WEBVTT 00:00:10.420 --> 00:00:11.380 position:50% align:middle Welcome. 00:00:11.380 --> 00:00:13.450 position:50% align:middle Glad to have you on this voyage. 00:00:13.450 --> 00:00:18.180 position:50% align:middle I'm Lauren Papillion, and we are navigating through the APRN 00:00:18.180 --> 00:00:20.450 position:50% align:middle license discipline process. 00:00:20.450 --> 00:00:26.920 position:50% align:middle We are going to cover the board and its jurisdiction, the complaint and investigation process, 00:00:26.920 --> 00:00:29.470 position:50% align:middle discipline and alternatives to discipline. 00:00:29.470 --> 00:00:35.180 position:50% align:middle The post-discipline process, and along the way and at the end we will have other 00:00:35.180 --> 00:00:37.540 position:50% align:middle examples and discussion. 00:00:37.540 --> 00:00:43.180 position:50% align:middle I don't want to go overboard with the navigational theme, but I do like the analogy of a ship, 00:00:43.180 --> 00:00:45.410 position:50% align:middle which is a tangible piece of property. 00:00:45.410 --> 00:00:48.370 position:50% align:middle You can own a vehicle to get around. 00:00:48.370 --> 00:00:54.150 position:50% align:middle You have a property right in your APRN license distinct from the RN license, 00:00:54.150 --> 00:01:00.000 position:50% align:middle and you should keep these licenses well maintained so you can keep smooth sailing through your advanced 00:01:00.000 --> 00:01:02.250 position:50% align:middle practice registered nursing. 00:01:02.250 --> 00:01:07.300 position:50% align:middle If your license is like a ship, who is the captain of the ship? 00:01:07.300 --> 00:01:09.480 position:50% align:middle You, the licensee. 00:01:09.480 --> 00:01:16.750 position:50% align:middle The board issues the license and enforces the law, but it is the APRN's responsibility to know the law 00:01:16.750 --> 00:01:21.980 position:50% align:middle that applies to his or her license and to avoid the need for discipline. 00:01:21.980 --> 00:01:29.730 position:50% align:middle If you do become the target of an investigation, knowing the APRN license discipline process will help 00:01:29.730 --> 00:01:36.730 position:50% align:middle you either avoid or minimize discipline and if disciplined, to make the appropriate repair to your 00:01:36.730 --> 00:01:41.660 position:50% align:middle license so you can resume safe and competent practice. 00:01:41.660 --> 00:01:50.560 position:50% align:middle When navigating license discipline, always consider the benefit of legal counsel. 00:01:50.560 --> 00:01:56.580 position:50% align:middle You may think of boards of nursing as scary creatures of the deep but boards are really just 00:01:56.580 --> 00:01:58.570 position:50% align:middle creatures of statute. 00:01:58.570 --> 00:02:00.340 position:50% align:middle What does that mean? 00:02:00.340 --> 00:02:08.600 position:50% align:middle The state legislature passes an enabling statute or act that creates the board defining its membership, 00:02:08.600 --> 00:02:14.540 position:50% align:middle jurisdiction, powers, rulemaking authority, and other activities. 00:02:14.540 --> 00:02:22.660 position:50% align:middle Most everything the board does is limited to what is authorized in its practice act and in the board's own 00:02:22.660 --> 00:02:29.310 position:50% align:middle rules and regulations which are promulgated under that statutory authority. 00:02:29.310 --> 00:02:36.270 position:50% align:middle Rulemaking authority is critical to the work of the board because much of the specifics of the disciplinary 00:02:36.270 --> 00:02:42.060 position:50% align:middle process is going to be in the rules and not the Practice Act itself. 00:02:42.060 --> 00:02:47.840 position:50% align:middle When it comes to navigating discipline, this can be a powerful tool for an APRN. 00:02:47.840 --> 00:02:55.330 position:50% align:middle If the board goes outside of its Practice Act authority or any other legal authority that applies to the board, 00:02:55.330 --> 00:02:59.570 position:50% align:middle such as the Administrative Procedure Act or the Constitution. 00:02:59.570 --> 00:03:07.850 position:50% align:middle This could potentially void or delay the agency's action or some other consequence to the agency. 00:03:07.850 --> 00:03:15.740 position:50% align:middle I've had many APRNs ask me why the board thinks it can do what it's doing, and I'm always prepared to point 00:03:15.740 --> 00:03:18.770 position:50% align:middle to the source of the board's authority. 00:03:18.770 --> 00:03:21.850 position:50% align:middle Our enabling statute is like a map. 00:03:21.850 --> 00:03:27.170 position:50% align:middle We need to be able to find our authority somewhere on there. 00:03:27.170 --> 00:03:34.140 position:50% align:middle Boards generally want to be compliant if it's brought to the board's attention that we are off the map 00:03:34.140 --> 00:03:40.530 position:50% align:middle in an area outside our authority, the board will want to get back within its authority. 00:03:40.530 --> 00:03:47.430 position:50% align:middle For example, title protection is an issue that's come up recently in my jurisdiction. 00:03:47.430 --> 00:03:53.350 position:50% align:middle Our statute does not provide title protection, so the board does not enforce this. 00:03:53.350 --> 00:04:00.090 position:50% align:middle Should the legislature amend the act to provide title protection, the board will start enforcing it. 00:04:00.090 --> 00:04:04.040 position:50% align:middle As the law changes, the board follows. 00:04:04.040 --> 00:04:10.170 position:50% align:middle Employment issues and business operations are often outside the jurisdiction of the board. 00:04:10.170 --> 00:04:16.730 position:50% align:middle APRNs may own or operate businesses, including healthcare-related businesses, 00:04:16.730 --> 00:04:26.100 position:50% align:middle but complaints made against an APRN related to the ownership or operation of that business may or may not 00:04:26.100 --> 00:04:30.954 position:50% align:middle be within the board's jurisdiction, depending on the nature of the complaint 00:04:30.954 --> 00:04:32.350 position:50% align:middle and the conduct. 00:04:32.350 --> 00:04:39.900 position:50% align:middle If the complaint of conduct is not related to nursing practice, the board may not be the proper 00:04:39.900 --> 00:04:41.830 position:50% align:middle authority to discipline. 00:04:41.830 --> 00:04:50.690 position:50% align:middle Even if the activities do appear to violate some other law or regulation, the board may need to close its 00:04:50.690 --> 00:04:57.460 position:50% align:middle complaint and refer the matter to another agency that has jurisdiction. 00:04:57.460 --> 00:05:04.470 position:50% align:middle Many jurisdictions like mine have a statement of purpose or legislative intent in their act. 00:05:04.470 --> 00:05:07.370 position:50% align:middle This is so important to the work of the board. 00:05:07.370 --> 00:05:13.580 position:50% align:middle We know that practice standards evolve and the law and rules should be updated as needed. 00:05:13.580 --> 00:05:19.040 position:50% align:middle But agencies will have a certain amount of discretion in applying discipline. 00:05:19.040 --> 00:05:27.330 position:50% align:middle The Legislature's statement of intent helps the agency focus on applying that discretion consistently 00:05:27.330 --> 00:05:30.750 position:50% align:middle toward this defined public purpose. 00:05:30.750 --> 00:05:40.120 position:50% align:middle For example, we received a complaint from an employer against an APRN for an alleged boundary violation, 00:05:40.120 --> 00:05:42.850 position:50% align:middle something the board takes very seriously. 00:05:42.850 --> 00:05:51.740 position:50% align:middle But here the complaint was primarily based on the APRN breaching an employment contract between the APRN and 00:05:51.740 --> 00:06:00.000 position:50% align:middle the employer, where the APRN agreed not to have a relationship with any current obviously, 00:06:00.000 --> 00:06:07.750 position:50% align:middle but also former patients and don't want to get into too many specifics. 00:06:07.750 --> 00:06:19.500 position:50% align:middle But the definition of former patient was very broad and included a defined number of years after discharge. 00:06:19.500 --> 00:06:23.790 position:50% align:middle It is not the role of the board to enforce employment contracts. 00:06:23.790 --> 00:06:32.300 position:50% align:middle If the employer terminates the APRN based on breach of contract, that's a matter of employment law. 00:06:32.300 --> 00:06:39.140 position:50% align:middle However, employer policies and procedures do often align with practice standards. 00:06:39.140 --> 00:06:44.830 position:50% align:middle So we do give these violations due consideration. 00:06:44.830 --> 00:06:50.380 position:50% align:middle But here the board looked to its own rule defining boundary violations, 00:06:50.380 --> 00:06:54.550 position:50% align:middle which did not specify a specific length of time. 00:06:54.550 --> 00:06:58.510 position:50% align:middle The board, of course, considered the length of time since discharge, 00:06:58.510 --> 00:07:02.640 position:50% align:middle which was several years, but short of the number of years required 00:07:02.640 --> 00:07:08.630 position:50% align:middle by the contract, there was no indication of romantic involvement during treatment, 00:07:08.630 --> 00:07:12.820 position:50% align:middle and the APRN was not the primary treatment provider for this patient. 00:07:12.820 --> 00:07:19.080 position:50% align:middle Signing off on some charts, but no real substantive treatment and the patient did 00:07:19.080 --> 00:07:22.890 position:50% align:middle not appear to be negatively impacted in any way. 00:07:22.890 --> 00:07:28.890 position:50% align:middle We did consider that the APRN had agreed to this term in a private employment contract, 00:07:28.890 --> 00:07:36.610 position:50% align:middle but legislative intent instructs the board to regulate in the public interest and ultimately there was not a 00:07:36.610 --> 00:07:43.410 position:50% align:middle sufficiently compelling public interest to discipline this specific conduct. 00:07:43.410 --> 00:07:49.270 position:50% align:middle Let's discuss the complaint and investigation process. 00:07:49.270 --> 00:07:54.260 position:50% align:middle Most investigations began when the board receives a complaint. 00:07:54.260 --> 00:08:00.090 position:50% align:middle It is a passive process in the sense that the information needs to come to the board. 00:08:00.090 --> 00:08:07.650 position:50% align:middle Complaints come from all types of sources, patients, employers, health department, law enforcement, 00:08:07.650 --> 00:08:12.900 position:50% align:middle and oftentimes from the APRN, who may be required to self-report. 00:08:12.900 --> 00:08:19.090 position:50% align:middle Complaints filed with my board must be in writing but may be anonymous. 00:08:19.090 --> 00:08:23.060 position:50% align:middle Form requirements vary by jurisdiction. 00:08:23.060 --> 00:08:27.270 position:50% align:middle All complaints go through a screening process. 00:08:27.270 --> 00:08:35.350 position:50% align:middle We look at the complaint and whether if we can prove the conduct, would it even be a nurse 00:08:35.350 --> 00:08:39.290 position:50% align:middle practice act violation? 00:08:39.290 --> 00:08:45.170 position:50% align:middle And if we can prove it, is it sufficiently serious to warrant discipline? 00:08:45.170 --> 00:08:51.650 position:50% align:middle Many complaints are closed with an ending letter or an informal warning letter. 00:08:51.650 --> 00:08:59.320 position:50% align:middle If the board opens a formal investigation, the matter is assigned to an investigator and given a 00:08:59.320 --> 00:09:04.980 position:50% align:middle priority level, which is largely based on the risk of harm to the public. 00:09:04.980 --> 00:09:13.940 position:50% align:middle Lower-priority investigations often have longer deadlines to close, but this may not be ideal for the 00:09:13.940 --> 00:09:17.260 position:50% align:middle APRN under investigation. 00:09:17.260 --> 00:09:26.240 position:50% align:middle I suggest working cooperatively with the assigned investigator to see if you can constructively help 00:09:26.240 --> 00:09:30.160 position:50% align:middle to get the investigator what he or she needs to complete the investigation. 00:09:30.160 --> 00:09:38.670 position:50% align:middle During the formal investigation, the APRN has due process rights and also obligations 00:09:38.670 --> 00:09:39.370 position:50% align:middle to the board. 00:09:39.370 --> 00:09:47.570 position:50% align:middle The APRN has a right to notice of the alleged violation and to review the evidence at the appropriate time so 00:09:47.570 --> 00:09:54.160 position:50% align:middle the APRN can respond, and there may be an affirmative duty to provide a 00:09:54.160 --> 00:10:00.070 position:50% align:middle response to the board and to keep the board updated with a current address. 00:10:00.070 --> 00:10:10.890 position:50% align:middle There may also be obligations on other licensee witnesses to cooperate with a board investigation. 00:10:10.890 --> 00:10:15.560 position:50% align:middle At the end of the investigation, the investigator will prepare a report of his 00:10:15.560 --> 00:10:18.070 position:50% align:middle or her findings. 00:10:18.070 --> 00:10:25.470 position:50% align:middle This goes through more layers of review to decide whether to pursue discipline or close 00:10:25.470 --> 00:10:33.790 position:50% align:middle without discipline, either because the violation is not substantiated or the board has elected to issue 00:10:33.790 --> 00:10:37.660 position:50% align:middle an informal warning or letter of concern. 00:10:37.660 --> 00:10:43.040 position:50% align:middle After a certain amount of time, the ability to bring a claim or prosecution 00:10:43.040 --> 00:10:44.480 position:50% align:middle can be barred. 00:10:44.480 --> 00:10:51.900 position:50% align:middle Criminal, civil, and administrative actions can all have time limits, or they can have no time 00:10:51.900 --> 00:10:53.270 position:50% align:middle limit at all. 00:10:53.270 --> 00:10:56.790 position:50% align:middle It depends on the jurisdiction. 00:10:56.790 --> 00:11:03.900 position:50% align:middle For instance, medical malpractice payouts often come to the board's attention years after the incident date, 00:11:03.900 --> 00:11:10.000 position:50% align:middle an APRNs will often take issue with how much time has passed since the incident and the 00:11:10.000 --> 00:11:16.950 position:50% align:middle board's investigation, but usually, a lot less time has passed since the board received 00:11:16.950 --> 00:11:21.010 position:50% align:middle notice of the incident and when it started its investigation. 00:11:21.010 --> 00:11:26.390 position:50% align:middle And the board has a right to investigate potential Nurse Practice Act violations, 00:11:26.390 --> 00:11:28.860 position:50% align:middle including medical malpractice complaints. 00:11:28.860 --> 00:11:37.570 position:50% align:middle On when to disclose a reportable event, most APRNs report during the renewal process, 00:11:37.570 --> 00:11:40.670 position:50% align:middle but there can be a benefit to reporting early. 00:11:40.670 --> 00:11:47.130 position:50% align:middle I recommend consulting an attorney to discuss the risks and benefits of when to report, 00:11:47.130 --> 00:11:51.570 position:50% align:middle but please don't fail to report that is never the right choice. 00:11:51.570 --> 00:12:01.390 position:50% align:middle Now, if the complaint has been substantiated, we move on to discipline or alternatives to discipline. 00:12:01.390 --> 00:12:05.850 position:50% align:middle When there is discipline, the discipline will be described in a written, 00:12:05.850 --> 00:12:10.230 position:50% align:middle publicly available document forever attached to the license. 00:12:10.230 --> 00:12:17.450 position:50% align:middle APRNs should look at every word in that document to make sure it is trimmed and tailored as best as the 00:12:17.450 --> 00:12:20.090 position:50% align:middle APRN can negotiate. 00:12:20.090 --> 00:12:25.350 position:50% align:middle The document will describe the factual findings, the level of discipline, 00:12:25.350 --> 00:12:31.910 position:50% align:middle and other sanctions and stipulations such as fines and practice restrictions. 00:12:31.910 --> 00:12:39.530 position:50% align:middle Discipline will be reported to nurses and that code and narrative description can also be a point of discussion 00:12:39.530 --> 00:12:41.400 position:50% align:middle with the board. 00:12:41.400 --> 00:12:51.100 position:50% align:middle Discipline can be on the RN license or the APRN license or the board could agree to dispose of the matter 00:12:51.100 --> 00:12:56.150 position:50% align:middle with an informal warning or letter of concern, which is not discipline, 00:12:56.150 --> 00:13:02.450 position:50% align:middle but it is a record of the board and can be used in future board proceedings. 00:13:02.450 --> 00:13:09.740 position:50% align:middle If the board has an alternative to discipline program and if the APRN meets criteria, 00:13:09.740 --> 00:13:11.980 position:50% align:middle that can be an option also. 00:13:11.980 --> 00:13:17.630 position:50% align:middle If the board staff and the APRN can negotiate a settlement agreement, 00:13:17.630 --> 00:13:23.960 position:50% align:middle that document will go to the board for ratification and there will be no right to appeal. 00:13:23.960 --> 00:13:31.900 position:50% align:middle Before signing any consent order or settlement agreement, the APRN may want to discuss the proposed 00:13:31.900 --> 00:13:38.620 position:50% align:middle discipline with his or her employer to know whether there will be any adverse employment outcomes. 00:13:38.620 --> 00:13:45.060 position:50% align:middle The opportunity to make changes to the board order is before it is signed and becomes a contract 00:13:45.060 --> 00:13:46.730 position:50% align:middle with the board. 00:13:46.730 --> 00:13:52.490 position:50% align:middle After that, it's a matter between the APRN and his or her employer. 00:13:52.490 --> 00:13:56.620 position:50% align:middle If the parties can't agree, the matter will be set for administrative hearing. 00:13:56.620 --> 00:14:01.850 position:50% align:middle The rules of evidence and the burden of proof will vary by jurisdiction. 00:14:01.850 --> 00:14:03.810 position:50% align:middle Know what those are. 00:14:03.810 --> 00:14:08.750 position:50% align:middle There will be a cost structure for the hearing, so know what you are fighting about before you 00:14:08.750 --> 00:14:09.470 position:50% align:middle get to hearing. 00:14:09.470 --> 00:14:18.020 position:50% align:middle An APRN may want to consider admitting to certain facts that are not in dispute and are not central to what the 00:14:18.020 --> 00:14:20.700 position:50% align:middle APRN is asking of the board. 00:14:20.700 --> 00:14:28.310 position:50% align:middle Know also if your jurisdiction allows parties to present proposed orders to the board and if so, 00:14:28.310 --> 00:14:32.550 position:50% align:middle consider preparing one and presenting that to the board. 00:14:32.550 --> 00:14:40.800 position:50% align:middle After a hearing, an APRN will have a right of appeal, with or without the need to exhaust administrative 00:14:40.800 --> 00:14:44.660 position:50% align:middle remedies depending on the jurisdiction. 00:14:44.660 --> 00:14:52.480 position:50% align:middle Administrative remedies can include asking the board itself to reconsider the decision it made. 00:14:52.480 --> 00:15:00.630 position:50% align:middle The Alternative to Discipline program is used when the APRN is in violation of the Nurse Practice Act and 00:15:00.630 --> 00:15:08.240 position:50% align:middle could be disciplined but is allowed into a non-disciplinary program providing monitoring structure 00:15:08.240 --> 00:15:12.610 position:50% align:middle and support for safe reentry into practice. 00:15:12.610 --> 00:15:20.100 position:50% align:middle It is non-disciplinary as long as the APRN is compliant with the program requirements. 00:15:20.100 --> 00:15:29.640 position:50% align:middle Entry into alternative to discipline can include substance use disorders and also sometimes medical, 00:15:29.640 --> 00:15:32.830 position:50% align:middle mental, and physical disorders. 00:15:32.830 --> 00:15:38.450 position:50% align:middle Many nurse practice act violations involve alcohol or drug-related conduct. 00:15:38.450 --> 00:15:41.440 position:50% align:middle So want to discuss those a little bit separately. 00:15:41.440 --> 00:15:48.050 position:50% align:middle These violations can be handled through discipline, alternatives to discipline, 00:15:48.050 --> 00:15:53.760 position:50% align:middle or even with a non-disciplinary warning letter. 00:15:53.760 --> 00:16:01.150 position:50% align:middle Many participants in the Alternative to Discipline program have substance use disorders. 00:16:01.150 --> 00:16:11.350 position:50% align:middle The board looks at all levels of conduct on duty, off duty, and also pre-licensure activity and events 00:16:11.350 --> 00:16:16.580 position:50% align:middle that occurred during periods of lapsed licensure. 00:16:16.580 --> 00:16:21.770 position:50% align:middle Substance use disorder is something the board takes very seriously. 00:16:21.770 --> 00:16:22.940 position:50% align:middle Host discipline. 00:16:22.940 --> 00:16:31.210 position:50% align:middle The best advice I can give is to be compliant and work with the case manager on any issues that arise 00:16:31.210 --> 00:16:34.550 position:50% align:middle in the post-discipline period. 00:16:34.550 --> 00:16:43.150 position:50% align:middle If both licenses are encumbered, the RN license and the APRN license with probation or 00:16:43.150 --> 00:16:50.980 position:50% align:middle other stipulations, those restrictions are likely to be removed in a progressive fashion. 00:16:50.980 --> 00:16:58.150 position:50% align:middle Being removed from the RN license first and at intervals and after a period of compliance 00:16:58.150 --> 00:17:00.290 position:50% align:middle at each stage. 00:17:00.290 --> 00:17:07.380 position:50% align:middle At the end, the APRN can hope to have both licenses fully restored. 00:17:07.380 --> 00:17:12.760 position:50% align:middle Boards will often use outside evaluators to give recommendations. 00:17:12.760 --> 00:17:19.650 position:50% align:middle Those evaluators must be approved by the board based on certain criteria set by the board, 00:17:19.650 --> 00:17:28.790 position:50% align:middle mostly to ensure the evaluators understand the demands and nuances of occupational licensure and 00:17:28.790 --> 00:17:39.050 position:50% align:middle nursing practice, and that these evaluators have education and training in substance use and addiction. 00:17:39.050 --> 00:17:42.040 position:50% align:middle Common probation stipulations. 00:17:42.040 --> 00:17:47.705 position:50% align:middle Work restrictions are often seen with probated licenses. 00:17:47.705 --> 00:17:55.840 position:50% align:middle The APRN may be required to have an employer agreement and the employer may be submitting performance reports 00:17:55.840 --> 00:17:58.180 position:50% align:middle to the board. 00:17:58.180 --> 00:18:06.230 position:50% align:middle There are often restrictions on handling controlled substances, restrictions on practice settings such 00:18:06.230 --> 00:18:09.140 position:50% align:middle as home health and hospice. 00:18:09.140 --> 00:18:15.870 position:50% align:middle Restrictions on time of practice, such as night shifts and overnight shifts. 00:18:15.870 --> 00:18:25.460 position:50% align:middle Restrictions on holding management roles such as charge nurse or supervising other nurses. 00:18:25.460 --> 00:18:35.120 position:50% align:middle Direct supervision is another common requirement, and this is the biggest concern for APRNs 00:18:35.120 --> 00:18:37.410 position:50% align:middle we have found. 00:18:37.410 --> 00:18:45.190 position:50% align:middle We have at least 100, I'd say APRNs working in my jurisdiction with some kind 00:18:45.190 --> 00:18:51.370 position:50% align:middle of employment agreement in place for direct supervision. 00:18:51.370 --> 00:18:57.570 position:50% align:middle We have found that any APRN who wants to work with the probated license is able to do so. 00:18:57.570 --> 00:19:06.900 position:50% align:middle But it is true that some APRNs may not be able to continue in their current position if that current 00:19:06.900 --> 00:19:12.880 position:50% align:middle position is unable to provide direct supervision. 00:19:12.880 --> 00:19:22.700 position:50% align:middle Other common probation stipulations include drug and alcohol screening, continuing education requirements. 00:19:22.700 --> 00:19:31.750 position:50% align:middle As for the term of these stipulations, they can either be for a set period of time or they can 00:19:31.750 --> 00:19:42.840 position:50% align:middle be indefinite and the APRN must return to the board and request the removal of the restriction and show cause 00:19:42.840 --> 00:19:46.380 position:50% align:middle for why that restriction should be removed. 00:19:46.380 --> 00:19:53.700 position:50% align:middle Scope of practice and prescriptive authority are two major areas where we see and discipline. 00:19:53.700 --> 00:20:00.590 position:50% align:middle In some states, prescriptive authority is included with APRN licensure, and in other states it must be 00:20:00.590 --> 00:20:03.070 position:50% align:middle applied for separately. 00:20:03.070 --> 00:20:09.790 position:50% align:middle Know also that prescriptive authority will include diagnosis and treatment. 00:20:09.790 --> 00:20:14.280 position:50% align:middle It is not just writing medication prescriptions. 00:20:14.280 --> 00:20:22.600 position:50% align:middle I have two cases I would like to discuss highlighting the scope of practice concerns that the 00:20:22.600 --> 00:20:25.800 position:50% align:middle board deals with. 00:20:25.800 --> 00:20:32.980 position:50% align:middle In the first case, an APRN was reported to the board by DEA for being a top prescriber. 00:20:32.980 --> 00:20:43.240 position:50% align:middle The APRN was prescribing narcotics at a high level above those of even some oncologists and was also 00:20:43.240 --> 00:20:53.540 position:50% align:middle prescribing ADHD medications to a large volume of patients, including patients under five years. 00:20:53.540 --> 00:20:59.970 position:50% align:middle In evaluating the case, the board looked at the APRN's specialty here, 00:20:59.970 --> 00:21:02.140 position:50% align:middle a family nurse practitioner. 00:21:02.140 --> 00:21:10.980 position:50% align:middle The board looked at whether the APRN had any additional training or expertise in the areas. 00:21:10.980 --> 00:21:18.340 position:50% align:middle This APRN was very actively prescribing and that was not found to be the case. 00:21:18.340 --> 00:21:27.990 position:50% align:middle The board also looked at the documentation this APRN was making and whether that documentation supported the 00:21:27.990 --> 00:21:33.350 position:50% align:middle decision-making for these patients and that was not found. 00:21:33.350 --> 00:21:43.650 position:50% align:middle In fact, the documentation in the chart was very scant, very little, very little charting. 00:21:43.650 --> 00:21:52.190 position:50% align:middle In the second case, the APRN was reported anonymously to the board. 00:21:52.190 --> 00:21:59.510 position:50% align:middle And when investigated, the violations described by the anonymous complainant 00:21:59.510 --> 00:22:03.760 position:50% align:middle in the complaint were not substantiated. 00:22:03.760 --> 00:22:11.200 position:50% align:middle However, during the investigation, it was discovered that the APRN had written a 00:22:11.200 --> 00:22:16.870 position:50% align:middle non-narcotic controlled substance for chronic pain. 00:22:16.870 --> 00:22:25.670 position:50% align:middle In our state, APRNs are prohibited from treating obesity or chronic pain or prescribing controlled 00:22:25.670 --> 00:22:32.790 position:50% align:middle substances for chronic pain, and that is regardless of the education and experience 00:22:32.790 --> 00:22:35.040 position:50% align:middle of the APRN. 00:22:35.040 --> 00:22:42.720 position:50% align:middle This is something that in our state is defined in our rules. 00:22:42.720 --> 00:22:49.440 position:50% align:middle And so, that is another takeaway APRNs need to be aware of. 00:22:49.440 --> 00:22:54.820 position:50% align:middle So here in our state, APRNs are not permitted to prescribe controlled 00:22:54.820 --> 00:23:02.380 position:50% align:middle substances for chronic pain, and thus it was a violation by this APRN to have 00:23:02.380 --> 00:23:11.030 position:50% align:middle treated this patient with controlled substances for chronic pain. 00:23:11.030 --> 00:23:21.510 position:50% align:middle Again, the board looked at the documentation for this APRN and all the charts were in fact very 00:23:21.510 --> 00:23:27.200 position:50% align:middle excellently documented, including the chart for this patient. 00:23:27.200 --> 00:23:33.160 position:50% align:middle So, in the first case, that's a higher degree of concern for the board. 00:23:33.160 --> 00:23:44.320 position:50% align:middle It shows a systemic practice of this APRN and will likely result in a much higher level of discipline, 00:23:44.320 --> 00:23:48.040 position:50% align:middle likely probation at a minimum. 00:23:48.040 --> 00:23:53.530 position:50% align:middle The second case is a violation and is of concern to the board. 00:23:53.530 --> 00:24:00.000 position:50% align:middle But this APRN will be much more successful in negotiating with the board on the issue of discipline. 00:24:00.000 --> 00:24:07.540 position:50% align:middle There are several mitigating factors that this APRN can bring to the board's attention, 00:24:07.540 --> 00:24:18.040 position:50% align:middle and something like probation may not be necessary for a nurse who has only been found to have deviated for one 00:24:18.040 --> 00:24:24.820 position:50% align:middle patient and something that their training and experience may support. 00:24:24.820 --> 00:24:33.450 position:50% align:middle But the practice scope of practice and our state does not allow them to treat to their 00:24:33.450 --> 00:24:35.460 position:50% align:middle full practice authority. 00:24:35.460 --> 00:24:44.160 position:50% align:middle So again, be very cognizant of the rules of each state and whether scope of practice is limited, 00:24:44.160 --> 00:24:52.540 position:50% align:middle not just by education and training, but also by the specific rules and requirements 00:24:52.540 --> 00:24:56.950 position:50% align:middle of each practice jurisdiction. 00:24:56.950 --> 00:24:59.500 position:50% align:middle We have reached the end of our voyage. 00:24:59.500 --> 00:25:02.687 position:50% align:middle I'll be available live to answer any questions you may have.