Missouri case serves as a wake-up call for all ED nurses
Identifying signs of abuse in an injured child is one of the worst parts of any ED nurse’s job. But there is another frightening possibility that you may not be aware of: If you miss a case, choose not to report your suspicions, or make a judgment call that turns out to be wrong, you could face criminal charges.
That is exactly what happened to a Missouri ED nurse when she treated a 2-year-old boy with bruises on his back and, according to prosecutors, failed to report them to the attending physician. The nurse told authorities she did not report possible abuse because she believed the foster mother’s explanation that the child got the bruises by leaning back in his booster seat. The child was brought back to the ED four days later with seizurelike symptoms. He slipped into a coma and died from what is suspected to be shaken-baby syndrome.
The nurse was charged with two misdemeanors for failing to report the possible abuse after the first ED visit. At press time, the outcome of the case was pending. Regardless of the outcome, however, this case is a wake-up call for all ED nurses, says Pamela S. Rowse, RN, assistant nurse manager for the ED at St. Rose Dominican Hospitals in Henderson, NV. "This is a case that will serve as a precedent to the rest of the country about our role in reporting suspected child abuse," Rowse says. "We have an obligation to the children that we treat, as well as to our profession. We as ED nurses may be their only hope."
The recognition and reporting of child abuse is a common occurrence in the ED — a fact that could put you at higher risk for criminal charges, says Sharon LaDuke, RN, patient documentation analyst at Claxton-Hepburn Medical Center in Ogdensburg, NY. "That can make an ED nurse or physician a high-profile target for a charge of failure to report, compared to others who were involved in the same case," LaDuke explains.
You must consider these facts when making a decision about reporting suspected child abuse:
• Your state laws require you to report. All states include nurses, physicians, and paramedics as mandated reporters, notes Angie Black, RN, BSN, trauma coordinator at Children’s Memorial Hospital in Chicago. "Each state also has a legal time limit for making the report," she adds. At Children’s, orientation for ED nurses includes a lecture on recognition and treatment of child abuse that reviews state laws on mandated reporting, says Black.
• You don’t have to be certain abuse is occurring. Once you suspect abuse, you are legally required to report, says Black. "The key word here is suspicion," she emphasizes. "We do not have to prove it. We just need to suspect it."
The issue is similar to that of adverse drug reaction reporting, says LaDuke. "It can be hard to get nurses to report adverse reactions, because even though they suspect that the symptoms they are seeing were caused by a medication, they are reluctant to document their conclusions," she says. "They may feel it’s not within their scope of practice to judge."
But the fact is, you aren’t required to prove that symptoms are the result of an adverse reaction, says LaDuke. "You are only required to report your suspicions and let the appropriate committee sort it out," she says.
• Don’t let others involved keep you from reporting. If you suspect child abuse or neglect, first report your suspicions to the attending physician, says Black. "But even if the physician does not feel the need to report, the nurse needs to follow through and make that report on their own," she says. (For more on child abuse, see "Are you examining every child for signs of abuse?" ED Nursing, August 2002, p. 135, and "Take these 4 steps if you suspect abuse," on p. 138 in the same issue.)
Passing on the information to a physician or another nurse in report, leaving a message for social services, or doing a referral for follow-up is not enough, advises Rowse. "You still are ultimately responsible to make sure the abuse was reported," she says. "We as nurses must stand our ground and report, regardless of the other individuals involved in the case."
Never ignore your gut feeling, says Black. "This is a wonderful diagnostic tool that should not be discounted," she says. Many nurses and physicians fear reporting because they worry they could be wrong, says Black. "The law actually provides immunity for civil or criminal liability for reporting child abuse and neglect if the report was made in good faith," she explains.
• Don’t let yourself be singled out. Among all the caregivers involved in the Missouri child’s ED visit, only an ED nurse was singled out for criminal prosecution, emphasizes LaDuke. "Maybe it’s simply that state health and local criminal officials felt that because a recently hospitalized child died, something had to be done to somebody," she says. Carefully document what you see, the history you are given, and who you have reported this information to, such as "Dr. Jones notified of bruises to patient’s buttocks," says Black. "That way, you are not the only one left standing, as this nurse is in Missouri," she says.
Even if a social worker does the actual reporting, as is the case at Children’s ED, you still should document this reporting, says Black. "If someone else is reporting, make sure you document that Social Worker Jane Doe contacted Child Protective Services at 1800,’" she says. "Usually, they will be given a case number/case worker’s name that can be added to the chart."
• If you are questioned, obtain good legal representation. If you’re questioned about a case of abuse, it’s a mistake to speak to investigators without legal representation, says LaDuke. "The Missouri nurse made herself an easy target by speaking to investigators, instead of invoking her right to silence — as the physician in this case reportedly did," she says.
You need a lawyer immediately
An attorney who specializes in the handling of high-profile criminal cases now is representing the Missouri nurse, notes LaDuke. "The importance of excellent and immediate legal representation cannot be overstated," she says. Even if found innocent of a crime, she may face a professional misconduct charge and prosecution from the state’s licensing agency/board of nursing, says LaDuke. "If such a development occurs, she will need representation by an attorney who’s an expert at representing licensees in misconduct cases," she says. To find attorneys specializing in these areas, LaDuke recommends asking physicians or attorneys for contacts or referrals, and contacting your local bar association or state nurses association.
• If the explanation doesn’t make sense, you must report. The main question to consider if you suspect abuse is, "Does the story match the injury?" says Rowse. "Perpetrators of child abuse will come up with really elaborate and changing stories to explain the injuries of the children that were in their care," she says. "Falls from a coffee table, couch, or changing table don’t result in major subdural hematomas, retinal hemorrhaging, and rib fractures."
Often, abuse may not be obvious or clear-cut, says Rowse. "The majority of shaken babies that present to EDs don’t look abused," she adds. You must report if an injury is questionable for any reason, says Rowse. "If you can’t make a decision about the causative factors, you must make sure that further investigation is done," she says. "The child’s welfare has to be foremost in our minds."
For more information on reporting of suspected child abuse, contact:
• Angie Black, RN, BSN, Trauma Coordinator, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 63, Chicago, IL 60614. Telephone: (773) 880-3146. Fax: (773) 880-4588. E-mail: email@example.com.
• Sharon LaDuke, RN, Patient Documentation Analyst, Claxton-Hepburn Medical Center, 214 King St., Ogdensburg, NY 13669. Telephone: (315) 393-8880, ext. 5283. Fax: (315) 393-3984. E-mail: firstname.lastname@example.org.
• Pamela S. Rowse, RN, Assistant Nurse Manager, Emergency Department, St. Rose Dominican Hospital — Rose de Lima Campus, 102 E. Lake Mead Drive, Henderson, NV 89015. Telephone: (702) 616-4600. Fax: (702) 616-4604. E-mail: PRowse@chw.edu.