Client rights, restraints, and reporting

Legal and rights items ask whether you protected autonomy and safety without inventing authority you do not have. Ethical principles, informed consent witnessing, advance directives, and DNR comfort deepen in Ethics and care coordination. Delegation scope lives in Delegation and assignment. This chapter owns negligence, restraints, privacy breaches, mandatory reporting, and risk paperwork.

Negligence: four elements

Negligence is practice below the standard of care that causes harm. Exams expect four pieces: you had a duty to the client, you breached that duty, the breach caused the injury, and damages resulted. Forgetting to raise side rails when policy and assessment required them, then finding a fall injury, is the classic pattern. A bad outcome after excellent care is not automatically negligence. A breach without harm may still be a practice failure but fails the full negligence definition on many stems.

Malpractice language on exams is professional negligence: the same elements applied to licensed practice. Intentional torts differ. Battery is touching without consent. Assault is threat. False imprisonment is restraining or detaining without justification. Client rights include respectful care, information, participation, refusal, and privacy. A competent adult who refuses a medication or procedure after explanation is exercising autonomy. Notify the provider, explore reasons, document, and do not hide the drug in pudding.

• Against-medical-advice discharge: explain risks, notify provider, document. Do not physically block the door without legal authority.
• Advance directives and DNR comfort care still apply. See the ethics chapter for DNR-plus-oxygen teaching.
• Minors and guardianship follow jurisdiction rules tested as emancipated, married, or independent patterns.

Restraints: least restrictive first

A restraint limits movement when the client is a danger to self or others and lesser measures have failed or are unsafe. Convenience for staffing, punishment, and so they don't pull the IV overnight without trying alternatives fail the stem. You need a time-limited order, the correct device applied safely, and ongoing assessment: circulation, sensation, skin, toileting, food and fluid, range of motion, and psychological response.

1. Try reorientation, sitter, bed alarm, diversion, pain control, and toileting schedule first when feasible.
2. Obtain or clarify the order. Never implement a standing PRN restraint for convenience.
3. Apply the least restrictive device that manages the danger.
4. Release as soon as safe. Document the behavior that required restraint and every check.
5. Renewal and face-to-face provider assessment follow facility and regulatory timelines on stems.

Chemical restraint (meds used to restrict movement for staff convenience rather than treatment) is scrutinized the same way. Seclusion rules parallel physical restraints in psych stems: least restrictive, ordered, timed, monitored. Soft limb restraints still require the same assessment discipline as vests. Vest restraints carry strangulation risk if the client slides down, so many stems prefer alternatives. Why least-restrictive first: every restraint trades autonomy and carries injury risk. The ethical and legal bar is that less invasive options were tried or were clearly unsafe.

Confidentiality and mandatory reporting

Privacy means need-to-know sharing with the care team and silence everywhere else: elevators, social media, cafeteria hypotheticals with identifiers. Clients may authorize family updates. Without authorization, give general non-specific information only as policy allows. HIPAA stems punish curiosity accessing charts of clients you do not care for.

Mandatory reporting overrides ordinary confidentiality when the law requires it. You report reasonable suspicion of abuse or listed communicable diseases. You do not need a confession or a completed police investigation first. Tell the client when appropriate that you must report. Do not promise secrecy you cannot keep. Threats of imminent serious harm to an identifiable person may also require protective action under jurisdiction rules tested as duty to warn or protect patterns.

Why waiting for proof fails: children and elders often cannot safely accuse a caregiver in front of that caregiver. The nurse's job is to recognize red flags (inconsistent injury stories, patterned bruises, fear, delay in seeking care) and report. Investigation belongs to the agency that receives the report. Adult intimate-partner violence and sexual-assault kit consent are taught in Family violence and sexual assault; competent adults are not forced into a shelter as the only answer.

Incident reports and risk management

Incident (occurrence) reports exist to improve systems and document unusual events: falls, med errors, visitor injuries, equipment failure. Write objective facts (what was seen, done, and measured), not nurse was careless. Do not chart incident report completed in the medical record in most tested policies. Chart the clinical assessment and care given instead. Notify the charge nurse and provider as required and monitor the client for injury.

Risk management also includes safe handoff, refusing an unsafe assignment through the chain of command (see the delegation chapter for scope), and documenting refusals and education. When a med error happens, assess the client first, then notify, then complete the report. The order matters on exams because a polished report never resurrects a client you failed to assess.

Priority map