| (III) re-evaluate the nurse's current conduct to determine
if the nurse did complete sufficient remediation and is deemed safe
to practice.
(3) An incident-based nursing peer review committee
is not required to submit a report to the Board if:
(A) the committee determines that the reported conduct
was a minor incident that is not required to be reported in accordance
with provisions of §217.16 of this title; or
(B) the nurse has already been reported to the Board
under TOC §301.405(b) (NPA) (employer reporting requirements).
(4) Unless the exceptions outlined in paragraph (3)(A)
and (B) of this subsection are met, an incident-based nursing peer
review committee shall report a nurse to the Board if it is determined
that the nurse has engaged in conduct subject to reporting.
(5) If the committee determines it is required to report
a nurse to the Board, the committee shall submit to the Board a written,
signed report that includes:
(A) the identity of the nurse;
(B) description of the conduct subject to reporting;
(C) a description of any corrective action taken against
the nurse;
(D) a recommendation as to whether the Board should
take formal disciplinary action against the nurse, and the basis for
the recommendation;
(E) the extent to which any deficiency in care provided
by the reported nurse was the result of a factor beyond the nurse's
control; and
(F) any additional information the Board requires.
(6) If an incident-based nursing peer review committee
determines that a deficiency in care by the nurse was the result of
a factor(s) beyond the nurse's control, in compliance with TOC §303.011(b)
(NPR Law) (related to required nursing peer review committee report
when external factors contributed to a nurse's deficiency in care),
the committee must submit a report to the applicable patient safety
committee, or to the CNO or nurse administrator if there is no patient
safety committee. A patient safety committee must report its findings
back to the incident-based nursing peer review committee.
(7) An incident-based nursing peer review committee
is not required to withhold its determination of the nurse being incident-based
nursing peer reviewed, pending feedback from a patient safety committee,
unless the committee believes that a determination from a patient
safety committee is necessary in order for the incident-based nursing
peer review committee to determine if the nurse's conduct is reportable.
(A) If an incident-based nursing peer review committee
finds that factors outside the nurse's control contributed to a deficiency
in care, in addition to reporting to a patient safety committee, the
incident-based nursing peer review committee may also make recommendations
for the nurse, up to and including reporting to the Board.
(B) An incident-based nursing peer review committee
may extend the time line for completing the incident-based nursing
peer review process (extending the 45 days by no more than an additional
45 days) if the committee members believe they need input from a patient
safety committee. The incident-based nursing peer review committee
must complete its review of the nurse within this 90-day time frame.
(8) An incident-based nursing peer review committee's
determination to report a nurse to the Board cannot be overruled,
changed, or dismissed.
(j) Nurse's Duty to Report.
(1) A report made by a nurse to a nursing incident-based
nursing peer review committee will satisfy the nurse's duty to report
to the Board under TOC §301.402 (mandatory report by a nurse)
provided that the following conditions are met:
(A) The reporting nurse shall be notified of the incident-based
nursing peer review committee's actions or findings and shall be subject
to TOC §303.006 (confidentiality of nursing peer review proceedings);
and
(B) The nurse has no reason to believe the incident-based
nursing peer review committee made its determination in bad faith.
(2) A nurse may not be suspended, terminated, or otherwise
disciplined, retaliated, or discriminated against for filing a report
in good faith under this section and TOC §301.402(f) (retaliation
for a report made in good faith prohibited) or advising a nurse of
the nurse's rights and obligations under this section and §301.402(f).
A violation of this subsection or TOC §301.402(f) is subject
to TOC §301.413 that provides a nurse the right to file a civil
suit to recover damages. The nurse may also file a complaint with
the regulatory agency that licenses or regulates the nurse's practice
setting. The BON does not have regulatory authority over practice
settings or civil liability.
(k) State Agency Duty to Report. A state agency that
has reason to believe that a nurse has engaged in conduct subject
to reporting shall report the nurse in writing to:
(1) the Board; or
(2) the applicable nursing peer review committee in
lieu of reporting to Board.
(l) Integrity of Incident-Based Nursing Peer Review
Process.
(1) Incident-based nursing peer review must be conducted
in good faith. A nurse who knowingly participates in incident-based
nursing peer review in bad faith is subject to disciplinary action
by the Board.
(2) The CNO or nurse administrator of a facility, association,
school, agency, or of any other setting that utilizes the services
of nurses is responsible for knowing the requirements of this rule
and for taking reasonable steps to assure that incident-based nursing
peer review is implemented and conducted in compliance with the NPA,
NPR Law, and this section.
(3) A determination by an incident-based nursing peer
review committee, a CNO, nurse administrator, or an individual nurse
to report a nurse to the Board cannot be overruled, dismissed, changed,
or reversed. An incident-based nursing peer review committee, CNO,
and individual nurse each have a separate responsibility to protect
the public by reporting a nurse to the Board as set forth in TOC §§301.402,
301.405, 217.11(1)(K) of this title, and this section.
(m) Reporting Conduct of other Practitioners or Entities:
Whistleblower Protections.
(1) This section does not expand the authority of any
incident-based nursing peer review committee or the Board to make
determinations outside the practice of nursing.
(2) In a written, signed report to the appropriate
licensing Board or accrediting body, and in accordance with TOC §301.4025
(report of unsafe practices of non-nurse entities), a nurse may report
a licensed health care practitioner, agency, or facility that the
nurse has reasonable cause to believe has exposed a patient to substantial
risk of harm as a result of failing to provide patient care that conforms
to:
(A) minimum standards of acceptable and prevailing
professional practice, for a report made regarding a practitioner;
or
(B) statutory, regulatory, or accreditation standards,
for a report made regarding an agency or facility.
(3) A nurse may report to the nurse's employer or another
entity at which the nurse is authorized to practice any situation
that the nurse has reasonable cause to believe exposes a patient to
substantial risk of harm as a result of a failure to provide patient
care that conforms to minimum standards of acceptable and prevailing
professional practice or to statutory, regulatory, or accreditation
standards. For purposes of this subsection, an employer or entity
includes an employee or agent of the employer or entity.
(4) A person may not suspend or terminate the employment
of, or otherwise discipline, retaliate, or discriminate against, a
person who reports, in good faith, under this subsection or who advises
a nurse of the nurse's rights and obligations under this subsection.
A violation of this subsection is subject to TOC §301.413 (NPA)
that provides a nurse the right to file a civil suit to recover damages.
The nurse may also file a complaint with the regulatory agency that
licenses or regulates the nurse's practice setting. The BON does not
have regulatory authority over practice settings or civil liability.
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