Advanced Registered Nurse Practitioner

The Washington State nursing laws and rules don't define patient abandonment.

The Washington State Board of Nursing (WABON) has investigated and disciplined nurses for issues surrounding the concept of abandonment as it relates to the nurse’s duty to a patient.

The WABON’s position applies to the licensed practical nurse, registered nurse, and advanced registered nurse practitioner.

Some behavior may be considered an employer-employment issue and not patient abandonment.

The American Nurses Association (ANA) defines patient abandonment as “a unilateral severance of the established nurse-patient relationship without giving reasonable notice to the appropriate person so that arrangements can be made for the continuation of nursing care by others…”

The nurse’s duty is not defined by any single event, such as clocking in or taking a report.

From the WABON standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.

The primary concern is whether the nurse's actions compromised patient safety or caused patient abandonment. The nurse must:

• Have first accepted the patient assignment, thus establishing a nurse-patient relationship, and then,
• Severed that nurse-patient relationship without giving reasonable notice to the appropriate person (e.g., supervisor, patient, contractor) so that arrangements can be made for the continuation of nursing care by others.

Failure to fulfill a nursing responsibility may result in unsafe nursing care. Failure to practice with reasonable skill and safety is a ground for disciplinary action by the WABON.

The decision to take disciplinary action is based on the facts of the individual case, and the unique circumstances of each situation, and their application to grounds for disciplinary action in the nursing laws and rules.

The concept of the nurse’s duty to promote patient safety also serves as the basis for determining behavior that could be considered unprofessional conduct.

The Board believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.

Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse’s license.

There are some unique circumstances about which at may be considered patient abandonment.

An example is a registered nurse with a private practice or a contract to provide care to a patient who does not arrange for another qualified care provider to continue the care, may be considered patient abandonment.

A complaint should be reported to the Washington State Board of Nursing (WABON) for possible disciplinary action.

Conduct that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.

The Washington State Board of Nursing (WABON) holds nurses accountable to the minimum standard of care, which requires the nurse to fulfill a patient care assignment or transfer responsibility to another qualified person once a nurse has accepted an assignment.

The Washington State Board of Nursing (WABON) has no jurisdiction over employers, employment-related issues or disputes.

Other laws regulating facility licensure may apply certain responsibilities to the employer for patient safety, such as developing effective patient care systems or providing adequate numbers of qualified staff.

Specific requirements for a given facility may be obtained by contacting the applicable licensing authority for the institution.

WABON believes that the following are examples of employment issues that would not typically involve violations of nursing laws and rules:

• Resignation without advance notice, assuming the nurse’s current patient care assignment and work shift have been completed.
• Refusal to work additional shifts, either “doubles” or extra shifts on days off.
• Other work-related issues, such as frequent absenteeism, tardiness, or conflicts between staff/employees.
• Not showing up for work or not calling in.
• Refusing to work all remaining scheduled shifts after resigning.
• Refusing an assignment for religious, cultural, legal, or ethical reasons.
• Not returning from a leave of absence.
• Refusing to work in an unsafe situation.
• Refusing to delegate to an unsafe caregiver.
• Refusing to give care that may harm the patient.
• Refusing to accept an assignment or a nurse-patient relationship.
• Refusing to work mandatory overtime beyond the regularly scheduled number of hours.
• Refusing to work in an unfamiliar, specialized, or “high-tech” practice area when there has been no orientation, educational preparation, or employment experience.
• Refusing to “float” to an unfamiliar unit to accept a patient assignment.

Examples of abandonment:

• Accepting the assignment and then leaving the unit without notifying a qualified person.
• Leaving without reporting to the on-coming shift.
• Leaving patients without licensed supervision (especially at a long-term care facility with no licensed person coming on duty).
• Sleeping on duty.
• Going off the unit without notifying a qualified person and arranging coverage of patients.
• Leaving in an emergency.
• Overlooking or failing to report abuse or neglect.
• Giving care while impaired.
• Giving incompetent care.
• Delegating care to an unqualified caregiver.
• Failure to perform assigned responsibilities.
• Closing a private practice without making reasonable arrangements for the patient to transfer care.

It is important to consider what the nurse-patient assignment involves.

Acceptance of a patient assignment may vary from setting to setting and requires a clear understanding of the workload and the agreement to provide care.

In this situation, since the nurse failed to see the patient for a week and failed to request another nurse visit, this may be considered patient abandonment.

A complaint should be reported to the Washington State Board of Nursing (WABON).

Conduct, that is not actionable by the WABON is most appropriately addressed by the employer, consistent with employment laws, rules, and policies.

A nurse may have to choose between the duty to provide safe patient care and protecting the nurse's own life during an emergency, including but not limited to disasters, infectious disease outbreaks, acts of terrorism, active shooter incidents, and workplace violence.

All nurses must adhere to nursing laws and rules regardless of practice setting, position title, or role.

There is also no routine answer to the question, "When does the nurse's duty to a patient begin?"

The nurse's duty is not defined by any single event, such as clocking in or taking a report.

From a Washington State Board of Nursing (WABON) standpoint, the focus for disciplinary sanctions is on the relationship and responsibility of the nurse to the patient, not to the employer or employment setting.

WABON believes nurses should be vigilant and exercise sound professional judgment when accepting assignments that may be requested by employers who need nurses to fill vacant shifts for licensed nursing staff or other staffing-related situations.

The nurse should take steps to protect patients if there is time and use a method that does not jeopardize the nurse’s safety or interfere with law enforcement personnel.

An example is an active shooter incident. This scenario may include evacuating the area or preventing entry to a place where the active shooter is located. However, a nurse may find insufficient time to do anything but ensure their own safety during the situation, In this case, as soon as the situation has been resolved the nurse should promptly resume care of patients.

In accordance with FBI active shooter training provides, the safe and ethical response would be to maintain the safety of oneself instead of rushing to an injured party in a dangerous situation. When the immediate danger to self is over, a nurse would go to any injured person and assist in the most informed and efficient way possible.

Clear communication between staff and supervisors is essential to finding solutions that best focus on patient care needs without compromising patient safety or a nurse's license.

The Washington State Board of Nursing (WABON) recommends that employers develop and periodically review policies and procedures to provide nurses with clear guidance and direction so patients can receive safe and effective care.

A nurse must accept only assignments that consider patient safety and are commensurate with the nurse’s educational preparation, experience, knowledge, physical, and emotional ability.

This is an employer-employment issue that the Washington State Board of Nursing does not have authority over.

Complaints of “patient abandonment” when it is evident from the allegation that it is an employment issue will not be investigated by WABON.

Some general factors that would be considered in investigating a complaint alleging a nurse left an assignment would include, but not be limited to:

• The extent of dependency or disability of the patient.
• Stability of the patient.
• The length of time the patient was deprived of care.
• Any harm to the patient/level of risk of harm to the patient.
• Steps taken by the nurse to notify a supervisor of the inability to provide care.
• Previous history of leaving a patient care assignment.
• Emergencies that require nurses to respond, including but not limited to disasters, disease outbreaks, and bioterrorism.
• Workplace violence, including but not limited to an active shooter situation.
• Other unprofessional conduct concerning the practice of nursing.
• The nurse's general competency regarding adherence to minimum nursing standards.

As with all allegations received by WABON, the alleged conduct by a nurse will be thoroughly investigated to determine what, if any, violations of the nursing laws and rules have occurred.

Depending upon the case analysis, actions may range from the case being closed with no findings or action, to suspension or revocation, or voluntary surrender of the nurse’s license.

If evidence of violations exists, WABON must determine what sanction is appropriate for the nurse’s license and what specific stipulation requirements will be applied.

Washington State does not have a “Safe Harbor” law.

Safe Harbor is a means by which a nurse can request a peer review committee determination of a specific situation concerning the nurse’s duty to a patient, affording nurse immunity from the board action against the nurse’s license.

POLST is a set of portable medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals.

POLST is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year. Advanced care planning is thoughtful conversations between health care professionals, the patient and/or surrogate.

It is within the scope of the appropriately prepared and competent LPN to discuss end-of-life care with the patient or surrogate under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse (RN).

For more information and resources on POLST, go to:

• Advisory Opinion: Portable Order for Life Sustaining Treatment (POLST) (PDF)
• DOH: Portable Orders for Life Sustaining Treatment (POLST)
• WSMA: Advance Care Planning
• WSMA: POLST Form & Brochure

The patient (or surrogate decision-maker) and the health care provider should discuss information to assure the POLST reflects the patient's wishes, as expressed in an advance directive or through communications with family or others. The patient's most recent communications, made in the context of their current medical condition, are the most likely to reflect their current wishes. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. RCW 7.70.065(1)(c).

Yes.

The licensed ARNP, physician, or physician assistant may sign POLST.

• The health care practitioner signing the form assumes full responsibility for obtaining informed consent from the patient or surrogate decision-maker.
• The form must also be signed by the patient or surrogate to be valid.
• Verbal orders are acceptable with a follow-up signature following facility policy.

The ARNP should periodically review the POLST instructions with the individual or family for any treatment preference changes and consistency with any advance directive, especially if there are substantial changes in the person's health status or if there are substantial revisions to the form.

For more information and resources on POLST:

• Advisory Opinion: Portable Order for Life Sustaining Treatment (POLST) (PDF)
• DOH: Portable Orders for Life Sustaining Treatment (POLST)
• WSMA: Advance Care Planning
• WSMA: POLST Form & Brochure