Ranking LPN/LVN RN APRN
1 Improper Treatment /Care
Medication Errors Improper Treatment/Care 2 Medication Errors Improper Treatment /Care Abuse – Drug Diversion Patient’s Rights 3 Abuse – Drug Diversion Patient’s Rights Abuse – Drug Diversion Patient’s Rights Medication Errors
Board Outcomes by Top Allegations
– RNs and LPNs/LVNs
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% Improper Treatment/Care Medication Errors Abuse - Patient's Rights/Substance Abuse No Action – 50%Board Outcomes by Top Allegation
- APRNs
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% Improper Treatment/Care Medication Errors Abuse - Patient's Rights/Substance Abuse No Action -- 61.7%Observations
•No definitive trend where LP incident led to PL lawsuit
•Frequency of LP claims is higher than PL claims for RNs
but not APRNs
•Majority of complaints result in a ‘No Action’ decision by
the BON
•Practice location is not a predictor of a complaint
•Complainants include employers, patients, patient’s
family members or significant other, regulatory agencies, co-workers
•Top Allegation outcomes are similar to the overall
outcome distribution
Case Studies
Case Study #1
Practice Setting: Patient Home, Assisted Living Facility Complainant: Patient’s daughter
Registered Nurse 44 years of age Specialty: Care Manager
Allegation(s):
Complaint Background
•Providing services as a Care Manager
•92 year old with co-morbidities including asthma, chronic obstructive pulmonary disease
•Acknowledged by family members as providing superior services to patient
•Care began while patient was still at home and insured helped with transition to Assisted Living Facility
•Pt complained of wheezing because of an asthma flareup.
Continued…
•Apparent discussion with physician about sending pt to the hospital never happened
•Physician claims to have advised our insured to contact family – suspicion that file documentation was modified after patient injury occurred
•Pt was seen pushing wheelchair of another resident to the dining room after the initial incident
•The next day the patient died.
Outcome
•No Action
•Defense Expense = $6,816.00
•If NSO coverage was not in place the defense cost to an uninsured nurse would have been $12,000.
Case Study #2
Practice Setting: Educational Facility Complainant: Students
Registered Nurse 58 years of age Specialty: Nurse Educator
Full set of allegations
•Established a school to provide nursing education including continuing education
•Failed to affiliate with an institution of higher education
•Failed to seek accreditation
•Public communication was deceptive
•False advertising
Outcome
•No Action
•Defense Expense to policy limits of $25,000
•If NSO coverage was not in place the defense cost to an uninsured nurse would have been $48,000.
Case Study #3
Practice Setting: Medical Office Complainant: Multiple Patients APRN: 36 years of age Specialty: Pain Management
Allegation(s):
Failure to treat and charged for services not rendered
Complaint Background
•Timing discrepancies in documentation when patients were to have been seen by NP and billings
•Failed to follow up with and respond to phone calls of patients •Utilized labs for blood work that were not part of the network
where patients would be covered
•Failed to monitor labs to adjust prescribed pain medications •One of the patients was an RN
Outcome
•Letter of Concern •Defense Expense = $4,071
•If NSO coverage was not in place the defense cost to an uninsured nurse would have been $5,500.
Case Study #4
Practice Setting: Medical Office
Complainant: Employer
APRN: 60 years of age
Specialty: Pain Management
Allegation(s):
Prescribing non-FDA approved medications to patients
Complaint Background
•Pattern of cutting and pasting history using a pt history template •Received notice from provider that the PPO and EPO
agreements were terminated
•Billings with no supporting documentation •Appeared before the Health Plan provider panel
Outcome
•No action
•Defense Expense to policy limits at the time = $10,000 •If NSO coverage was not in place the defense cost to an
uninsured nurse would have been $52,000. •# of years to resolve = 2 year
Risk Control Recommendations
•Work continually on communication and interpersonal skills
▫“Seek first to understand then to be understood’
S. Covey – 7 Habits of Highly Effective People
▫‘What story are you telling yourself about the other
person”
Crucial Conversations, Vital Smarts
•Maintain consistent documentation
Risk Control Recommendations
•Follow established procedure
•Deliver clear and timely communication to patients, their families and your colleagues
•Recognize the stressors that may lead to abuse and allegations of unprofessional conduct
•Be proactive in seeking help
•Keep current with changes in the Nurse Practice Act
•Maintain your nursing competencies
•Ensure thorough and accurate documentation in patient care records
▫Who, what, when, where, how and why
Risk Control Recommendations
•What could you add to this list?
Disclaimer
• The purpose of this presentation is to provide general information, rather than advice or opinion. It is accurate to the best of the speaker's knowledge as of the date of the presentation. Accordingly, this presentation should not be viewed as a substitute for the guidance and recommendations of a retained professional and legal counsel. In addition, Aon, Affinity Insurance Services, Inc. (AIS), Nurses Service Organization (NSO) or Healthcare Provider Service Organization (HPSO) do not endorse any coverage, systems, processes or protocols addressed herein unless they are produced or created by AON. AIS, NSO, or HPSO, nor do they assume any liability for how this information is applied in practice or for the accuracy of this information.
• Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and AON, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. To the extent this presentation contains any descriptions of CNA products, please note that all products may not be available in all states. Actual terms, coverage, amounts, conditions and exclusions are governed and controlled by the terms and conditions of the relevant insurance policies. The CNA Professional Liability insurance policy for Nurses and Allied Healthcare Providers is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA Company. CNA is a registered service mark and trade name of CNA Financial Corporation.
• NSO and HPSO are registered trade names of Affinity Insurance Services, Inc., a unit of Aon Corporation. Copyright © 2014, by Affinity Insurance Services, Inc. All rights reserved.
For more information, please contact: Loretta D’Antonio, NSO
Loretta.dantonio@aon.com 215.773.4604 (w)
