Chapter 2 The Legal Regulation of Nursing in Nevada

INTRODUCTION 2:2

STRUCTURE OF THE BOARD OF NURSING 2:2

DEFINITION OF SCOPES OF PRACTICE IN THE NURSE PRACTICE ACT 2:4

LICENSING REQUIREMENTS AND CONTINUING EDUCATION 2:6

Registered Nursing 2:6

Licensed Practical Nursing 2:7

Interim licensure 2:7

Failure/reapplication 2:7

License renewal 2:8

Continuing education requirement 2:8

ADVANCED PRACTICE NURSING (APN) 2:9

Requirements for certification 2:10

Scope of practice 2:10

Renewal of APN 2:13

Revocation 2:14

APPLICATION FOR APN CERTIFICATION 2:14

NURSE SPECIALTY CERTIFICATION 2:15

Requirements for title 2:15

Scope of practice 2:16

Renewal 2:16

Revocation 2:16

Certified Registered Nurse Anesthetists (CNAs) 2:16

Scope of practice 2:16

Requirements for CNA certification 2:18

License renewal 2:18

Revocation 2:19

STANDARDS OF NURSING PRACTICE 2:19

DELEGATION AND SUPERVISION OF NURSING CARE 2:24

Delegating 2:24

Supervising 2:25

DISCIPLINARY ACTION BY THE BOARD 2:27

General procedure 2:27

Grounds for disciplinary action 2:28

Statutes & Regulations

INTRODUCTION

The nursing profession is directed and regulated by numerous laws and by a variety of institutions. In Nevada, nurses are legally bound by the applicable laws found in the Nevada Revised Statutes, the nursing regulations found in the Nevada Administrative Code, case law handed down by Nevada courts, and sometimes by the professional and ethical standards of nursing organizations, such as the American Nurses Association. The primary source and authority for the legal regulation of Nevada nurses is the Nevada State Board of Nursing. This chapter first explores the structure, functions, and authority of the Nursing Board, and focuses on the nursing regulations promulgated by it. Various other facets of the legal regulation of nursing, such as case law written by courts, and the legal regulation of nursing specialties will also be detailed. The following chapter, The Legal Regulation of Nursing in Nevada, focuses on the self-regulating aspects of the profession, rather than those regulations imposed upon it by law.

STRUCTURE OF THE BOARD OF NURSING

The Nevada Nurse Practice Act created the structure and functions of the Nevada State Board of Nursing (Board). NRS 632.005. The Nevada legislature gave the Board the primary responsibility of protecting the publics health from unprofessional and unqualified nurses, thus granting the Board broad powers to regulate the nursing profession. The Board establishes the scope of nursing practice and monitors nurses to ensure that the established standards of practice are met. It is also responsible for establishing standards for the licensing of nurses and, when necessary, for administering professional sanctions and discipline.

The Nevada State Board of Nursing (Board) consists of seven members appointed by the governor. NRS 632.020.

The members are:

Four Registered Nurses (RNs) who are graduates of an accredited school of nursing, are licensed as professional nurses in the State of Nevada and have been actively engaged in nursing for at least five years preceding the appointment.

One practical nurse who is a graduate of an accredited school of practical nursing, is licensed as a practical nurse in the State of Nevada and has been actively engaged in nursing for at least five years preceding the appointment.

One nursing assistant who is certified pursuant to the provisions of the chapter.

One member who is a representative of the general public.

NRS 632.030.

The Board members must be United States citizens, and residents of the state of Nevada for at least two years. The members appointed to the Board must be selected to provide the broadest representation of the various activities, responsibilities and types of service within the practice of nursing and related areas. Each member serves a term of four years, and may serve no more than two consecutive terms.

Nevada law also provides for a nursing assistant advisory committee to assist the Board. The members of the advisory committee consist of: one representative of a long-term care facility, one representative of an acute care facility, one representative from a home health agency, one representative from the health division of the Department of Human Resources, one representative of the welfare division of the Department of Human Resources, one representative of the aging services division of the Department of Human Resources, one representative of the American Association of Retired Persons, a nursing assistant, a registered nurse, and a licensed practical nurse.

The Board meets at least every four months to set policy and conduct business as may properly come before it. This includes determining the time, location and content of the nursing examinations, making financial decisions, and holding disciplinary hearings. Each year the Board meets and elects from its membership a president, vice president and secretary. The Board employs an executive director and such staff as the Board and the executive director deem necessary. The executive director must be currently licensed to practice nursing in the State of Nevada. NRS 632.030 – 632.125.

The Board can be reached at the following address and phone number:

Nevada State Board of Nursing

1755 E. Plumb Lane, Suite 760

Reno, Nevada 89505

Phone: (775) 688-2620

Fax: (775) 688-2628

DEFINITION OF SCOPES OF PRACTICE IN THE NURSE PRACTICE ACT

The legal guidelines for the practice of nursing are detailed in the Nevada Revised Statutes (NRS) and the Nevada Administrative Codes (NAC). The NRS statutes are the laws enacted by the state legislature which provide, among other things, the broad conceptual framework for the regulation of nursing. The legislature grants the Board of Nursing authority to draft the regulatory code sections of the NAC which provide more specific rules regarding the practice of nursing. The regulatory language in the NAC is remarkably readable, when compared to many other state or federal codes, and thus needs very little interpretation. In this text, all relevant statutory and code sections are included at the end of each applicable section. For full copies of the statutes and regulations, write to the Nevada Board of Nursing or download them from the Nevada State website at:

www.leg.state.nv/nac and www.leg.state.nv/nrs

The NRS also contains Nevadas Nurse Practice Act, which sets out the scopes of practice for various types of recognized nurses in the state. The Nurse Practice Act defines registered nurse, licensed practical nurse, and nursing assistants and sets forth the legal scope for the practice of nursing as one of these types of nurses. In general, the practice of nursing is the general observation, diagnosis and treatment of changes in a persons health. The term does not include acts of medical diagnosis or prescriptions of therapeutic or corrective measures, except as authorized by specific statute. NRS 632.0169.

A registered nurse in Nevada is a person who is licensed to practice professional nursing. NRS 632.019. The scope of the practice of professional nursing is defined as the performance for compensation of any act in the observation, care and counsel of the ill, injured or infirm, in the maintenance of health or prevention of illness of others, in the supervision and teaching of other personnel, in the administration of medications and treatments as prescribed by an advanced practitioner of nursing, a licensed physician, a licensed dentist, or a licensed podiatric physician, requiring substantial specialized judgement and skill based on knowledge and application of the principles of biological, physical and social science, but does not include acts of medical diagnosis or prescription of therapeutic or corrective measures. NRS 632.018.

More specifically, the administrative code lists several specific tasks that a registered nurse is authorized to perform competently:

(a) The diagnosis and treatment of human responses to actual or potential health problems;

(b) Exercising sound judgment;

(d) Carrying out his duties based on an established plan of care;

(e) Evaluating, assessing and altering, if appropriate, the established plan of care;

(f) Delegating appropriate duties to other nurses;

(g) Supervising a nurse to whom he has delegated nursing duties;

(h) Maintaining accountability in the delegation of care;

(i) Administering medication and carrying out treatments which are properly authorized;

(j) Determining the necessity and appropriateness of health care services for a patient or prospective patient and determining that patients eligibility for payment of those health care services by a licensed insurer;

(k) Managing the cases of patients assigned to him by coordinating services and collaborating with other health care professionals in the provision of health care services;

(l) Planning for the discharge of patients; and

(m) Managing risk in the provision of health care services.

NAC 632.212

A registered nurse is further authorized to perform or supervise the assessment and evaluation of the health of patients, the development of care plans, and the provision of direct or delegated care. NAC 632.216. The code also authorizes registered nurses several tasks related to patient health maintenance, the treatment of patients with medication, and additional duties in her area of specialization. NAC 632.220-225 lists these tasks in detail.

The practice of practical nursing is the performance for compensation of selected acts in the care of the ill, injured or infirm under the direction of a registered professional nurse, and advanced practitioner of nursing, a licensed physician, a licensed dentist or a licensed podiatric physician, not requiring the substantial specialized skill, judgment and knowledge required in professional nursing. NRS 632.017. Thus a LPNs scope of practice is legally limited, in some cases, not by detailing what she may do in her job, but by limiting her from performing those tasks that require the skill of an RN. The specific scope of practice of a LPN is detailed in NAC 632.230 to 632.242. LPNs may perform additional tasks other than those learned in a LPN educational program if she has at least 1500 hours of clinical experience and meets other stringent requirements. NAC 632.242.

A nursing assistant is any person, except a nursing assistant trainee, who for compensation practices or offers to practice as a nursing assistant and has submitted evidence that she is qualified to so practice and is certified as required by the NRS statutes. NRS 632.285.

In many instances, Nevada law authorizes nurses to perform additional tasks in cases of emergencies. Despite any statutory authorization, nurses should of course ensure that they are in compliance with their employers policies regarding emergency care.

LICENSING REQUIREMENTS AND CONTINUING EDUCATION

Registered Nursing

Persons interested in receiving a license to practice as a registered nurse in Nevada must qualify for and pass the State licensing exam. The content of this exam is at the discretion of the Board, but currently the National Council Licensure Exam for Registered Nursing or NCLEX-RN is used. NCLEX is a set of standardized national tests used by most states as their licensing tests. The Nevada Board also has the option of administering oral or practical tests in addition to this written test. NRS 632.150.

In order to qualify to take the licensing exam, the applicant must have graduated from or received a certificate of completion from an approved program of registered nursing. This program must include theoretical and clinical course work in medical-surgical nursing, maternal (obstetric) and child nursing, and psychiatric nursing.

If the applicant graduated in Nevada, the Director of the School of Nursing will send an Affidavit of Graduation to the Board documenting that the applicant has graduated and is eligible to take the examination. The applicant may also request that the registrar’s office of her nursing school send an official transcript (after the degree is posted) to the Board of Nursing. The out of state graduate must request the registrar’s office to send the Board of Nursing an official transcript (after the degree is posted). NRS 632.150 and NAC 632.150.

To take the exam, a completed application must be filed with the board four months before the date of the examination. The application must include:

2-inch by 2-inch photograph taken of the applicant within the past 2 years;

a complete set of the applicants fingerprints; and

the appropriate fee, currently $100.

NAC 632. 155.

Licensed Practical Nursing

The applicant for an LPN license must have successfully completed high school or passed the GED. The applicant must pass the approved test for licensure as an LPN, the NCLEX-PN. Also, the applicant must have successfully completed a course of study in an accredited school of practical or vocational nursing. The curriculum must have included theoretical and clinical courses in medical-surgical nursing, maternal-child nursing, and mental health concepts.

To take the licensing exam, the applicant must file a completed application with the Board at least four months before the date of the examination. The application must include:

2-inch by 2-inch photograph taken of the applicant within the past 2 years;

a complete set of the applicants fingerprints; and

the fee, currently $90.

NAC 632.150, 632.155.

The LPN applicant is additionally required to submit to the Board written proof that she is:

over 18 years old; and is

of good moral character.

Interim Licensure

Both RN and LPN applicants may obtain interim licenses which allow them to practice in a limited capacity while awaiting the results of their licensure exam. This interim license is limited to three months. NAC 632.160.

Failure/Reapplication

If an applicant fails either the RN or the LPN exam, they may apply for and take the exam a second time. If an applicant fails a second time, the applicant must submit to the Board a plan of study before reapplying a third time. An applicant who fails a third time must re-enter and complete a course in nursing theory at an accredited school before reapplying to take either examination. NAC 632.120-166.

License Renewal

The Nurse Practice Act requires that licensees renew their licenses every two years. The renewal requires:

submission of a completed renewal application;

payment of the renewal fee (currently $100);

proof of successful completion of the continuing education requirement (see below);

submission of a complete set of fingerprints;

attestation that the applicant has committed no act which could subject the application to denial; and

attestation that the applicant has developed no condition which might interfere with the ability to practice nursing.

NRS 632.341 and NAC 632.192.

Continuing Education Requirement

The Nurse Practice Act requires that licensees complete 30 hours in a continuing education program during the 2 years before the license renewal date. The licensees birthday is the renewal date. A licensee who has graduated from an accredited school of professional nursing or practical nursing, is exempt from the continuing education requirement for the first biennial period after graduation.

The Board pre-approves certain continuing education programs. However, the Board may approve other courses which are directly related to the practice of nursing. The Board may also approve course work which bears a reasonable relationship to current developments within the field of nursing or in any special area of practice in which the licensee engages. NRS 632.343. This provision is slightly vague and allows the licensee some latitude in choosing courses which are not already approved. Caution should be used when submitting credit for course work which has not been pre-approved because the Board is under no obligation to give credit for course work beyond that which they have explicitly approved. NRS 632.343.

In addition to the content requirements the NAC imposes certain requirements upon continuing education providers. The course provider must be one of the following:

a Board-approved provider;

a national nursing organization;

an academic institution;

a provider of continuing education that is recognized by another board of nursing; or a provider that is recognized by the regulatory board of a related discipline that approves courses of continuing education.

NAC 632.355.

Original certificates of completion of the course work must be kept for four years after the course was presented and must contain the following information:

the title of the course;

the name of the provider;

the name of the entity which approved the course;

the date the course was given;

the name and license number of the nurse; and

the number of continuing education hours earned

NAC 632.340.

The licensee is not required to submit proof of the continuing education hours at the time of license renewal, but rather is only required to show successful completion during the Boards periodic audits. If audited, the nurse has 30 days to provide copies of the above-described certificates of completion of the requisite number of continuing education hours.

ADVANCED PRACTICE NURSING

The state of Nevada authorizes the Board to certify and regulate advanced practitioners of nursing. Nevada recognizes advanced practitioners of nursing in the following areas: nurse midwife, nurse psychotherapist, nurse practitioner, or clinical nurse specialist. A practitioner may obtain a certificate of recognition as an advanced practitioner of nursing if she meets the requirements established by the Board for such certification, and successfully completes approved educational programs designed to prepare the nurse to perform designated acts of medical diagnosis, prescribe therapeutic or corrective measures, and prescribe certain poisons, dangerous drugs and devices. NRS 632.237.

Requirements for Certification

Applicants for certification as an advanced practitioner of nursing (APN) currently must have a bachelors degree in nursing. Starting in the year 2005, the minimum entry degree will be a masters degree. To obtain certification as an APN, the applicant must have successfully completed an accredited or approved program of instruction. The program must be at least 1 year long with both classroom and clinical components. The program must include an advanced course in health assessment, pathophysiology, and the preparation for independent practice as an advanced practitioner of nursing. The program must also include concentration courses in at least one medical specialty.

The clinical experience must allow the student to integrate the theoretical knowledge and skill taught in the classroom, with emphasis in the medical specialty chosen by the student. It must also train the student to make clinical decisions, including diagnosing medical conditions and initiating proper treatment.

The applicant must submit proof of having performed as an advanced practitioner for a minimum of 400 hours a year for 3 out of the previous 5 years. These hours are likely to be acquired while the applicant works as a student under the auspices of the advanced practice program. Alternately, an applicant is not required to comply with the 400 hour requirement, if evidence is submitted that she will complete 1,000 hours of practice without prescribing privileges under a collaborating physician. This alternative permits an apprenticeship in instances when the applicant already has a sponsoring physician. NRS 632.120, 632.237; NAC 632.260.

Scope of Practice

In Nevada, a registered nurse may become an APN as a nurse midwife, nurse psychotherapist, nurse practitioner, or clinical nurse specialist. Once certified the APN may:

engage in selected medical diagnosis and treatment; and

prescribe poisons, dangerous drugs and devices under protocols developed with and approved by a collaborating physician.

NRS 632.237.

In addition to the ordinary functions of a registered nurse, the APN may engage in the following acts, if they are within the standard of medical practice in which she is certified and appear in her protocols:

systematically assess the health status of persons and families by:

taking, recording and interpreting medical histories and performing physical examinations; and

performing or initiating selected diagnostic procedures.

based on information obtained in the assessment of a persons health, manage the care of selected persons and families with common, acute, recurrent or long-term health problems.

Management may include:

initiation of a program of treatment;

evaluation of responses to health problems and programs of treatment;

informing a person or family of the status of the patients health and alternatives for care;

evaluation of compliance with a program of treatment agreed upon by the person or family and the advanced practitioner of nursing;

modification of programs of treatment based on the response of he person or family to treatment;

referral to appropriate providers of health care;

treatment of minor lacerations which do not involve damage to a nerve, tendon or major blood vessel; and

commencement of care required to stabilize a patients condition in an emergency until a physician can be consulted.

In addition to the above acts which are specifically defined by statute, the Board allows the APN to perform any other act if:

the advanced practitioner is certified to perform that act by an organization recognized by the Board;

the performance of the act was taught in a program of education attended by the advanced practitioner of nursing;

the performance of the act was taught in a comprehensive program of instruction successfully completed by the advanced practitioner, which included clinical experience; or

the act is within the scope of practice of an advanced practitioner of nursing as determined by the Board.

NAC 632.255.

As recognized by the state of Nevada, the advanced practitioner of nursing is a protocol-driven practice. Protocols are the written directions for assessment and management of specified medical conditions upon which the APN and physician have agreed as a basis for their practice. Protocols must include guidelines for assessment and treatment of the medical conditions, and must establish when the APN will treat and when physician consultation or referral must be obtained. The Board explicitly requires that the protocols must:

reflect the current practice of the advanced practitioner of nursing;

reflect established national or customary standards for the medical specialty;

be maintained at the place where the advanced nurse practitioner practices; and

be available for the board to review.

The requirement of articulated guidelines that are written and available to the APN avoids some problems encountered early in the history of APNs where the protocols were vague unwritten rules often disputed between the physician and APN.

The Board also requires the APN to accurately document and maintain appropriate records concerning her patients. These records must then be reviewed by the collaborating physician who monitors compliance with the established protocols. These records may also be reviewed by the Board.

One of the more important differences between the registered nurse and the APN is the prescribing privilege. The regulation of this privilege is monitored by both the Board of Nursing and the Pharmacy Board. Additionally, the collaborating physician is monitored in this area by the Board of Medical Examiners. In order to receive authorization to prescribe the APN must:

successfully complete a recognized program of advanced nursing which includes an advanced course in pharmacotherapeutics; or

successfully complete a program of academic study that:

is approved by the Board;

consists of at least 2 semester credits in advanced pharmacotherapeutics; and

is completed within the 2 years immediately preceding the date the application is submitted to the Board; and

successfully pass a state examination on Nevada law relating to pharmacy.

Additionally, the applicant must document 1,000 hours of active practice in the preceding 2 years as an advanced practitioner under a collaborating physician. The physician must submit a signed statement that indicates her belief that the applicant is qualified to prescribe drugs listed in the practitioners protocols.

Only over‑the‑counter medications may be listed in protocols. Prescription medications are added when applying for the authority to prescribe, but may not be included in protocols when applying for basic APN certification. Controlled substances may not be included in protocols under treatment or management.

An applicant who has practiced in a state other than Nevada within the two years immediately preceding the application to write prescriptions must describe the requirements of that state, including what she was authorized to prescribe and any disciplinary action taken against her.

An APN authorized to prescribe certain poisons, dangerous drugs, or devices, and who changes specialties must reapply for authority to prescribe, meeting all the requirements above-stated, unless the new specialty is sufficiently similar to the current area of practice. Should the collaborating physician change or expand his area of specialty, such that the APN has to prescribe new items, the physician will need to submit a list of the new items and develop new protocols appropriate to these items. The new protocols must follow the same standards set forth above. NRS 632.120,632.237, NAC 632.257, 632.258, 632.259, 632.2595.

Forms and regulations regarding authority to prescribe as well as copies of regulations regarding collaborating physicians and dispensing of medication may be obtained from:

Nevada State Board of Pharmacy

1201 Terminal Way, Room 212

Reno, NV 89502

(702) 322‑0691

Nevada State Board of Medical Examiners

1105 Terminal Way, Room 301

Reno, NV 89502

(702) 688‑2559

Renewal

To renew the advanced practitioner certification, the APN must submit proof that she has reviewed the relevant protocols with the collaborating physician, and show proof of completing a minimum of 800 hours in the specialty area. The APN must also submit a statement that no disciplinary actions have been brought against her, including malpractice actions. Finally, the APN must submit proof of completing 45 contact hours of continuing education.

Revocation

after a hearing, the Board may deny the issuance or renewal of, or suspend or revoke, a certificate of recognition as an Advanced Practitioner of Nursing if it finds that an Advanced Practitioner of Nursing has:

Performed tasks beyond those permitted pursuant to this chapter or otherwise authorized by the board, or breached an approval agreement or a protocol;

Been negligent in performing services for patients;

Impersonated a physician or permitted others to represent to the public that he is a physician;

Represented himself as able to practice without a collaborating physician;

Violated any provision or failed to meet any requirement of this chapter;

Made, or caused to be made, a false, fraudulent or forged statement or representation to procure or attempt to procure a certificate of recognition as an advanced practitioner of nursing;

Violated any statute or regulation relating to prescribing, dispensing or administering any controlled substance, poison, dangerous drug or device; or

Failed to perform nursing functions in a manner consistent with established or customary standards.

A nurse has a constitutionally guaranteed property right in her license. The Fifth Amendment to the United States Constitution has been interpreted as requiring that a practitioner who faces revocation of her license be granted a full hearing prior to such revocation. The requirements for this hearing are described in the section on disciplinary hearings. It is unclear if revocation of the advanced practitioner certification inevitably results in the revocation of the practitioners nursing license.

APPLICATION FOR ADVANCED PRACTITIONER OF NURSING CERTIFICATION

Following are the instructions for the APN certification application:

No processing of application can be completed until ALL items are received. Temporary certification cannot be issued until temporary Nevada RN license number has been issued. A COMPLETE APPLICATION INCLUDES:

Completed application form(s); be certain all “initials” areas are filled.

If prescribing and/or dispensing privileges are desired, complete application(s) for that authority. Submit all documentation requested therein. Applicants for dispensing privileges need to contact the Board office concerning taking the pharmaceutical examination. There is no fee for prescribing or dispensing privileges; dispensing exam fee is $150. Dispensing privileges will not be granted (nor the test administered) until prescribing privileges have been granted.
Check/money order in the amount of two hundred ($200) dollars for the application fee.
Official transcript from an accredited/approved practitioner program. The transcript must come directly from the institution which conferred it. The program must be one academic year or longer in length, and must include four (4) months of classroom instruction.
Documentation of accreditation/approval of practitioner program attended. A letter from program director/school is sufficient.
If applicant completed APN program after July 1, 1992, official transcript documenting graduation from an accredited BSN program OR evidence of current national certification (copies of certificate must be notarized)

All other requirements to which applicant attests on the application form(s) must be on file at each practice site and available for review upon request from the Board of Nursing. The Board staff will conduct random annual audits among certified APNs.

Once an application is completed, a qualified applicant may be issued a temporary certification for basic privileges (no temporary certification is issued for prescribing privileges). Temporary certification is valid until the application is ratified by the Board of Nursing at a regularly scheduled Board meeting. The applicant’s completed file must be received at least four (4) weeks before the Board meeting to be eligible for placement on the meeting agenda. Incomplete files will be held until the next scheduled Board meeting.

NURSE SPECIALTY CERTIFICATION

The State of Nevada recognizes and regulates the clinical nurse specialist. Currently the regulation of the specialist is considerably less detailed than that of the advanced practitioner. Nonetheless, there are several requirements that a nurse must adhere to before she can legally use the Clinical Nurse Specialist title.

Requirements for Title

The minimum requirement for practice are a masters degree in nursing with education in an approved area of clinical specialty. The program of education must be specifically intended for and designed to prepare clinical nurse specialists. There is also a somewhat vague requirement that the clinical nurse specialist must demonstrate competence in the ability to assess, conceptualize and diagnose nursing and complex health problems.

Scope of Practice

The clinical nurse specialist may act directly as an expert clinician in the care of patients. She may also act as a consultant, nurse leader, educator, researcher, or agent.

Renewal

The clinical nurse specialist is not a certified skill, but rather a title recognizing an advanced degree in the field of nursing. As such there is no separate renewal necessary.

Revocation

Because the clinical nurse specialist is not a state certified practitioner, there is no procedure to separately revoke this title. The clinical nurse specialist is subject to all normal disciplinary actions available to the registered nurse and, where degree of skill is an issue, is held to the higher standard of the clinical nurse specialist title. Thus, in malpractice cases, the law will find that a nurse who holds herself out as a clinical nurse specialist should be able to perform nursing functions with the degree of skill of a specialist, rather than that of a registered nurse.

Certified Registered Nurse Anesthetists

Scope of Practice

In contrast to the regulation of certified nurse specialists, the regulation for Certified Registered Nurse Anesthetists (CNA) is extremely specific and detailed. The CNA does not make the determination to administer anesthesia. The doctor, dentist, or podiatrist maintains the decision-making power regarding use of anesthesia. However, the CNA has a broad range of functions under Nevada law once a doctor, dentist, or podiatrist makes the decision to use anesthesia for a test or procedure. Their functions may include the following tasks:

Obtain a history of the patient’s health, as appropriate to the anticipated procedure, test or treatment;
Assess the client’s condition, as appropriate to the anticipated procedure, test or treatment;

Recommend, request, and order pertinent diagnostic studies and evaluate the results of those studies;
Prepare a written preanesthetic evaluation of the patient and obtain the patient’s informed consent for the anesthesia;
Select, order and administer preanesthetic medications;
Order, prepare, and use any equipment and supplies necessary for the administration of anesthesia and perform or order any necessary safety checks on the equipment;
Order and prepare any drugs used for the administration of anesthesia;
Select and order anesthesia techniques, agents and adjunctive drugs;
Perform and manage general, regional and local anesthesia and techniques of hypnosis;
Perform tracheal intubation and extubation and provide mechanical ventilation;
Provide perianesthetic invasive and noninvasive monitoring, as appropriate, and respond to abnormal findings with corrective action;
Manage the patient’s fluid, blood and balance of electrolytes and acid base;
Recognize abnormal response by a patient during anesthesia, select and take corrective action;
Identify and manage any related medical emergency requiring such techniques as cardiopulmonary resuscitation, airway maintenance, ventilation, tracheal intubation, pharmacological cardiovascular support and fluid resuscitation;
Evaluate the patient’s response during emergence from anesthesia and institute pharmacological or supportive treatment to ensure adequate recovery from anesthesia;
Provide care consistent with the principles of infection control and anesthesia safety to prevent the spread of disease and prevent harm to the anesthetized patient and others in the anesthetizing environment;
Select, order and administer post-anesthetic medication;
Report to the person providing post-anesthetic the patient’s physical and psychological condition, perioperative course and any anticipated problems;
Initiate, order and administer respiratory support to ensure adequate ventilation and oxygenation in the immediate post-anesthetic period;
Release the patient from the post-anesthetic care unit or discharge the patient from the ambulatory surgical setting;

Include in a timely manner as a part of the patient’s medical records a thorough report on all aspects of the patient’s anesthesia care; and
Assess the patient’s post-anesthetic condition, evaluate the patient’s response to anesthesia and take corrective action.

NAC 632.500.

Additionally, the nurse anesthetist may accept additional responsibilities which are appropriate to the practice setting and within her expertise. Such responsibilities may include, but are not limited to, the selection and administration of drugs and techniques for the control of pain in the preoperative, intraoperative and postoperative setting.

The Nevada regulations also require the CNA to follow any guidelines established by the facility in which she works. These guidelines must be in writing and approved by the facility and must conform to all applicable statutory and regulatory codes of the state.

Requirements for Certification as a Certified Nurse Anesthetist

The applicant for certification as a certified nurse anesthetist (CNA) must have either a bachelors or masters degree in nurse anesthesia from an accredited school and currently hold a valid license as a registered nurse. Additionally, the applicant must successfully complete a program of training which has been approved by the State Board of Nursing and pass a qualifying exam from a recognized organization.

License Renewal

Certification as a CNA must be renewed biennially when the nurses license is renewed. In addition to meeting the RN license renewal requirements, the CNA must also submit proof of current certification and satisfaction of the continuing education requirements. The CNA must submit evidence of current certification as a nurse anesthetist from the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists. The continuing education requirement for the CNA is 45 contact hours related to the practice of nurse anesthesia, 15 of which must be in anesthesia pharmacology. If the CNA has recertified with the national body within a year of the renewal, the recertification will be considered to have satisfied 40 contact hours of the continuing education requirement. Presumably these hours will also satisfy the continuing education requirement for the RN license renewal.

Revocation

A CNAs license may be revoked as part of a disciplinary action by the Board. Exceeding authority, failing to follow designated procedures, or administering anesthetic without the consent of a doctor, dentist, or podiatrist are grounds for revocation. Additional grounds for revocation include: falsification of certification materials, violations of regulations relating to prescription privileges, and any other practice which is determined to fall below accepted standards of practice. Finally, all grounds for disciplinary action against the CNAs license as a registered nurse are grounds for revocation of the CNA license also.

To obtain more information on advanced nursing practice or the CNA specialty visit the following websites:

National Association of Pediatric Nurse Associates and Practitioners at www.napnap.org

American Association of Nurse Anesthetists at www.aana.com

American College of Nurse Midwives at www.midwife.org

Association of Womens Health, OB, and Neonatal Nurses at www.awhonn.org

STANDARDS OF NURSING PRACTICE

The Nevada State Board of Nursing has created several committees in varying areas of nursing and specialty practices to advise the Board on aspects of their particular standards of nursing practice. These committees appointed by the Board include:

(a) The committee to advise and report on complaints concerning the practice of nursing;

(b) The committee to advise and report on matters relating to the establishment of state standards;

(d) The committee to interpret and comply with the statutory changes within the field of nursing;

(e) The committee to report on matters relating to the practice of advanced practitioners of nursing; and

(f) The committee to review and maintain standards of education and continuing education programs for all areas of nursing.

NRS 632. 073; 632.120; NAC 632.211.

The regulations divide the standards of care into general areas of concern or emphasis. The regulations first identify areas in which a registered nurse shall show competence, including the following:

The diagnosis and treatment of human responses to actual or potential health problems;

Exercising sound judgment;

Making decisions;

Carrying out his duties based on an established plan of care;

Evaluating, assessing and altering, if appropriate, the established plan of care;

Delegating appropriate duties to other nurses;

Supervising a nurse to whom he has delegated nursing duties;

Maintaining accountability in the delegation of care;

Administering medication and carrying out treatments which are properly authorized;

Determining the necessity and appropriateness of health care services for a patient or prospective patient and determining that patients eligibility for payment of those health care services by a licensed insurer;

Managing the cases of patients assigned to him by coordinating services and collaborating with other health care professionals in the provision of health care services;

Planning for the discharge of patients; and

Managing risk in the provision of health care services.

NAC 632.212.

The regulations describe standards of practice which relate to interpersonal dynamics between the registered nurse and colleagues, other healthcare providers, and patients. These regulations state that a nurse shall:

(a) Perform or supervise the direct observation of patients under his care;

(b) Ensure the effectiveness, use and maintenance of procedures used to communicate to other providers of health care a patients symptoms, reactions and progress; and

(c) Recognize, understand and allow for a patients choice regarding his psychological, biological, social and cultural needs and religious beliefs.

NAC 632.214.

The Board has created regulations which detail the standards that apply to patient care as performed by the registered nurse. Registered nurses shall perform the following:

The assessment and evaluation of the health of each patient under his care based on his knowledge or understanding of the biological, psychological, social and cultural factors affecting the patients condition;

The development of a written plan for the care of each patient under his care based on the present and predicted needs of the patient, and shall review and revise that plan if necessary;

The evaluation of a patients health and the initiation of acts which are necessary to provide adequate care to a patient when needed, giving direct care to a patient, assisting with the care of the patient or delegating the care of the patient to persons qualified to provide that care;

Making judgments and decisions regarding the status of a patient and the planning, carrying out, evaluation, and modification of the patients care as needed;

The documentation of observations, assessments and responses of patients and the care provided by nurses for those patients; and

In situations which threaten the life of a patient, acts which are necessary to stabilize the patients condition and prevent more serious complications, performed pursuant to an established policy.

The regulations involving the operating or delivery room setting provide that the registered nurse may perform:

(a) The duties of a circulating nurse or surgical first assistant in an operating room;

(b) Uncomplicated deliveries of infants if:

He is an advanced practitioner of nursing; and

The delivery is performed under the direction of a physician; and

iii. The duties of a licensed practical nurse.

NAC 632. 216.

The Board has promulgated regulations regarding the registered nurses standard of care for maintaining the patients health. These regulations require that the registered nurse must perform or supervise the following:

The identification of the immediate and long‑term goals for the care of patients under his care;
The assessment of the need for and the provision of health education and counseling of a patient under his care based on the needs of the patient, involving the patient and his family and friends, so that the patient may better understand the immediate and long‑term goals for his care;
The recognition of the various psychological and social needs of the patients;
The provision and encouragement of an environment conducive to the safety and health of patients;
The collaboration with other providers of health care to provide safe care for the patient; and
The use of resources in the community to continue the proper care of a patient after he leaves the care of the registered nurse.

NAC 632.218.

Finally, the board defines the registered nurses scope of practice with regard to taking physician orders and administering medications as follows:

A registered nurse shall perform or supervise:

(a) The verification of an order given for the care of a patient to ensure that it is appropriate and properly authorized and that there are no documented contraindications in carrying out the order;

(b) Any act necessary to understand the purpose and effect of medications and treatments and to ensure the competence of the person to whom the administration of medications is delegated; and

A registered nurse shall take orders only from a licensed physician, dentist, podiatric physician or advanced practitioner of nursing. A registered nurse may refuse an order if he takes appropriate action to ensure the safety of a patient.

NAC 632. 220.

The above regulations are more likely to expose the registered nurse to potential litigation and disciplinary action than any other part of the law. It also gives the least deference to the reality of hospital based nursing practice because the code does not take into account the decreasing numbers of nurses, the increasing acuity of the patients cared for by nurses, and the decreased amount of time available for each task. This code section sets the nurse up as the gatekeeper for any decision made by the physician, dentist, or podiatrist, and requires the nurse to pass judgment on physician orders at the risk of employment reprisals or litigation. On the positive side, it is possible that this code section might be used to protect the nurse from such employment based reprisals for refusing to perform a physician order.

A recent case illustrates the potential conflict that occurs when a nurse questions the treatment given to a patient. In Missouri, a nurse noticed that a recently-admitted patient showed several signs of toxic shock syndrome, and attempted to relate her findings to a physician. The physician disagreed and did not order the necessary antibiotics. The nurse went to her supervisor, who also disagreed. Eventually, the nurse contacted a hospital administrator, who agreed with the nurses evaluation. Unfortunately the patient ultimately died from toxic shock syndrome. The nurse, who complained to several other people that her findings were ignored, was fired for violating hospital policy. The Missouri court found that the nurse had a absolute duty to speak up on behalf of her patient, and could not have her employment terminated simply for attempting to advocate for her patient. Kirk v. Mercy Hosp., 851 S.W.2d 617 (Mo. 1993). The case is not binding on Nevada courts; however, Nevada nursing regulations are substantially similar in nature, it is likely that a nurse who exercises her duty to advocate on behalf of a patient, even if doing so goes against a physicians order or even perhaps against hospital policy, cannot be terminated. Nonetheless, it is always advisable to carefully follow the policies of an institution for disagreeing with the care of a patient.

Nevada regulations require a registered nurse to verify any order given for the care of a patient to ensure that it is appropriate and that there are no documented contraindications in carrying out the order. NAC 632.220. Nevada specifically gives registered nurses the authority to refuse an order if [s]he takes appropriate action to ensure the safety of the patient.

Similarly, nursing regulations require that a licensed practical nurse exercise some independent judgment before carrying out an order. A LPN must verify that the order given is appropriate and must verify that there are no documented contraindications in carrying out the order. NAC 632.236. Although not given the specific authority to refuse an order, the LPN is nonetheless given quite a bit of legal freedom to question and verify an order before carrying it out.

Finally, a nurse should not refuse a physicians order unless she is absolutely certain that the patients health will not be further jeopardized by refusing the order. Nevada law only allows a nurse the discretion to refuse an order if she can ensure the continued safety of the patient. In other words, if a nurse refuses an order and she is wrong, and the patient is harmed because the order was not followed and alternative steps to maintain the patients health were not instituted, the nurse will be liable. Although Nevada law gives a nurse considerable discretion, it is always advisable, whenever possible to follow the hospitals policy for recording grievances and disagreements. In particular, follow the hospitals established chain of command, except perhaps in situations when it is clear that following a physicians order will result in immediate irreparable harm to a patient.

DELEGATION AND SUPERVISION OF NURSING CARE

Delegating

The Board recognizes that the registered nurse frequently needs to delegate certain tasks and supervise the practice of others, and has developed regulations to both authorize and control delegations and assignments. Despite the authorization, a nurse who delegates tasks should remain aware of the potential liability if she makes an assignment or delegation that is beyond the scope of the abilities of the person to whom the task is assigned. In general, a registered nurse or a licensed practical nurse may not delegate a task to a person who is not authorized to perform that task. NAC 632.244. Thus, a nurse may not delegate a task to a person if that task is beyond the scope of practice of the person to whom it is assigned. In addition, a nurse who delegates tasks is usually responsible for the performance of the assigned work, thus potentially doubling the liability of a nurse supervisor. As with most instances of negligence, the standard of care is reasonable prudence; if the assignment is made with the level of skill exercised by a reasonably prudent nurse supervisor, she may be able to avoid liability in the event that an incident occurs.

The following regulations provide the guidelines regarding this area:

A registered nurse may delegate nursing care to other nurses and supervise other personnel in the provision of care if those persons are qualified to provide that care.
A registered nurse shall perform or supervise any act necessary to ensure the quality and sufficiency of the nursing care of a patient which is delegated to or by other nurses under his supervision.
Before delegating the care of a patient to another nurse, a registered nurse shall consider the following:

(a) The amount of direction required by the nurse to whom the care is being delegated;

(b) The complexity of the nursing care needed by the patient, recognizing that simple care may be performed by following an established policy while more complex care requires greater knowledge and a higher level of judgment, direction and supervision;

(d) The established policies and procedures relating to the care of the patient and the procedures used to communicate to other providers of health care the patients symptoms, reactions and progress.

A registered nurse who delegates nursing care to another nurse or assigns duties relating to that care to other personnel is responsible for the actions taken by those persons in carrying out the duties delegated or assigned.

NAC 632.222.

Subsections 1 and 2 primarily grant authority to the nurse to delegate procedures when it is necessary and the procedure can be accomplished safely. Sections 3 and 4 set out the requirement that the delegating nurse have extensive knowledge of the skills and competency possessed by the co-worker to whom duties are being delegated prior to delegating such duties. Significantly, these sections provide that liability falls on the registered nurse for the actions taken by a co-worker to whom duties were delegated.

This section also raises questions about who assumes liability for patient care mishaps during break relief. Is the nurse originally assigned to a patients care responsible for delegating care during a break, or is the charge nurse or the hospital responsible for requiring the original nurse to take a break? These sections also raise the question of whether the hospital has a responsibility to ensure that any nurse working in one of its settings is qualified to practice there. If this is the case, the delegating nurse should be absolved of responsibility for relying on the hospitals decision. Unfortunately, these regulations probably leave the nurse open to litigation any time she delegates any care to another practitioner.

Supervising

The tort of negligent supervision often includes within its scope the idea of negligent assignment. Liability can be imposed on a nurse manager who fails to properly supervise a nurse to whom a task was assigned, particularly if the nurse manager was aware, or should have been aware, that the employee was not competent to perform the task. Clearly, if a nurse employee indicates that she is unqualified to perform a procedure, the supervisor will have received the requisite knowledge of incompetence that could lead to liability. In addition, even the failure of a nurse manager to properly allocate the time and resources of the available staff, which was a factor in causing a patients injury, can lead to liability.

Despite the above discussion, taken from common law (case law), the Nevada regulations which govern the supervision of others by the registered nurse are more reasonable than those concerning delegation, mainly because the nurse who undertakes the task of supervision does so voluntarily. The regulations state:

A registered nurse who supervises other persons shall:

(a) Determine the priority of the needs of each patient and group of patients under his care;

(b) Provide direction in formulating, interpreting and carrying out the objectives and policies related to nursing care;

(c) Assist those persons who are being supervised to develop the skills needed for their competence in providing for the care of a patient;

(d) Assist the persons who are being supervised in carrying out the planned care of a patient; and

(e) Evaluate the effectiveness of the nursing care given to each patient or group of patients under his care.

NAC 632.224.

The regulations for the nurse acting or employed as a charge nurse or nurse supervisor provide that:

A registered nurse who is employed as a charge nurse is responsible for the management of other personnel under his supervision and shall:

(a) Establish the authorized scope of practice for the nurses he supervises and establish and document a process to carry out, maintain and improve the knowledge, skills and ability of those nurses to provide safe and effective care.

(b) Before assigning those persons, verify their ability to carry out safely duties which are identified in a written policy and to follow the procedures established by the employing agency.

(c) Establish written guidelines to be followed by personnel under his supervision for receiving and administering prescriptions. The guidelines must include procedures for:

(1) Identifying the type of patient to be served;

(2) Identifying the intended medical treatment; and

(3) Resolving any questions related to a prescription, if the prescription is not received directly from an advanced practitioner of nursing, a licensed physician, a licensed dentist or a licensed podiatric physician.

(d) Ensure that the guidelines established pursuant to paragraph (c) are available at each site where nursing care is provided under the supervision of the chief nurse.

(e) Create a safe and effective system for delivery of nursing care which complies with nationally recognized standards.

(f) Maintain a copy of the references used to determine the authorized scope of practice for the nurses he supervises and make them available to governmental agencies upon request.

If a chief nurse is not assigned to the practice area of a registered nurse, the registered nurse shall determine the authorized scope of his practice and establish and document verification of his competency.

NAC 632.224.

To limit legal liability, a supervising nurse should always try to anticipate and prevent problems before they arise. If staffing shortages force you to make assignments of unqualified or minimally qualified persons, document your actions and the reasons for them. Send a memo to the appropriate supervisor and administrator stating that you were forced to assign unqualified individuals to tasks unsuited to their skills. If appropriate, communicate to other personnel that a unqualified individual will be performing a task and will require additional supervision and assistance.

In addition to legal liability for negligent selection (assignment) and negligent supervision, nurse managers and supervisors face disciplinary action from the Nevada State Board of Nursing. Even if a patient is not harmed, a nurse may be disciplined for assigning or delegating functions, tasks or responsibilities to unqualified persons. Another section of the same regulation states that failing to supervise a person to whom functions of nursing are delegated or assigned will be considered unprofessional conduct that will be disciplined. NAC 632.890.

DISCIPLINARY ACTION BY THE BOARD

General Procedure

One of the most challenging tasks assigned to the Board is to act as the disciplinary body for all categories of nursing licensees. A nursing license is a constitutionally protected property right and the Board is a governmental body regulated not only by Nevada law but also by the due process requirements of the Fifth Amendment of the United States Constitution. Therefore, before suspending or revoking any license or certification, or taking any other action, the Board is required to provide the licensee or certificate holder with proper notice and a hearing.

Proper notice requires that the licensee or certificate holder receive, in writing, a list of the charges against him or her and a copy of any complaint that has been filed. This notice must be either delivered in person or sent via certified or registered mail. This notice must be sent at least 20 days before the hearing date. The licensee must raise any issues of improper notice at the beginning of the hearing, or they will be considered waived. The licensee or certificate holder may request in writing copies of any communications, reports, and affidavits that the board has which relate to the matter under consideration.

Within 30 days of notice or as soon as practicable, the Board must conduct a hearing on the matter. If requested by the licensee or certificate holder, the hearing must be held in the county where she resides. The Board may delegate the actual hearing to a hearing officer, and the officer then acts on her recommendations. The Board is required to reach a decision and notify the licensee or certificate holder of its decision within 60 days after the final hearing. If disciplinary action is taken, the investigative information and the Boards ruling become a public record. NRS 632.350; 632.400.

Nothing in the statutes prevents the licensee or certificate holder from hiring an attorney to represent her before and during a disciplinary hearing. In fact, the regulations explicitly encourage the licensee or certificate holder to seek legal representation. Because few things are as distressing or detrimental to ones career as the loss or suspension of ones license, it is highly recommended that an attorney be consulted before facing the hearing. It is also recommended that the nurse employ an attorney who is independent of the facility where the nurse is employed. This ensures that the attorney will focus on the nurses interests.

Grounds for Disciplinary Action

NAC 632.890 lists thirty-eight separate, specific grounds for which disciplinary actions may be brought. Because these grounds are very specific and exhaustive, they are listed here verbatim:

Discriminating on the basis of race, religious creed, color, national origin, age, disability, ancestry, or sex in the rendering of nursing services;
Performing acts beyond the scope of the practice of nursing;
Assuming duties and responsibilities within the practice of nursing without adequate training;
Assuming duties and responsibilities within the practice of nursing if competency is not maintained, or the standards of competence are not satisfied, or both;
Disclosing the contents of the examination for licensure or certification, or soliciting, accepting, or compiling information regarding the contents of the examination before, during, or after its administration;
Assigning or delegating functions, tasks, or responsibilities of licensed or certified persons to unqualified persons;
Failing to supervise a person to whom functions of nursing are delegated or assigned, if responsible for supervising that person;
Failing to safeguard a patient from the incompetent, abusive, or illegal practice of any person;
Practicing nursing while, with or without good cause, his physical, mental, or emotional condition impairs his ability to act in a manner consistent with established or customary nursing standards, or both;
Practicing nursing if any amount of alcohol, a controlled substance, or dangerous drug that is not legally prescribed is present in the body of the nurse or nursing assistant as determined by a test of the blood, saliva, breath, or urine of the nurse or nursing assistant given while the nurse or nursing assistant is on duty;
Having present in the body of the nurse or nursing assistant, alcohol, a controlled substance, or dangerous drug that is not legally prescribed during a test of the blood, saliva, breath, or urine of the nurse or nursing assistant given as a condition of employment;
Failing to respect and maintain a patients right to privacy;
Violating a patients confidentiality;
Performing or offering to perform the functions of a licensee or holder of a certificate by false representation or under a false or an assumed name;
Failing to report the gross negligence of a licensee or holder of a certificate in the performance of his duties or a violation of the provisions of chapter 632 of NRS or this chapter;
Failing to document properly the administration of a controlled substance, including, but not limited to:

(a) Failing to document the administration of a controlled substance on the Controlled Substance Administration Record, the patients Medication Administration Record and the Nursing Progress Notes, including the patients response to the medication;

(b) Documenting as wastage a controlled substance and taking that controlled substance for personal or other use;

(d) Soliciting the signature on any record of a person as a witness to the wastage of a controlled substance when that person did not witness the wastage; or

(e) Signing any record as a witness attesting to the wastage of a controlled substance which he did not actually witness;

Soliciting services, soliciting or borrowing money, materials or other property, or any combination thereof, from a:

Patient;

Family member of a patient;

Person with significant personal ties to a patient, whether or not related by blood; or

Legal representative of a patient;

Diverting supplies, equipment, or drugs for personal or unauthorized use;
Aiding, abetting, or assisting any person in performing any acts prohibited by law;
Inaccurate recording, falsifying or otherwise altering or destroying records;
Obtaining, possessing, furnishing, or administering prescription drugs to any person, including himself, except as directed by a person authorized by law to prescribe drugs;
Leaving an assignment without properly notifying the appropriate personnel or abandoning a patient in need of care;
Exploiting a patient for financial gain or offering, giving, soliciting, or receiving fees or gifts for the referral of a:

Patient;

Family member of a patient;

Person with significant personal ties to a patient, whether or not related by blood; or

Legal representative of a patient;

Failing to collaborate with other members of a health care team as necessary to meet the health needs of a patient;
Failing to observe the conditions, signs, and symptoms of a patient, to record the information or to report significant changes to the appropriate persons;
Failing to abide by any state or federal statute or regulation relating to the practice of nursing;
Failing to perform nursing functions in a manner consistent with established or customary standards;
Causing a patient physical, mental, or emotional harm by taking direct or indirect actions or failing to take appropriate actions;
Engaging in sexual contact with a patient or client;
Failing as a chief nurse to:

(a) Institute standards of nursing practice so that safe and effective nursing care is provided to patients;

(b) Institute standards of competent organizational management and management of human resources so that safe and effective nursing care is provided to patients; or

(c) Create a safe and effective environment, including the failure to assess the knowledge, skills and ability of a licensee or holder of a certificate and determine his competence to carry out the requirements of his job;

Failing to report the unauthorized practice of nursing;
Endangering the safety of the general public, patients, clients, or coworkers by making actual or implied threats of violence or carrying out an act of violence;
Abusing or neglecting a patient;
Misappropriating the property of a patient;
Failing to comply with a condition, limitation, or restriction which has been placed on his license or certificate;
Engaging in the practice of nursing or performing the services of a nursing assistant without a license or certificate issued pursuant to the provisions of this chapter and chapter 632 of NRS;
Displaying a license, certificate, diploma, or permit, or a copy of a license, certificate, diploma, or permit, which has been fraudulently purchased, issued, counterfeited, or materially altered;
Engaging in any other unprofessional conduct with a patient or client that the Board determines is outside the professional boundaries generally considered acceptable in the profession.

NAC 632.890.

Note that a nurse need not actually engage in unprofessional conduct in order to be disciplined by the Board. Merely aiding another to commit an unprofessional act or failing to report unprofessional conduct is grounds for discipline.

The Board is not restricted to bringing disciplinary action for these listed violations only. As the ultimate arbiter of what is reasonable practice, the Board has wide discretion to bring disciplinary action for any conduct which it considers detrimental either to the individual patient or to the practice of nursing. Beyond formal revocation or fines, the Board is granted regulatory authority to take informal action against a nurse who has received complaints against her. These informal procedures may include conferences or meetings. Such informal proceedings do not preclude the Board from bringing future disciplinary actions against a nurse.

The Board has broad discretion in its choice of disciplinary action. In response to the outcome of a disciplinary hearing, the Board can dismiss the complaint, reprimand the licensee or certificate holder, temporarily suspend the license or certificate, or impose and collect an administrative fine with revocation of a license invoked for failure to pay. The Board may also revoke or deny the license or certification or renewal of same, or put the practitioner on probation, with the terms determined by the Board.

You may obtain notice of proposed regulations, disciplinary hearings, and Nursing Board meetings by filing out the provided form. The request to be placed on the mailing list is valid for six months and must be renewed by mail.

Intentionally left blank

Date ________________________________

Executive Director

Nevada State Board of Nursing

1755 E. Plumb Lane, Suite 760

Reno, Nevada 89505

Dear Executive Director:

As the Nevada legislature has provided in Nevadas Administrative Procedures Act, Nevada Revised Statutes (NRS) 233B.0603, I hereby request to be placed on the Board of Nursings mailing list for all public notices including intent to adopt, amend or repeal regulation(s). Pursuant to NRS 233B.061, I request to be placed on the mailing list for proposed regulations including workshops and/or hearings.

As provided in Nevadas Open Meeting Act, NRS 241.020, I request written notice of all meetings of Board of Nursing and specifically request all materials as provided in NRS 241.020.4 (agenda for public meeting, proposed ordinance or regulation to be discussed, including any other supporting material provided to members of the Board except materials pertaining to the closed portion of the meeting, or materials confidential by law or agreement).

My mailing address is:

Name ____________________________________________

Street Address _____________________________________

City, State Zip ____________________________________

Sincerely,

_____________________________

Signature