Case Studies

Background

A nurse assigned to care for patients in a skilled nursing facility removed medications for multiple patients from the medication cart for the following day. She placed the medications into small baggies marked with each patient’s first name, last initial, and room number, and then placed these smaller baggies into a large bag. The nurse then placed that bag in the drawer of the medication cart so they were ready for her medication administration pass on her next shift. Upon her arrival the following day, she noted that the large bag of medications was no longer in the drawer. She again removed all scheduled morning medications for her patients; however, this time she placed them into medication cups marked with patient identifiers and documented the medications as administered, even though they had not yet been administered.

What Went Wrong:

• The nurse demonstrated a pattern of failure to maintain minimum standards of acceptable nursing practice, such as the “Five Rights” of medication administration, which ensure a nurse is administering to the right patient the right medication, the right dose, and the right route at the right time.
• The nurse failed to maintain a patient record that accurately reflected the nursing care provided and made a materially incorrect entry in the medical record by documenting that the medications had been administered, when they had not been.

Why it Matters

Following principles of safe nursing practice helps to prevent medication errors, protect patients from harm and ensures an accurate record of care, which is vital for continuity of care, communication among team members and legal accountability.

Standard of Practice:

• Remove medications for each individual patient just prior to administration to reduce the risk of medication errors, which can lead to serious patient harm or even death.
• Follow acceptable nursing practice standards, like the “Five Rights” of medication administration, to provide consistent and high-quality care and protect oneself from legal liability.
• Ensure documentation is completed timely and is accurate, concise and clear.

Reflection Questions

• What are your responsibilities and accountabilities as a nurse in regards to medication administration?
• What is my employer’s policy or procedure for medication administration and medication documentation?
• What are the legal implications of any inaccuracies or omissions in my documentation?
• How can I improve my workflow to become more efficient in a way that maintains quality of care and acceptable nursing standards?

Background

In the interest of public safety and professional transparency, the Board highlights the case of an RN applicant whose failure to disclose past criminal history resulted in disciplinary action before licensure was granted. This case serves as a vital reminder that the path to nursing begins with absolute honesty during the application process.

Lessons Learned:

• Disclosure is Not Optional: You must report all criminal offenses. In this case, incidents from 1996 and 2024 were not disclosed; leading to an investigation.
• The “Dismissed” Rule: Even if charges were dismissed, you must still report the arrest or citation when the application specifically asks for it.
• Administrative Accuracy is Your Responsibility: Electronic signatures on applications serve as a declaration that all statements are true in every respect.
• Past Conduct Impacts Current Standing: Conduct such as theft from an employer can be viewed as “unprofessional conduct” that might be harmful to the public.
• Financial and Time Costs of Non-Disclosure: Failure to be transparent can result in civil penalties (e.g., $250.00) and strict 60-day deadlines for payment, or your application will be denied.

Why it Matters

Integrity is the foundation of the nursing profession. The Board must ensure that those entering the field demonstrate the honesty required to manage patient records, medications, and sensitive information.

Three Key Takeaways:

• Read the Application Questions Literally: If the question asks if you have ever been cited or charged, “No” is only acceptable if your record is entirely clear.
• The Board Investigates Independently: The Board conducts thorough investigations; do not assume a “minor” or “old” incident will not be found.
• A Consent Agreement is Public Record: Disciplinary actions are reported to national databases; affecting your professional footprint permanently

Reflection Questions

• Have I suppressed any information that would affect the Board’s view of my safeness to practice?
• Do my past actions, even those resolved legally, align with the ethical and legal standards of the nursing profession?
• Am I prepared to handle the public and financial consequences of a “failure to disclose”?

Background

This case study, involving Nurse A, provides critical lessons regarding the professional and legal expectations for nursing applicants and licensed professionals in Arizona. Following an investigation into her April 2024 application, the Board issued a $250 Civil Penalty as a condition for licensure due to her failure to disclose criminal history.

The Key Takeaways:

The nurse practitioner:

• Honesty in the Application Process is Mandatory: Applicants must disclose all required criminal history, including charges or arrests, even if the charges were eventually dismissed or resolved through a diversion program. In this case, Nurse A failed to disclose a 2022 shoplifting arrest and a 2023 criminal trespassing arrest.
• “Unprofessional Conduct” Includes Deceit: The Board defines “unprofessional conduct” to include committing fraud or deceit when attempting to obtain a license. Making false or inaccurate statements during an investigation or on an initial application is a specific violation of the Nurse Practice Act.
• Previous Diversion Programs Do Not Erase Disclosure Requirements: While Nurse A successfully completed a diversion program for her shoplifting charge, leading to its dismissal, she was still legally required to report the initial offense and subsequent court-ordered actions to the Board.

Why it Matters

Integrity is the cornerstone of the nursing profession. The Board’s primary responsibility is to protect the public interest by ensuring that all licensees meet ethical and legal standards. When an applicant suppresses information, it undermines the Board’s ability to accurately assess their fitness to practice safely. Furthermore, failure to disclose such information can lead to denial of licensure or civil penalties.

Reflection Questions

• Am I fully aware of my reporting obligations? Do I understand that “minor” incidents or dismissed charges often still require disclosure under the specific rules of the Nurse Practice Act?
• How does my conduct outside of the workplace reflect on my professional standing? Am I mindful that actions such as shoplifting or trespassing are categorized as “unprofessional conduct” that can jeopardize my license?
• Do I prioritize transparency over the fear of consequences? When faced with a difficult disclosure, do I recognize that honesty is always the safer path than attempting to suppress information that the Board will likely discover during its investigation?

Background

A nurse practitioner treated a patient with complex health needs. Over time, their communication became overly personal. The nurse texted phrases like “You are my girl” and “I love you” and even sent a teddy bear. She also admitted to drinking alcohol while on the phone with the patient. When the patient unexpectedly came to the nurse’s home, the provider called the police and ended the care relationship. Upon review, the Board found that the nurse had also falsely documented the visits.

What Went Wrong

The nurse practitioner:

• Violated professional boundaries
• Practiced under the influence of alcohol
• Misrepresented the care provider in the documentation

These actions violated several provisions under Arizona law and Board rules, including failure to maintain objectivity, accurate records, and safe professional conduct.

Why it Matters

Nurses often care deeply for their patients—but blurred boundaries can harm judgment and trust. Even actions that feel compassionate can lead to emotional dependency or confusion for the patient. Professional boundaries are not barriers to kindness—they are safeguards for everyone involved.

Standards of Practice

• Use only professional and secure communication tools—never personal phones or social media.
• Keep messages clinical, clear, and supportive—but not emotional or personal.
• Avoid giving gifts or discussing your private life with patients.
• Never practice while impaired by any substance—even off-site or virtually.
• Always document truthfully: reflect on who delivered care and what occurred.
• Consult a supervisor or ethics resource early if you feel emotionally entangled or over-involved.

Reflection Questions

• Would I feel comfortable having my communication with this patient reviewed by my supervisor?

Background

A nurse practitioner failed to report a 2017 misdemeanor charge for assault. Over the next five years, she answered “No” on both her RN renewal and APRN certification applications when asked if she had any criminal history not previously reported. Later, she also inaccurately documented that a quadriplegic patient could self-propel a wheelchair, which delayed essential equipment.

• The nurse practitioner: ! Did not notify the Board of a criminal charge within 10 days (as required by law)
• Incorrectly answered Board applications in 2019 and 2021

Entered inaccurate patient documentation These actions violated multiple Arizona nursing rules, including failure to disclose, misrepresentation on official forms, and failure to provide accurate patient care documentation.

Why it Matters

Failure to disclose-even if charge is dismissed-can seriously damage a nurse’s credibility and license status. The Board must be able to trust that all information submitted is truthful. Inaccurate documentation also risks patient safety and delays care.

Standards of Practice

Always report criminal charges to the Board within 10 days-even if you think it’s minor or resolved.

• Review each license or renewal application carefully. When in doubt, disclose.
• Remember: Honesty on applications is legally binding-false answers can lead to disciplinary action.
• Document patient assessments and care plans with accuracy and clarity.
• If you’re unsure how to document a complex case, ask for guidance.

Reflection

• Have I ever assumed something didn’t “count” and failed to report it?
• Would my documentation stand up to review by a licensing board or another provider?

Background

While working as a staff labor and delivery registered nurse (RN), the nurse performed an amniotomy (rupture of the amniotic membranes) of a laboring patient without the involvement of a provider, or a provider’s order. The nurse made comments about wanting to do something to move along the patient’s labor/delivery and informed the patient’s spouse that she did not share her actions with anyone prior to performing the amniotomy. The facility policy states that “It is not within the scope of practice for a registered nurse to perform an amniotomy.” The Arizona State Board of Nursing’s Advisory Opinion on Amniotomy concludes that it is not within the scope of practice for a RN to break amniotic membranes. The nurse inaccurately documented that the patient’s amniotic membranes broke spontaneously.

Findings of Fact

The nurse practiced outside of the scope of an RN when she performed an amniotomy on a patient.

The standard of practice for an RN is to follow state-issued standards of practice and organizational policy. The nurse violated the facility’s organizational policy and the standard of practice when she performed an amniotomy.

Additionally, it is the standard of practice of an RN to document accurately and truthfully and communicate honestly with colleagues regarding their actions. Respondent violated the standard of practice when she failed to inform her colleagues of her actions and documented that the patient’s amniotic membranes broke spontaneously.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

8. Falsifying or making a materially incorrect, inconsistent, or unintelligible entry in any record: a. Regarding a patient, health care facility, school, institution, or other workplace location; or

9. Failing to take appropriate action to safeguard a patient’s welfare or follow policies and procedures of the nurse’s employer designed to safeguard the patient;

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed. And currently cited as Rule R4-19-403: 2. Demonstrate honesty and integrity;

Board Outcome

The Board offered a Consent Agreement for a Decree of Censure as there was concern that the actions taken were willful, without regard to policy, and could have had an impact on the safety of patients. The nurse agreed to and signed the Decree of Censure. A Decree of Censure is a disciplinary action that does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and/or incompetent practice.

Background

A Registered Nurse (RN) opened a mobile IV hydration clinic in 2019 and employed RNs to provide treatment to clients. The RN reviewed the clients’ present illnesses, medical histories, current medications, and allergies and noted them in their charts. The RN took vital signs and completed the assessments. The clients were given an IV hydration menu, and the RN compounded the IV fluids with the supplements of choice using “Standing Orders.” The clients were never assessed by a provider, but if an RN had any concerns they could reach out to the Medical Director.

Findings of Fact

The nurse was practicing out of scope when he assessed and diagnosed clients’ need for treatment without a provider assessment. During this time, the RN also practiced outside of scope when he compounded intravenous solutions with supplements, which according to Arizona revised Statute (ARS) 32-1961 is unlawful for any person except a pharmacist or a pharmacy intern acting under the direct supervision of a pharmacist. The RN practiced outside of scope when he administered medications in a dose and/or via a route that was not ordered by a provider, but was decided by the clients. The RN employed and supervised other RNs working at the clinic performing similar activities.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

1. A pattern of failure to maintain standards of acceptable and prevailing nursing practice;

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board issued a Decree of Censure, a disciplinary action, for a violation of the scope of nursing practice. A Decree of Censure does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and incompetent practice.

Background

Patient XX, a 38-year-old female admitted to a behavioral health facility on a Court Ordered Evaluation (COE) for a diagnosis of bipolar disorder, consistently refused psychiatric medications. Patient XX was not under Court Ordered Treatment (COT), and the patient was fighting the petitions in court.

Nursing staff noted in Patient XX’s medical record that the patient refused psychological medications because Patient XX felt the medications were unnecessary, was terrified of possible side effects, and taking the medications went against her beliefs. Patient XX occasionally took over-the-counter medications for pain and sleep. The nurse administered a psychiatric medication by putting the medication into Patient XX’s applesauce without her knowledge or consent. The nurse reported that the patient was emotionally labile, anxious, and agitated, and the nurse thought the medication would help the patient.

Findings of Fact

The nurse knowingly administered an ordered medication to Patient XX, which the patient had previously refused, by putting the medication into the patient’s food without the patient’s knowledge. The standard of practice requires the RN to honor a patient’s right to refuse a medication.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-402 (B):

2. Demonstrate honesty and integrity;

8. Respect a client’s rights, concerns, decisions and dignity;

And Rule R4-19-403:

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board offered a Consent Agreement for a Decree of Censure, which the nurse agreed to and signed. A Decree of Censure is a disciplinary action that does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and incompetent practice.

Background

Patient XX, a 30-year-old female with a history of infertility and thickening of her uterine lining. Patient XX was scheduled for an endometrial biopsy to determine the cause of the thickened uterine lining.

A nurse in an infertility clinic received training to perform endometrial biopsies from a clinic physician. The nurse then scheduled and performed an endometrial biopsy on Patient XX, which resulted in abnormal uterine bleeding for ten days.

Findings of Fact

The nurse practiced beyond her scope when she performed an endometrial biopsy on Patient XX. An RN shall perform only those nursing activities for which the RN has a foundational education through a nursing program, and continued didactic and clinical training for advanced procedures, which are within the scope of practice of an RN as determined by the Board.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601(27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board offered a Consent Agreement for a Decree of Censure, which the nurse agreed to and signed. A Decree of Censure is a disciplinary action that does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and incompetent practice.

Background

A nurse practitioner (NP) was reported to the Board for alleged fraudulent documentation and billing practices. The NP documented that she had a telehealth visit with Patient XX, but Patient XX confirmed that no visit took place on the date in question. After an investigation and chart reviews by the practice’s Compliance and Risk Management Department, it was found the NP had copied and pasted 47% of her visit notes, 34% of the visits did not occur or did not occur at the stated time and duration, and 12% had incorrect billing codes or point of service. It was noted that the NP also documented and billed for an in-office visit for Patient XX, which had been held via telehealth. She stated this was her first employment as a NP and she was told to copy and paste notes during her orientation training by another provider. The NP stated she did not receive billing and coding training during her orientation, and the electronic health record had telephonic, and in-person visit options, but not a telehealth.

Finding of Facts

The nurse practitioner violated the standard of practice for nurse practitioners when she did not correctly document and bill appointments using correct visit codes; copied and pasted visit notes; did not accurately document visit notes to reflect the information shared and discussed during the visit; and documented and billed for an appointment that never occurred.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601 (27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or the public.

(g) Willfully or repeatedly violating a provision of this chapter or a rule adopted pursuant to this chapter.

(j) Violating this chapter or a rule that is adopted by the Board pursuant to this chapter.

And currently cited as Rule R4-19-403:

1. A pattern of failing to maintain minimum standards of acceptable and prevailing nursing practice;

7. Failing to maintain for a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to the patient;

8. Falsifying or making a materially incorrect, inconsistent, or unintelligible entry in any record: a. Regarding a patient, health care facility, school, institution, or other work place location;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board offered the nurse practitioner a Consent Agreement for a Civil Penalty of $1,000, to be paid in full in 60 days, which the NP agreed to and signed. A Civil Penalty is a disciplinary action that does not encumber the nurse practitioner’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the NP is published online, which is intended to protect the public from unsafe and incompetent practice. The NP was also placed on probation for 12 months with stipulations that include an Ethics evaluation, continuing education requirements for documentation and billing, chart reviews, and direct supervision while in the clinic.

Background

Patient XX, an 87-year-old female with heart failure, diabetes, and an altered mental status, who resided in a nursing home. Patient XX turned off her bed and chair alarms, was often restless, and had recently experienced an increase in falls.

A former nursing home Director of Nursing, who was currently working as a nursing home staff nurse, was caring for Patient XX. The nurse was also responsible for many other patients, passing medications, and assisting patients in getting ready for bed. Staffing levels did not support 1:1 supervision on Patient XX to prevent additional falls, so the nurse placed Patient XX into a recliner and placed a coffee table under the foot rest of the recliner to prevent Patient XX from getting out of the chair and falling again.

Findings of Fact

The Centers for Medicare and Medicaid Long Term Care Restraint guidelines state, “The resident has a right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms. For this purpose, “convenience” is defined as “any action taken by the facility to control a resident’s behavior or manage a resident’s behavior with a lesser amount of effort by the facility and not in the resident’s best interest.”

The nurse did not have, nor did the nurse attempt to obtain, an order to initiate a restraint.

Conclusions of Law

Currently cited as ARS § 32-1663 (D) as defined in § 32-1601(27) (effective September 29, 2021)

27. “Unprofessional conduct” includes the following, whether occurring in this state or elsewhere:

(d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or public.

(j) Violating this chapter of a rule that is adopted by the board pursuant to this chapter.

And currently cited as Rule R4-19-403:

9. Failing to take appropriate action to safeguard a patient’s welfare or follow policies and procedures of the nurse’s employer designed to safeguard the patient;

12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse;

31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed.

Board Outcome

The Board offered a Consent Agreement for a Decree of Censure, which the nurse agreed to and signed. A Decree of Censure is a disciplinary action that does not encumber the nurse’s license or certification but is reported to the national nurse licensing and disciplinary information system, and the name of the nurse is published online, which is intended to protect the public from unsafe and incompetent practice.