Avoiding Liability Bulletin – July 2024
Intrapartum nursing is a challenging and rewarding area of nursing practice. One of the essential duties of a labor and delivery nurse includes monitoring the labor of the mother during the birthing process.
In the following 2024 case (Williamson v. West Virginia Board of Registered Nurses, Court of Appeals of West Virginia, 2024), an RN’s decision to stop an IV epidural infusion led to a state board of nursing’s finding of professional misconduct against her.
Facts Leading Up to the Board Decision
The RN was a hospital “senior labor and delivery nurse.” During one shift, a fellow labor and delivery nurse asked her to assist with a patient who was admitted to the labor and delivery unit of the hospital.
The patient was receiving an IV epidural infusion to induce labor and to manage her pain. The epidural was known to possibly cause numbness in the legs.
The RN was concerned that the patient was experiencing pain and “complete” numbness in her legs. She did not, however, document her concerns in the patient’s medical record.
During the labor, the patient also experienced severe vaginal swelling. The RN applied ice and a “peanut ball” to open her pelvis. The RN notified the patient’s OB-GYN physician of her interventions, and he told the RN to continue taking “those types of actions to promote the progress of labor.”
The RN did a vaginal exam of the patient whose labor had been ongoing for about two hours. She noted that the patient was fully dilated, and her vaginal swelling was still present but somewhat reduced.
At the time of the vaginal exam, the patient could not wiggle her toes or feel the required pressure needed for the fetus’ delivery. As a result, the fetus was traveling “back up the birth canal instead of down.”
The RN discontinued the epidural without consulting with her OB-GYN physician or the anesthesiologist.
Approximately 10 minutes later, the RN informed the OB-GYN physician that she had discontinued the IV. He did not seem “alarmed” by her conduct but told her to restart the epidural.
The notes in the patient’s medical record indicated that the RN informed the OB-GYN physician that the epidural IV had “fallen out.” Anesthesia was contacted and the department restarted the IV approximately fifteen minutes after it was discontinued.
The note went on to reflect that is was unclear how long the IV had been discontinued before the Anesthesia Department was contacted. The RN’s stopping the IV was not recorded.
Neither the mother nor the baby were injured as a result of the discontinuance.
After the RN’s supervisor contacted the DON, the DON initiated an investigation and met with the RN. The RN refused to respond to the internal investigation and hired an attorney.
The DON filed a complaint with the state board of nursing alleging that, among other things, that the RN’s discontinuance of the epidural was “professional misconduct” and “beyond the scope of professional nursing.”
Board of Nursing Proceedings
In her response to the Board’s complaint against her, she stated that the patient’s condition caused her to have “a major safety concern” for the patient and that was the reason she stopped the epidural IV and tried to help expedite the vaginal delivery.
The Board’s RN investigator report indicated that the RN told her that under the facility’s policy, she was authorized to act without a doctor’s order due to the safety concerns she had. The DON told the investigator that there were no safety concerns documented by the RN, no prior consultation with the OB-GYN, and the situation was not “emergent” which might necessitate acting without notification to the OB-GYN or anesthesia.
An administrative hearing was held with the RN, the DON, and the investigator testifying. Testimony included:
- The RN stressing the hospital policy that stated an RN may stop an infusion if there is a safety concern or the mother has given birth
- The RN relying on two Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Position Statements that did not expressly require a doctor’s order prior to discontinuing an epidural
- The RN thought the labor and delivery nurse who asked her to help was going to document the situation and that she did make a note in EPIC
- The DON stating that the hospital policy defined “safety concerns” were defined in nine ways, none of which were applicable in the situation before the board
- The DON explained that even though the policy did not specifically state a physician order was required, as a general rule a nurse does not have the authority to act on a patient concern without a physician order
The hearing officer concluded that the board of nursing had proven the RN violated several provisions of the state nurse practice act, including practicing beyond the scope of her practice and engaging in unprofessional conduct.
The board adopted the hearing officer’s report, reprimanded her for a six- month period, and order her to pay a fine and administrative costs of $500.00
The RN appealed the board’s decision on two issues: the board’s decision that she lacked the authority to unilaterally stop the epidural was an error because they did not correctly interpret and understand the hospital and AWHONN’s policy; and the board failed to find her testimony more credible than the DON and the investigator, neither of whom practiced in obstetrics, so their definitions of “safety concerns” should not be relied upon.
Appellate Court Opinion
The appellate court affirmed the board’s order.
In doing so, it opined that the DON’s and investigators’ interpretation of the hospital policy was based upon the specific safety concerns that needed to be present before an RN could take unilateral action in a specific situation.
It further declared that the RN had conceded that the board did have “full and complete” authority regarding professional disciplinary actions and this authority includes “its role as trier of fact” in those disciplinary proceedings.
The court also cited case law clearly supporting an agency’s determinations of subject matter within its areas of expertise and authority to be given “substantial weight.”
And, despite the RN’s assertion that she did document her actions in the patient’s EPIC record, the RN did not produce those records during the board proceedings. As a result, a finding in her favor cannot be provided by the appellate court.
What This Case Demonstrates for Your Nursing Practice
First and foremost, this case illustrates the uphill battle a nurse, or any other professional, has in challenging decisions in court by boards of professional licensure and practice. Unless the board decision is arbitrary, capricious, or discriminatory (based on bias or prejudice), those decisions are rarely overturned by administrative review challenges.
Second, it is important to remember the RN here was not a nurse practitioner with a clinical preparation in this area of nursing. Had she been so, the decision to terminate the IV epidural would have been one clearly within her scope of practice.
Other points to keep in mind include:
- Injury to a patient(s) is not a prerequisite for a board of nursing to take disciplinary proceedings against a nurse licensee
- Documentation of patient care is an important aspect of nursing practice, must be done in a patient’s medical record, and personally done by the RN providing care
- A state nurse practice act establishes the legal scope of practice and standards of practice for all nurse licensees and is state specific
- Additional standards, such as those from AWHONN and other professional nursing organizations, establish general guidelines of nursing practice within a specific nursing specialty that may or may not be included in a state’s legal scope of practice and standards of practice
- Facility policies and procedures also establish standards of practice within that specific facility that optimistically incorporate state legal and professional organization standards
- Patient safety is a legal and ethical responsibility of all nurses and must be a foremost consideration by a nurse when providing patient care
This information is for educational purposes only and is not to be taken as specific legal or other advice by the reader. Nor does it create an attorney-client relationship. If legal or other advice is needed, the reader is encouraged to seek such information from a nurse attorney, attorney or other professional.
