Legal Considerations for Nursing: This is a CALL TO ACTION for More Education, Training & Support to Keep Nurses Empowered & Safe in Practice!

Thank you for joining me for another episode of the Nursing Strategies for Success podcast, brought to you by The Nurse Speak, a show where we rally some of our nation's greatest nurse leaders, educators, experts, and advocates to tackle some of the greatest challenges that the nursing profession faces. My name is Damion Jenkins, and I'm your host for the show. So sit back, relax, and get ready to learn that nurses can do anything. All right, Maggie, thank you so much for being on the Nursing Strategies for Success podcast again. Thank you so much. Why don't you just take a moment to introduce yourself for the listeners? Let them know a little bit about who you are. Where you started in nursing and where you are today.

Sure. So Maddie Ortiz, I have my master's degree in nursing. I did not obtain that until about 15 years into practice. I started with my ADN. I worked in the ICU, ER, pre-op, PACU, endo, IR, cath lab. I like to joke everywhere but labor and delivery by choice. I've done travel nursing, local agency nursing. I did spend time at, uh, A Board of Nursing where I was formally trained to investigate nurses. That was my first crossover to legal nursing. I then became, left that entity, stayed there a short period of time, had grave concerns what was happening. Then I went to civil litigation. I became a civil expert. A legal nurse reached out to me and asked me if I'd look at a case. I said, sure. That was my second crossover. Uh, then I started, I created Advocates for Nurses. I became a nursepreneur like yourself. And I advocate and assist lawyers and nurses when they're under investigation by their regulatory agency. So everything I now do today is around that— charting courses, speaking, webinars, you know, getting on with you, because what we don't know, the lack of education as it pertains to our professional license, I know has grave consequences doing this. Decade. So I'm honored to be back on the show with someone I have a lot of respect for because I do believe that the education needs to happen more so in nursing school because it is not afforded to us. Texas is the only state that requires jurisprudence and New Mexico now, which is the intersection of your license and the law. Is it the end-all to be-all? It is not. And that's why I create resources and tools through videos, through written content, anything that I can do, because I just— what we don't know about our licenses is really harming us.

Yeah, for sure. So first of all, for those of the listeners that have not caught your earlier episode, I encourage everyone to go back and listen to that. And then you'll see the growth that's happened even with Maggie and all the things that she's done to help advocate for us to keep us safe in practice and out of jail, right? Out of litigation out of the courtrooms. And so I would like for you to just speak a little bit more about what you said regarding Texas, and you said New Mexico had something in particular, and what exactly is that and what does that mean for nurses?

Sure. So jurisprudence is basically our license falls under administrative law, to kind of dumb it down just a little bit. Okay. Because there are 3 different types of law. That is the type of law that if there's any litigation or we get in trouble by the Board of Nursing, that's what the entity falls under and how they're able to discipline us or take our license away or sanction us is because it falls under administrative law. That complexity can be kind of confusing. Not— it's taught in Texas schools, nursing schools. So jurisprudence is basically the education that's provided to anyone who holds a professional license. That teaches you about what it means to hold a license and that you can fall under, you know, you can criminal litigation, civil litigation, and then administrative litigation. And I'm just kind of dumbing it down. Um, we have to take the 6-hour CE for endorsement, and that's a nurse, a doctor, PT, OT, all of us. And then, uh, every third cycle, it's a 3-hour CE. You have to hold a nursing license in Texas to take the one that they offer. There are other organizations that kind of have, you know, reworked that like we all do, right? And then, um, so that other nurses could have, um, take it as well to better help a nurse understand what it means when you are handed your license and they're giving you the privilege. And a lot of us don't understand that. And I did not. Before I sat within that entity and had been practicing for 15 years. There's a lot of things that came to fruition then and since then that I have learned, um, even since I've last been here as it pertains to our license. So jurisprudence tries to package it all up. Um, like I, one of my things that I say, make it make nurse sense. Yeah. It tries to make it make nurse sense as it pertains to you holding a license.

Amazing. So I think that that sounds like something that all nursing programs should include, right? I know being a nurse educator for many, many years of my profession as a nurse and speaking to educators across the country and working with educators across the country, they all touch a little bit on legal considerations, but nothing to this level, nothing to really explain what it means to hold a professional license. What kind of responsibility comes with that privilege of earning that license, and that it could be snatched in a moment when you are no longer meeting the requirements to satisfy the privilege to hold that license. And, you know, a lot of the things that I see as an educator in the clinical space and in the virtual space where I consult with people from all over, a lot of people don't really understand what it means to hold a professional license. They don't really realize that although you went through all the trials and tribulations, time, money, sweat equity, you know, emotional distress, whatever it may be to earn that license, it's not yours. It is borrowed, right? Um, and it's just like renting an apartment. You don't own that space, but you are qualified to live within that space so long as you're meeting the requirements, like paying your rent on time, paying your renewal fees on time, making sure you're getting any required continuing education that that state might require you to do, to update your criminal background information, to go re-up on your fingerprinting. Maybe they have randomized drug screenings in that state. Whatever it might be, you have to practice according to their rules and regulations. You don't get to make up your own rules and regulations as you see fit. Am I right?

Oh, 100%. 100%, right?

So this really calls for a lot more education, not just with the nurses themselves but also with the leaders running these organizations. Because there's a new call, if you haven't heard— I'm sure you have— that they're now starting to pass legislation to hold licensed administrators accountable. To hold the people who own the healthcare organizations accountable for some of the fiscal, um, considerations that affect staffing or that affect, um, working equipment and resources, access to supplies to deliver the care that meets the standards that these licensed professionals are being held to. So there's a lot to talk about here. So, you know, Maggie, you see all kinds of interesting cases, some terrible, that nurses and even patients or residents have to go through. Um, and there does have to be a centralized issue, a centralized challenge. So what is that focus that you want to talk with everyone today about?

So I think you hit the nail on the head. It needs to start in nursing school.

Yeah.

If we're given this quote unquote privilege, I, we don't, no one knows. I can, I can pretty confidently say this juncture in my 25-year career that most nurses do not know. Like you said, it is a privilege to use that word. It's protected in 43 states. You own your nursing education. I own my master's of nursing and leadership. What I don't own is the word nurse. And you touched on many different things. So if you're using that word, I heard you say as an educator in the virtual space, as a nursepreneur, it doesn't matter how you're using that word. If you're using that word, you're doing something virtually, you're a nursepreneur. If you're doing telehealth, the person that you're speaking to and yourself have to be in the state that you hold. More likely than not, most states are compact at this state, at this point. But if you still fall outside, I think it's like the 7 or 8 states that are not. You have to be licensed in that state because then you can't use the word nurse.

Correct.

So it is protected and it doesn't matter what role that you are in. It doesn't matter if you're the CNO, you're the DON, you're an LPN. If you're using the word nurse, I can promise you I've seen your job description will be leveraged against you.

Yeah.

217.12.2 does say chief nursing officer in my own state. If you don't think that there's anything that specifically will be to you as a nursing leader, that is absolutely not true. And I have seen litigation and you talked about administrators, mm-hmm, criminal conduct. Let that sink in because you don't have a board to hold you. They oftentimes don't have a board. They have some kind of license and I, I'm speaking way outta my realm, but I have seen administrators criminally charged.

Yes.

And then nurses criminally charged for conduct. And if the conduct, if you're fraudulently documenting, if you're involved in anything that, let's just say it's not within your scope of practice to do as a nurse. Let's just say an LPN and then an RN is signing off on that. Let's just say it is the DON, which I have seen. And let's just say it's to the tune of $900,000. CMS got involved, led to the revocation of the license. Was felony charges, so won't be even being able to go back to ask for the license back within 5 years. But the felony charges alone ends people up on the National Practitioner Database and the Office of Inspector General list. Why is that? Because you used the word nurse. So I'm going to swing it all back to when we used the word nurse and I just laid on, layered on a whole bunch of things. So when a nurse reaches out to me and they're under investigation by a Board of Nursing, Those are the things that I help them unpack. What they don't realize is those things I can— I don't have a magic ball. I can't see into the future, but I was a prior investigator. Now I've been on the other side helping legal teams and nurses. The outcomes related to the violation, to things that nurses cannot even foresee, are so profound that it will affect their livelihood and their ability to generate money because they use the word nurse, and then you don't get to hold another professional license more often than not.

Yeah.

Or it becomes very difficult to do so because if you get the most trusted professional license revoked, just let that sink in.

You're kind of done. Yeah.

I mean, come on.

You're kind of done.

That argument will be, and you will be asked by the next board who will put you under investigation. They have to, just like if you get, want to endorse in a state and you have disciplinary conduct, on a prior license, they will immediately place you under investigation. Endorsement walks over to enforcement, would hand me your file, and then I would have to write up allegations asking you about this conduct. Does that make sense? Then you would have to defend that before they ever endorsed you to provide you with a license. And I have to presume since I went to national training, some of that would, uh, cross over to any board and anyone. If, I mean, I think that's a common sense argument to make.

Yeah, absolutely. And you know, with any kind of criminal charges brought against you, that's public record as well, right? That's easily retrievable through simple background checks that almost every employer, every renter, every bank, all of these folks use to determine eligibility or, you know, yeah, eligibility, right? Can you get into my apartment to rent? Are you a criminal? Can you get this job at the local market? It is still a very common practice in the United States of America to run criminal background checks on applicants. There's no litigation that says that's not allowed. In fact, it's a way to protect assets, right? It's a way to protect clients. It's a way to protect your coworkers, your teams, all the, the investments that you put into running a business. You should be able to run a criminal background check. So if you have criminal charges, it's not just a professional licensure you can't get moving forward. It's the rest of your life is going to be very difficult. Right? So it's really important that all of the licensed professionals out there, LPN all the way to CEO, right? Administrators, physical therapists, respiratory therapists, all of the different professional licensures that people can acquire, you know, engineers, right? Architects, they all have professional licenses. You have to follow the rules, guys, right? It's just that simple. And, you know, I've heard you talk a lot, Maggie, and I'm— I just really reposted one of your videos minutes before we got on this chat, and that was about refusing to take unsafe assignments, right? Refusing to put yourself in a situation that you already know there are too many red flags that put you at a risk beyond your capability. You just have to be able to say no. You have to be able to say, I'm sorry, but unless I have these resources available to me, I'm not going to be able to take that assignment. And there is some validity to people saying, but what else am I supposed to do? I don't have any other means of income. There are no other nurses to come in and cover. So what's the alternative? And oftentimes employers will kind of guilt the employee trying to advocate for what's best and say, no, you're not allowed to do that. You're going to make the residents suffer, the patients suffer. And what about your coworkers? It's not fair. Da da da. We're trying our best. But how much time goes on with you trying your best and every single day you're putting yourself, your patients, your coworkers at risk? Like, how is it feasible for these folks that this is the reality almost every single day, but yet they're still called to do the right thing? What are your recommendations for that?

Well, let me just start with, if you take an unsafe assignment, that's knowingly and willfully, I mean, that's the definition of medical malpractice under civil law. There's just no defense for it. And I'm not here, I know I don't wanna sound scary, but even at the Board of Nursing, my state says 217.11 says make an assignment as appropriate and then accept. So the only change in the verb is make and accept. So the charge nurse making the assignment, the person accepting the assignment, and even moves into like the emotional ability of you to accept that assignment. So I teach nurses to know the rules and regulations and you leverage those. So I'm not gonna say, you know, I'm not gonna say take the unsafe assignment. I'm gonna say I cannot accept an assignment that falls outside of the rules and regulations that dictate my professional license. And then that's under administrative law. In a professional, respectful manner, then you need to have that in a, like, a manila folder. And I have that resource available to you that says, you know, what, what, what the rule says. And then you move to medical malpractice, knowingly and willingly. That's, you know, you move into civil litigation again, all in your manila folder, in a respectful, professional manner. Then you escalate. Then let's get a hold of the house supervisor. Let's— you're going to the charge nurse. The charge nurse made the assignment. I'm taking it to the charge nurse, but I'm going to ask for the house sup to get involved. Depending on the setting that you're in, you would want to escalate to the highest level of care. Well, not highest yet, because you're going to go to— just going to use your chain of command. Charge, if that's your nurse manager, if that's your director of nursing. Oftentimes that's a house supervisor in a hospital or in a skilled setting that's going to get involved. Then you escalate there. You're not going to accept something that is not safe, because if you do, you will stand alone in front of the Board of Nursing and you will sit in your deposition by yourself while you're trying to defend what you did, that you accepted this unsafe assignment. And sure, you can say that the mitigating circumstance was that you felt bullied and that you felt harassed, but that doesn't mean that you're not getting a discipline by the Board of Nursing.

Right.

It will not go away for life. Now let's play that out. Someone dies.

Mm-hmm.

You won't, you'll pay your restitution to the Board of Nursing. You'll pay your restitution civilly, possibly even criminally, but the moral, ethical, you won't put that down. The moral injury, you just won't get out of underneath.

Yeah.

Now insert as a child or someone elderly. Now if it's someone's elderly, now that's assault, abuse of an adult. Look at what they did to Redonda because she was an older person. There's layers of if they're a child or they're older, if they have mental disabilities, that's just another layer. Now you're for sure going to be on the OIG National Practitioner Database. And if you— so let's go back to the argument, I can't get a job.

Yeah.

I think it's going to be easy to get a job when you're on these lists. I just had a nurse reach out to me. I mean, all day, every day, I can't get a job. And I look her right up and there it is. I can see her orders. It looks grossly offensive.

Yeah.

Right? Because anyone now can look up her orders. All I have to do is know your name, go to Nurses, and anyone else can pull up your PDF that says what you did. And now you're trying to get a job before you ever walk in the door. They already know what you did and you're not getting that interview. Yep. So I'll go back to, yes, you walk into a toxic environment where your leadership is not supporting you, then why are you there? Number one.

Yeah.

Okay. I live in a rural area. Okay. I'm going to go back to, then you're never going to work as a nurse. I have a hard time believing as a nurse that you can't find something remote. If you have to drive an hour away, I'm so sorry about that. But I'm going to go back to that other argument where you're, you're not going to work again ever in your life.

Yeah.

Or, or if you do, there's felony charges. You know what I mean? I know nurses that now, I mean, gave a Benadryl in a long-term care facility and charged criminally, got her license revoked.

Yep.

I mean, where to even begin with some of these things, you know, physically restrain someone or someone fell or because they took on too many people. So I understand it breaks my heart that we're here, but if we continue the same behavior, that's literally the definition of insanity. Yeah. So we all have to stand together. And then just the number 2 last argument, um, cause I know I got long-winded was Look at the schedule when it comes out. If you look at the schedule, normally it comes out 30 days ahead of time. If it's not coming out with an appropriate time, then why are you there? If they're not giving you enough time to plan your life and they don't value you enough, and you are very valuable as a nurse, then again, I'm going to double down and have some self-respect and find a different place to work because they don't value you. And it's not a matter of if or when that something's going to happen. So look at the schedule. If they're short-staffed, just say, hey, Sally, so I saw the schedule and there's 1 nurse and we need 9. So I will only be taking whatever is appropriate in that setting, but I will not be taking— I cannot take an unsafe assignment risking the patient's lives and my license. So their lack of planning is really not your emergency.

Yeah, absolutely. So I think what would be really helpful for the listeners, because I do have a very large audience from nursing students all the way through nurse entrepreneurs, could Could you list maybe some of the red flags that a nurse would be looking at to determine if it's a safe assignment or not? Because look, I work on both sides. I've been on both sides, administration and not. And I hear some administration say things like, oh, well, your perception of unsafe is not reality. How do you know it's not safe? If you're doing everything you're supposed to do, then it will be perfectly safe. If you're unable to do certain things, you have to escalate it to us so we can help you. But we all know when you're in the thick of it, Right? And when you have your 38 or 40 or 50 residents in a skilled facility, or you have your 15 med-surg patients by yourself, no matter how good you are, you and me alike, we would miss things, right? It's just, it's bound to happen. So what are some of the clear-cut red flags that a nurse can really stand ground on to say, this is an unsafe assignment, I'm not taking it?

Well, so the, my primary experience in full transparency, 15 years in the ICU, emergency room, cath lab, so procedural sedation, that area is a little bit different. Um, we just see different things in that area, but as a rule, look to what states have passed staffing ratios. That will give you a guide because there would have been research that supported the passing of ratios. So that would be your first tool. You're a nursing student and you're going to be hired in the ICU. You're gonna go to a step-down unit. You're gonna go to med surg. Have a good idea of what it has been passed in other states as generally recognized best practices and assignments in med surg, in a skilled facility, in rehab, you know, in the ICU. So I'll touch on an ICU for a second because there's a lot of stuff going on, you know, as it pertains to staffing, being tripled up. Is a hard no in the ICU. That's a hard no. Yeah, that's— I don't care what the acuity is, the ICU is either 1:1 or 1:2. Yeah, if you have patients like continuous renal replacement or CRRT, SLED, that's a 1:1. If you're doing high-frequency ventilation, there are certain things that you're going to do in an ICU setting that are 1:1. If you choose to take a 1:1 and you're in charge, That's an unsafe assignment.

Mm-hmm.

Uh, I've seen that a patient lost their leg. I was involved in the litigation, right? There was no defense, unfortunately, for the nurse who chose and then wasn't able to follow up on the loss of pulse in the leg. Had they called the cath lab, we could have moved that around, or we could have talked about removing it and, and needed to see what needed to happen.

Right.

But because they chose to take on an unsafe assignment, they failed to respond. One of the common allegations made against nurses when they take on an unsafe assignment, because time, there's only so much of it. And if you have taken on an unsafe assignment, by mere time, you cannot be in the spaces that you need to be and monitor appropriately. And did you escalate that? Did you tell the doctor who put that patient in that area, who wrote the order for the patient to be in the ICU or in a skilled setting to let them know that the level of care that they have written for is not being able to be provided due to staffing. You do have a duty to let the doctor know to escalate.

Correct.

And then we do need to— I don't think a lot of people realize that, to let them know in a respectful, professional manner that due to staffing, you're unable to meet the requirements.

Correct.

And then we need to get involved as well. You go to some of the stuff that I talked about. You use the rules and regulations to help guide you. Hopefully you have some seasoned nurses that are in your area that you're going to be able to lean in on. And unfortunately, the average experience of, let's just say, the hospital nurse— and my peer Rebecca Love talks about this— is 2.8 years.

Yeah, a lot of newer nurses out here, even in skilled facilities. You know, I'm currently finishing transitioning out of a director of education role at a 409-bed skilled facility in Manhattan.

So we're very—

Wow. Yeah, it's a huge facility. We're very busy. We're about 50% rehab and then 50% long-term care with a locked dementia unit. So lots of training and validation of skills is required. So, you know, to touch on some of the things that, you know, I asked for, You have a lot of procedural ICU acute care experience that you can speak to, and you've served on a lot of those cases. I have a lot of long-term care or skilled facility experience and have helped many people across those settings kind of realize what these red flags are. And the red flags are exactly like what you're saying. If you're— if you know it is not humanly possible for you to meet the requirements of the policy or the procedure, right? Let's say, for example, you've had a fall. Your fall patient is now on neuro checks because it was an unwitnessed fall. You didn't see it happen. You don't know if they hit their head. So it's a standard of care for nursing to implement neuro checks. A doctor does not have to order it, but if a nurse does not do neuro checks and something happens later, it becomes a failure to act or a failure to escalate or a failure to assess and determine if the person is safe, right? So if you know you have a couple neuro checks on the floor, you have several, uh, residents or patients that need IV therapy that needs to be monitored closely, you have people who are having behaviors that could put themselves or others at risk that require more frequent monitoring, if you have limited staff or staff that are newer and they need more supervision and more evaluation to make sure that they're doing things correctly, and you know it's just inhumanly possible for you to manage all of that on your own, those are your red flags, right? You should really be able to say to yourself, am I gonna be able to manage it? Because look, even if you have the perfect staffing ratios, things happen. And it's okay. People die, people get hurt, there's accidents, there's needle sticks, there's all of these things, and it's gonna happen. It's normal for these things to happen. The problem lies is when you are not responding in a timely manner to those incidences, or when you're not escalating through the appropriate channels, or when you're not following the step-by-step procedures that you've already been validated for that you should be following at all costs because it is designed designed to keep you from putting the person at further risk or harm, or to protect yourself from risk or harm. So when you know you can't put in a Foley catheter the right way, the sterile process way that you're expected to follow, because of time and limited resources, that's a hard no. I can't do this, doc.

And why, why is that? Why? Because a lot of nurses don't realize— because again, when I tell nurses Number, I think, 9 or whatever on the decision-making framework, the last one. And I talk about this and if every nurse here, if you don't know what it is, go to the National Council of State Boards of Nursing and they have a great picture of it. I encourage you to print that right on out. The last one says, are you willing to take the responsibility of the actions you're about to take? So when you do that, the possible outcome is sepsis.

Yep.

Death, the leading cause of death in patients in this nation. So if you do that act, therefore you're saying I am willing to take on the responsibility of the possible death of this person. Therefore, I will be standing in one of these three courts of law, possibly all of them, and I'm willing to defend my conduct. Then absolutely go ahead and do it.

Absolutely. And so, you know, some of us, you know, who have been in these settings for years and who have probably been through some pretty terrible situations We do build a certain level of prioritization, delegation. We learn how to like really check on those patients or residents who are at higher risk to keep them safe and focus on them first. And maybe, you know, not spend as much time with the residents who we are thinking may not need the things. But that's still a trap. It's still a trap because again, your time is limited. You only have so much time to get through the tasks and to monitor and stop. And yes, long-term care settings might have, Q-shift vital signs rather than every 4 hours or every 6 hours. But it doesn't matter because even if the doctor's order says Q-shift, if there's been a change in status for any of your residents, it requires more frequent monitoring. If the blood pressure is out of the normal parameters for the medications, you have to do more frequent monitoring. If your patient complains of sudden headache, you have to do more frequent monitoring. These are standards of nursing care. Just because the doctor doesn't order it, just because the facility doesn't have that as a normal expectation for your performance does not mean that you're not held to that standard. And this is where a lot more education needs to be provided for nurses before they even sit to get their license, because some of them are coming out thinking that it's super easy to get work, that it's amazing job, it's, it's, it's super luxurious and, and fashionable, and they're going to make a ton of money to just go in, pass some pills, do a little bit of charting, and, and be done. Maybe educate some of their patients, maybe help someone who's in pain. Sure, that, that sounds like the ideal world, but that's not the world we live in. Um, so there needs to be a lot more education regarding how to protect nurses from unsafe situations so they can keep their patients safe and keep themselves safe.

Well, even just hearing you talk, so I don't— I get calls a lot of times from LPNs, and when a patient falls, an LPN cannot assess. That's a triage. That's a change in status. Correct. Has a change in status. Can an LPM do an assessment on a new headache? They cannot. They can do a focus assessment, call the RN immediately. And if need be, they need to call 911. They are required to escalate to whatever they need. If there's no RN in the building, they then they have to call 911.

Yep.

They have to get— and it doesn't— and the problem is like we all know is our environments are toxic and you're your work environment may tell you like, don't call 911 or don't escalate. Or, but again, when you're standing in a court of law and I've seen this, you are why I wrote the book, Help, I'm a Nurse and I'm Being Deposed. Because if you're involved in civil litigation, um, that's, that's a big, huge deal. And then if you're found negligent, uh, one of my friends lost her professional license early on. And I talk about this in my charting course. You know, my name, everyone's name normally in civil litigation, if you've touched the chart is listed.

Yep.

It's normally the organization and then anyone who touched the chart. I'm, you may have been the primary nurse and you asked me to go do a blood sugar. I did a blood sugar. It was normal. I told you about it. And, but my name still may be listed on there. So my name was still listed on there, but this is only 3, 4 years into my career. I was a spot on documenter then.

Yeah.

Right? I, every, this patient was on a special bed. We couldn't turn them. They were grossly unstable. You know why they knew that? Because I wrote all that.

Yeah.

Because I was deviating from the standard of care of turning the patient every 2 hours. That deviation required me to write an additional note.

Correct.

So I wrote, you know what I mean? And then I had to look at that.

And who you notified and what you did otherwise, right? Correct.

Shifting hips, everything that I could possibly do because I, again, we could not move that patient. They were on a high-dollar bed. I put even in the percentage of air and the percentage of moving. I just copied what I was already doing. I was giving myself credit for the things that I was doing. And let's go back to what we were talking about staffing. When you take on an unsafe assignment, that also puts you in a position where more likely than not, you're not going to be able to document in real time. And therefore, at the end of the shift even, and we saw this in the LPN that got criminally charged when she was a travel nurse, walked into a skilled facility. This is the same time as Redonda. And she, um, signed— I mean, she pled where Redonda didn't. But same thing, the patient was new there, and the state had a right to fall in Pennsylvania, did have a bleed. Everyone is assessing, but she gets criminally charged as an LPN, got her license revoked. Yeah, but you see what I mean? She took on an unsafe assignment. She'd never been in the building before. It was roughly like 5 or 6 minutes a person. That was of her eating, drinking, are, you know what I mean? And because— and I say choose loosely, and I don't say that disrespectfully, and I know I can be a lot, but it's the nurses that call me that are sleeping in their car. It's the nurses that are calling me that won't work again. It's the nurses that are calling me and they don't even realize the long-term ramifications of— they just got their orders and I already know what this looks like more likely than not a year from now, 5 years from now, and how crippling it's going to be to them. And the number one reason why a nurse will take their life is a border nursing complaint. And so again, if you think it's hard to work now, folks, I'm here, I'm rough, I'm hard. But the last nurse that just reached out to me last week when she got her orders dropped, you know, her and her attorney, and she was like, thank you, Maggie, for being lecturing me, being rough on, you know what I mean?

Yeah.

She walked away with her license being dropped. Her and her legal team and myself. But it's, it's what you do or do not document. And her documentation was poor. Um, but all at that point you can say, in my normal practice, I would have done this or that. And that's the stuff that I write about in the book. But folks, I'm here to tell you, do not take on that unsafe assignment. What you do or do not document does matter because a year from now, 5 years from now, 15 years from now, depending on the modality that you work in, labor and delivery, that's 18 years. If you do not document anything, then that's a big deal. So no, I don't want to be Debbie Downer, and that's why you and I are here to educate. And I do think it's really important for the education to start in school with things like the expansion of things like jurisprudence. So that's why I went to several schools. I've talked to different schools. I encourage schools, hey, reach out to me. I'm more than happy to come and educate you and your nurses.

Yeah.

Um, the Massachusetts Nurses Association reached out to me. I'm honored. I'll be speaking, you know, uh, with, for them in February. I'm going to the nurse practitioner, um, Nurses Association, uh, the end of the month. I'll be at Health here as a nurse influencer because why? I don't think that people really fully understand what it means So I just want people to pause, maybe watch some of my videos. I don't have all the followers. I don't have all the likes. I don't monetize because I'm called to something bigger than myself. I am pursuing law school because I just don't want a nurse to ever be alone, or they're reaching out to me and it's, it's too late because they do have that letter from a Board of Nursing.

Yeah.

Or I hope that they don't already sign their agreed orders because then, you know, it's a done deal. And look at the Kansas. Kansas is a great place to look where I saw the Amy Sipple, Anna, some of these other nurses reach out to me. They leaned in on their representatives. They got a special oversight committee called when I sat down in my living room. This is my life's work that was being played out on. And people think that I'm a liar. That some of the stuff that I say is just unbelievable. And I encourage you to watch the, the two hearings and play it on 1.2 or 1.5 because they are long, folks.

Yeah, yeah.

But I was honored to go up there for the second one. I gave some testimony. I provided recommendations. And I told the representatives, you know what, this isn't brand new to me. This isn't just your state. It's the United States. And it's the flaw of the investigative process. So that is what I'm developing out. Well, I will develop out is I think that there's a gap there, the education for investigators when they're, like you said, how are you competent as a nurse investigator to investigate nurses if you don't get the appropriate training? That should be true for a nurse investigator and/or an LPN and RN in long-term care or in the ICU or the ER.

Right.

To be a level of competency if you're investigating a nurse, in my opinion.

Yeah, absolutely. And so correct me if I'm wrong, but are the board members of the nurse— the state boards of nurses, are they elected to those positions or are they just hired into those positions? I'm not quite sure how that works.

So every state is set up differently. And just to not go down a rabbit hole I, like I was telling some other nurses, regardless of how they get there, if I work up a case as the investigator and I present it to you and you're sitting on whatever it is, you're a board member, I present it to you after 2 years of working it up and I work it up biasly. Let's just say I'm an LPN and I'm working up an APRN and I present it to you. Possibly in a biased fashion as a board member, which way, which, what opinion do you think that you would have if I work it up biasly?

Sure.

So is it fair to hold the board members to a certain degree accountable?

Absolutely.

May not. And again, I still want some level of accountability or looking at that, or they should be asking some additional questions, but it's because there's endorsement, enforcement, like consulting, and then you have the board members. But by the time a board member gets involved, the case has already been worked up for possibly 2 years. Does that make sense?

Yeah, that makes sense. So, you know, going back to your original point is that the individuals who are working for the state boards of nursing need to have their own credentialing process and validation of skills and knowledge to even serve in those roles so that they can adequately provide oversight for are the professional, the professional standards of care, right? But if they're not being trained appropriately, then they're making probably biased decisions or assumptive decisions from maybe personal experience, which we should never use personal experience to make decisions on the behalf of someone else, right? This is a true violation of our standards of care that we process due process. Well, it's due process. But even just going back to our role as a nurse, you can't make decisions about patient care based on what's happened with other patients. It has to be objective. It has to be real time and has to be things with this individual, not what has happened with other patients. Yes, there's some—

even in that modality.

Exactly.

If you're investigating a case, Damion Jenkins, and it's an ICU case, Yeah. I mean, and you've never done that modality, just like I could never do anything in your space. And I don't.

Yeah.

Right. It would never stand in civil litigation. And civil litigation, civil procedure laws, I think it's under 704 in Texas, says that I or any expert has to be practicing. Most of them say within 5 years, has to be practicing the same or similar setting. Some states take it down to even if it's to the state or even rural because it may be very nuanced and therefore to afford that person a true defense and due process and full understanding of what did or did not happen. Knowing if you never worked in a rural area and you don't understand the limitations of those resources, then it's not appropriate for you to opine or give your opinion on that conduct and it wouldn't stand in civil procedures. So why therefore do we allow it under administrative law? And it's not— it is the way the administrative law is written. So therefore, some of the things I'm asking for, even as just for a third-party nurse to look at it, I have no problems with. And I even gave this in testimony in Kansas. I was invited to come and give some testimony. I even said I don't have a problem. And I teach this in my Intro to Legal Nursing course for a legal nurse to work up the case in a law firm for the lawyer to start navigating it around and then say, hey, this is long-term care. I need to get a hold of someone like Damion, or you need to get a hold of a long-term care expert and ICU. Then they lean in on— you provide some basic information like I get, or I have gotten as a legal nurse in a civil litigation. If I need additional medical records or something, then I would ask for it to make my unbiased opinion whether there were deviations in the standard of there or not. But no, most nurses don't even know when they become an investigator that there's duty, breach of duty, causation, and damages. That's like under civil, right? That's not the same standard, but it kind of is. But we're not— I don't— I didn't get any of that training when I became an investigator, right? I learned broad concepts about, um, interviewing a witness, about some of the procedural things, and then went back to my entity and then had to learn, like, study up on the disciplinary matrix. I studied up on standards of practice, unprofessional conduct, grounds for discipline, and then the matrix, as well as the decision-making framework, and then had to take that and apply it to see if there were deviations. But if I didn't have that modality, I was like, I'm not a nurse practitioner. I wasn't a psych nurse. So I there were other psych nurses that were investigators. So I was like, hey, I never done this modality. Will you help me with this?

Right.

I only stayed a short period of time and I could see that there were deficiencies. So all I ask all day, every day is just for due process for nurses when they're under investigation by a board of nursing. And what— I'm going to go back. I got really long-winded, but it's going to go back to what you said. And as an educator, you know, how are you competent as an investigator in this nurse enroll and you're still calling yourself a nurse because I'm going to double down on what we said from the very beginning. You're using two words, nurse investigator. So let me see your competency.

Correct. Amazing. So I'm sure Nurse Maggie, right, has kids for nurses, about to be a lawyer, right?

Pursue law school, apply to law schools. So yes, I'm, I'm gonna focus— I'm looking at schools that are focusing on administrative law. So I I have that better understanding. So I don't want— I am pursuing law school in the application process just so I'm not a lawyer. I never give legal advice. I'm just— You sure?

She'll be there eventually. Because again, the more educated we become, the more we can help people, right? And that's why many of us in nursing go on for advanced degrees. It's why we go on for additional skill sets. It's why we have a desire to pivot from one specialty to the next and to go from one state to the other or to work across state lines. As a consultant so we can just gain more knowledge to be of more assistance to patients, families, communities, the nursing profession, right?

Ourselves.

Yeah, ourselves. It helps us in the end of the day as well. So I'm sure with all of the things that you've seen, that you've done, and that you're working on, you have a foundation of education to provide for not only nurses on the front line, but you have education for nursing programs so that way they can beef up their legal implications for practice and really make sure their graduates are understanding. You have education for investigators so that way they can make sure that they are well-rounded and informed so that they can have resources that they can refer to. Because clearly, as you're saying, the state boards of nursing are not doing their due diligence to prepare their investigators. With all of the education they need, which sounds very familiar to a lot of the other nursing specialties that I've experienced over the years. So, you know, folks like you and I who we're dedicated to enhancing the nursing profession through our own avenues, we are providing this education that is available to enhance these individuals. So where you can really educate, you know, an investigator and nurses to protect themselves, I can really educate the nurse educators in the clinical space on how to prepare their lessons, prepare their orientations, prepare their documentation for the validation of skills and competence. So that way, when someone does make an egregious mistake on the floor and the whole building is in an uproar and the assumption of, oh, that nurse was never trained, they don't know what they're doing, it must be the educator's fault, you already have proof that the person did in fact pass a knowledge test and a hands-on skills demonstration, and that it could be possibly a deviation from the practice standard due to a variety of reasons: short staffing, lack of resources, the person's maybe overwhelmed, they've been working doubles, they're not thinking straight, or they did make a choice to not follow the procedure, which oftentimes when you do your own internal investigations, You find out what the reason is, right? But how do we document that we've identified that? How do we document what we're doing about that so that later when, you know, the investigation does roll around, when legal gets involved, or maybe you have a police report, maybe you have a summons to court, whatever it might be, you have proof that you as the educator did your due diligence to prepare the nursing staff to take care of the patients or residents in that fashion, and that it's no liability of yours, right? And they don't teach educators this stuff. They barely give educators what they need to fulfill the role at the baseline level, but they don't really teach how to make sure that you're capturing all of this with no exceptions, you know, to the rule. Because again, if things don't get done, you will get blamed. And I've seen examples where surveyors have come in and they were getting ready to issue IJs for egregious behaviors by the staff on the floor, and then because the educator had the documentation that showed they were previously validated for skills, the IJ was actually reduced to a non-harm level tag because it was then isolated as an individual lack of professional practice and not the facility's lack of professional practice on behalf of preparing the staff, right? So these things all play into these investigations. And whenever an investigation is happening, whenever things get to court, someone is gonna get blamed. That's the goal of it. Someone's being blamed. And so we have to make sure we're putting ourselves in positions to where we're not gonna be the one. Ones, right? The nurses should not be the ones getting blamed.

Yeah. And so for the educators, like you said, it will be what we call CYA, right?

Yeah.

And you have to make sure that you're doing your due diligence, doing your— getting the competencies. And if the independent nurse chooses to act outside, then that can be considered gross deviation from the standard of care, and it can be individual, just them named as far as— then there may have to be, let's just say, a redo of the petition, because now the organization petitions the judge and said, whoa, hey, no, now that original petition, you're saying it's all the staff and it is not, or it's the organization and it is not. And we can prove that. So then it gets reduced to, like you said, it's always about the end thing is money, who to blame.

Yep.

Then they'll have to reduce it down to it was just the nurse. Or the person who chose to do that egregious conduct and the damages. So there's duty, breach of duty, causation, and damages is normally the financial exchange that is made for the conduct, the damages. They lost a leg, they broke their arm, their hip, whatever that, that is. And some of that conduct that then if a nurse is found negligent in any of that, just say that they did deviate Again, we're going to double down on that. That does get reported to a board of nursing. Everyone, most nurses, if you're not— if you're going to be a nurse, when you endorse your license, you have to say if there was criminal conduct, civil litigation. Every 2 years, you have to answer that same question. If there's something new that comes up, most boards say within 15 to 30 days per the reg. Most nurses don't know that have to report. Something most do not. They will do it on their renewal. They can use that against you. They'll ask the date of the case and all that. But yes, it will come down to the competency.

Yep.

What can be— can or cannot be proved. So yes, make sure that you are doing your— it is a CYA for the organization. And being in some of these places, it can be tricky. And for the compact nurse, for the travel nurse, for the nurse nurse that's going to be a nurse, I'm going to say several things. You should never be a travel nurse or an agency nurse unless you have more than 5 years experience.

Absolutely.

Take on those roles. You are saying that I'm walking in the building and I have a level of expertise and I need minimal orientation to my surroundings. You're not being cross-trained and no one is training you. That can be considered gross negligence on the staffing agency side and on the organization side, you have a due— you're supposed to do your own due diligence if you hire a nurse on either side, the organization or the staffing agency. And you knew that they had no level experience, no competency in that skill set, and you still chose to— see what I mean? It's just where to even end sometimes with the litigation. And I hear nurses oftentimes say, some of us, we don't know, we just caught up. We come to the job. We see the assignment and we just start doing, and we don't oftentimes pause and realize that there's all types of litigation. And nurse after nurse after nurse after nurse tells me, I wish I would have paused. I wish I would have thought about this. I wish I would not have taken that assignment. I wish I would not have put those medicines in my car for as a home health nurse and transported those and didn't have a witness, or I didn't have a witness waste you know, these drugs with me for a year during COVID I— and now we're done. It's just— or you're a nurse practitioner and you weren't licensed in all the states and you wrote a controlled substance prescription for a controlled substance, and now the DEA is involved. I mean, it's just— I could go on and on and on, and I oftentimes feel like Debbie Downer, and it can be very depressing. So all of this again, Damion, to say we have to learn this in school. Yeah, we really do. And I don't think— more and more I think we're seeing nurses, nursing leaders involved in litigation.

Yeah.

And a form of fraud is making assignments, whether that's in the skilled facility or in the ICU. I am seeing CMS get involved and plucking as well, the nursing leader, because a level of care was billed for and that was not received. Physicians can be reported as well because they have partly a duty to know if the level of care that they wrote for is being received. And more often than not, they do know. Correct.

Correct.

If they don't speak up, they too can be reported as well. So it's a big deal.

Absolutely. So when the providers are coming to the nurse educators or the nurse leaders saying, hey, we're seeing an increase in sepsis, we're seeing an increase in Uh, pressure injuries, we're seeing an increase in, um, rehospitalizations, whatever the case may be. And then they don't always like the answer of, well, how do we expect the staff to adequately monitor for and report early changes to manage and prevent these types of things from happening when there's not enough of them on the units, right?

That's only a mitigating circumstance. Yeah, that is not a defense.

It's not a defense.

Only be a mitigating circumstance, right? And more likely than not, especially in front of the Board of Nursing, you still will be sanctioned.

Correct. And so informing the providers that this is the reality of our situation also gives them an opportunity to turn it back to administration and What are we doing about staffing? Because I can't adequately manage my assignment as a medical provider when I don't have enough nursing assistants or nurses to carry out my orders.

And then I will have to transfer my patient to another facility because they don't meet their needs.

Absolutely.

That's their duty. And if they do not do that, they too can be held accountable.

Absolutely. And so someone who, you know, I'm always— we're always learning, right? Once I learned that part of my responsibility as a nurse is to inform the provider that certain skills or services cannot be done due to the limitations of how quickly we can get to it for staffing reasons, whatever it might be, they are now responsible for also doing something about that, right? So it doesn't just put the onus on me, the nurse. And so that's one lesson that I want to make sure that nurses know. Not only just refuse the unsafe assignment, but if you took the assignment thinking that everything was gonna be copacetic and then it's turning out that it's not, maybe one of the nurses that you had with you has to go home suddenly because they're ill or sick or something happened with their child and they have to leave and there is no replacement. Now you're stuck in an unsafe situation. You have to escalate it. Once you're there, you're kind of stuck, right? We all know that nurses can't just leave unless there's someone else to take the assignment and monitor the patients and tend to them. So sometimes that gets real hairy, but I always tell the nurses, until another licensed nurse comes and takes the assignment from you and says, okay, you are now able to go home. I'm satisfied with my report. I'm satisfied with the narcotic count. I've received the keys or whatever supplies I need to do the work appropriately. Now you can leave. You're stuck there until it happens, no matter how much you like that or not. And I know there's some states that have laws that say an organization cannot mandate you to stay beyond your hours, but the standards of nursing care will always remain. You cannot leave your patients unless another licensed nurse takes the assignment. So if there's no one in the building to take it, you're kind of— you have no choice.

License supersedes all of that.

All of it. Exactly. And that's what I tell the nurses. And sometimes I do get I get, you know, a colleague or someone who reaches out to me that says, Damion, you know, it's not fair. I had to stay like an extra 7 hours over because there was no nurse to take it and there was a house supervisor. Why couldn't the house supervisor come and take the assignment? For the same reason that you wouldn't take an unsafe assignment. The supervisor is not in a position to say, oh, well, I'm the supervisor. I don't have any direct patients to take care of, so I can come and take your unit. Unit, no way, Jose, because then that puts them in a position to where they can't function within their role. And then once they are knowledgeable about an unsafe situation, they're in the same situation, they're now liable. So of course the supervisor is not going to come up to the floor to relieve you and then leave the building with no supervisor, right? Because once they take that unit, they have to stay there until someone else comes. So, you know, just make it very clear, like, we are at a much higher higher duty than clocking in, doing the bare minimum, and collecting a paycheck. Like, we have to understand that this is all part of it, and if your heart's not in it, then you need to find something else to do. And both Maggie and myself can give you lots of recommendations on different avenues that you can— a nurse— and work in. There's so many alternative careers for nurses that don't require being at the bedside or being put in those situations where you can leverage your knowledge in your skill set. So if that's something you're interested in, reach out. And with that, Maggie, how can people get in touch with you if they want to work with you, if they want to ask you questions about legal nursing, if they want to be represented because they're going through something, or they just want to get ahead of it and kind of make sure that they don't ever have to be in these situations? How can they reach out?

Yeah, so I don't represent nurses, but I do provide educational tools and resources all on Advocates, uh, F-O-R, or number 4, um, dot com. Uh, I do have Ask Maggie. Anyone can book time on my calendar. Uh, it's only $50 for 30 minutes. Uh, I do have to charge for my time, but I promise you, be well worth it. Uh, but advocatesfornurses.com, I have a website. Anyone can reach out to me, whatever you need. I can help you whether you're an organization, you can book services with me. I've created courses, I've done webinars. I had a CNO reach out to me. The staff watched my charting course for CE, and then I did a 30-minute Q&A. So whatever your needs are and whatever your question is, it's never a dumb one. The only dumb question is the one that you don't ask.

That's it.

Like you said, Damion and I are both here. Whatever you need, you're a nurse, you're amazing. If you're not happy where you're at, that's, that's okay. There are many, many things that you can do. You are a nurse.

There's a lot of things that you can do with that nursing license. LPN, RN, um, there's really a lot of opportunity for all levels of endless, endless, endless. Even CNAs. I know CNAs are opening businesses and/or assisting in helping to, you know, work within the healthcare system, but not necessarily at the bedside, to still use what they know to help people. Like maybe private caregivers. They're teaching private caregivers how to do ADLs, right? Things like that. It's all possible if you put your mind to it. Um, but for those of us who are still at the bedside, there's a lot of work to be done, but the first and foremost is beef up that education, beef, beef up your skillset, and then make sure that you're making safe decisions every single day. So awesome, Maggie. Thank you so much for being on the Nursing Strategies for Success podcast again. Everything that we shared, I'm sure will go far and wide and help a lot of people. And I hope to see you soon. You say you're gonna be meeting up with several different organizations. Organizations. I would love to link up and see how we can work together to really help spread this message and make sure people get the education that they need. So thank you.

I agree, agree. And I just have to say, your skin looks great, my friend.

Thank you. Yeah, something, something else that nurses can get into is skincare. You know, there's each— like, you know, each state has their own, like, do's and don'ts regarding what nurses can and cannot do. And using the word nurse, like you say, is very protected. So sometimes you have to get a little creative on how you go about doing but, uh, yeah, it's, it's really cool to be able to educate people about skin, use some devices to make skin look great, um, recommendations for products. There's a whole industry out there that's for many years been off-limits to nurses, but that's opening up, um, because of how much competence nurses are, um, giving themselves, the education, the training, and things like that.

So yeah, so I don't— if everyone doesn't know, that's what Damion Jenkins is in this space. Case. Yeah, um, he needs to be plugging himself.

So, well, you know, for the Nursing Strategies for Success podcast, this is for the nurse speak, all my education stuff. But yeah, it is a, it is a little side hustle that I've started up recently, and it's, it's been a lot of fun doing, um, skincare, educating folks, making their skin look beautiful. And people can find that easy if they just search online for that. So yeah, thanks, Maggie. And maybe I can help you with your skin.

Yes, I actually was going to reach out. Actually, I saw Amazing.

Awesome. Well, thanks again for being on the show, and we'll be in touch soon. Take care.

Bye.

Be well. And that concludes episode 7 of season 4 of the Nursing Strategies for Success podcast with this episode's guest, Maggie Ortiz. We hope that everything that we shared for you in this episode will help you to lead the charge, protect protect yourself, your patients, and your nursing license. All the ways to get in touch with Maggie will be in the show notes of this episode. And as always, if you have any questions about anything that we shared, feel free to visit thenursespeak.com and get in touch with me. I would love to have a conversation with you. So until next episode, take care. Take care, be well, and remember that nurses can do anything.