▪︎ Case Study with Legal Lessons: BON Charges for Inadequate Nursing Assessment

Nursing Law Center

The Board of Nursing recently filed charges against 2 registered nurses for gross negligence and incompetence for their failure to provide appropriate care for a patient c/o chest pain. Do you think the facts support the charges?

📑 Facts:

RN #1 was employed as the stroke team lead/emergency medical services registered nurse in the emergency department at ABC Medical Center in California. RN #1 was responsible for caring for emergency department stroke patients and assisting the nurse with assessing and monitoring patients upon arrival at the Medical Center. On or about October 1, 2023, the Ambulance District Paramedic R.M. called the Medical Center. In the presence of RN #1, R.M. told the Charge Nurse RN #2 that they had a 60-year-old male with 8 out of 10 chest pain, a heart rate of 131 with a rhythm of sinus tachycardia, and a blood pressure of 150/86. R.M. stated that it was a STAT (urgent) medical visit and he estimated a 10-minute arrival time. RN #2 then asked why they were coming in as STAT. The paramedic responded that the patient had difficulty breathing, was diaphoretic and flushed, and had severe chest pain.

At 1704 hours, R.M. and Emergency Medical Technician D.P. arrived at the Medical Center with the patient, who stated that his ICD had “fired off.” R.M. and D.P. asked that the Patient be roomed immediately, however, RN #1 did not assess the patient and instead, remained at her workstation. Further, RN #1 did not obtain a report on the patient from EAD staff. During the registration process, the patient was placed on a gurney in the hallway against the wall across from RN #1.

At approximately 1707 hours, the patient began to seize, and RN #2 directed the medics to place the patient in a room. RN #1 still did not perform an assessment of the patient at this time, and instead, RN #1 walked in the opposite direction of the patient into a different room.

Once placed in a room, the primary nurse for the patient asked the medic if the patient had a pulse, however, the medic could not find one. CPR was initiated and a “Code”2 was called. It was at this time that the attending physician was notified of patient’s condition. The “Code” was terminated at 1742 hours and the patient did not survive.

🕵️ Interviews by Board of Nursing investigators:

On or about June 27, 2024, during an interview with a Board investigator, when asked if she had prepared for the Patient’s arrival, RN #1 stated that there was nothing to prepare for and that she was not concerned with what she had heard on the initial call from EAD. RN #1 stated that until the registration process is complete, the patient remains an EAD patient. RN #1 stated that she had performed an “across the room” assessment of the patient and determined that he was not a critical patient.

⚖️ Charges Filed:

  1. RN #1 did not obtain a report on the patient from EAD staff.
  2. RN #1 did not adequately assess the patient upon his arrival to the Medical Center.
  3. RN #1 did not recognize the signs of critical illness or risk of impending deterioration.
  4. RN #1 did not adjust her plan of care after hearing that Patient’s ICD had fired.
  5. RN #1 did not assess the patient after his change in condition.
  6. RN #1 did not accept responsibility for the patient’s care or identify any personal opportunities for improvement regarding her interpretation of the emergency medical services report, the determination of a plan of care, or her assessment of the patient.

There were similar charges filed against RN#2.

🏛️ Board Discipline:

The Board is seeking to “revoke or suspend” both registered nurses’ licenses.

This is an important case because it shows how nursing decisions (or omissions) can create serious legal and professional consequences. From a legal/ethical perspective, here are the key lessons a nurse can learn from this case:

1. Duty to Assess Starts on Arrival (Not After Registration)

  • Lesson: Once a patient arrives at the hospital – even if registration is incomplete, the nurse has a professional and legal duty to perform an assessment.
  • Legal principle: Under California Nursing Practice Act and Title 22 regulations, failure to promptly assess a patient with reported life-threatening symptoms may constitute negligence and unprofessional conduct.

2. “Across-the-Room” Assessments Are Insufficient

  • Lesson: Visual assessments do not replace a hands-on nursing assessment when red-flag symptoms (chest pain, ICD firing, seizure, diaphoresis, tachycardia) are reported.
  • Legal principle: The standard of care requires using clinical judgment, vital signs, monitoring, and direct patient interaction, not assumptions.

3. Take EMS Reports Seriously

  • Lesson: Paramedics’ handoff reports are legally significant and must be integrated into the nurse’s care plan. Ignoring them can be viewed as disregarding critical clinical data.
  • Legal principle: Courts and Boards of Nursing view the EMS-to-ED handoff as a transfer of duty. A nurse who disregards this communication risks liability for failure to act on known risks.

4. ICD Shocks = Red Flag for Cardiac Emergency

  • Lesson: Any report of an implantable cardioverter defibrillator (ICD) firing should trigger immediate cardiac assessment, telemetry, and physician notification.
  • Legal principle: Failure to recognize high-risk symptoms can be considered a deviation from the nursing standard of care, exposing the nurse and hospital to malpractice claims.

5. Duty to Reassess After Change in Condition

  • Lesson: A nurse must immediately reassess when a patient deteriorates (e.g., seizure). Walking away rather than intervening may be seen as patient abandonment.
  • Legal principle: Both the Nurse Practice Act and Joint Commission standards require timely reassessment in response to changes in patient condition.

6. Shared but Not Avoided Responsibility

  • Lesson: RN #1 assumed that until registration was complete, the patient was “not her responsibility.” This is legally and professionally incorrect.
  • Legal principle: Courts have held that “I wasn’t assigned” is not a defense when a nurse knowingly ignores a critical patient.

7. Documentation and Accountability

  • Lesson: Statements made during an investigation (e.g., “there was nothing to prepare for”) can be used to show lack of insight and failure to accept responsibility.
  • Legal principle: Boards of Nursing weigh professional accountability heavily; lack of insight is often considered an aggravating factor in discipline.

8. Consequences of Failing to Meet the Standard of Care

  • Legal risk:
    • Board of Nursing: Possible license suspension or revocation for unprofessional conduct.
    • Civil malpractice: Family may sue for wrongful death based on negligence.
    • Employment: Termination for failure to meet hospital policies and standards.

What do you think? Share your comments and thoughts. 🙂

Laurie Elston JD BSN
www.NursingLawCenter.com
Law Office of Laurie R. Elston Inc.
📞 T: (805) 481-1001
📧 Email: Elston@charter.net

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