A registered nurse (RN) is conducting an initial home health evaluation for an 80-year-old client who recently suffered a stroke. The client's adult child, who is the designated healthcare power of attorney (POA), is present. The RN observes that the client is unkempt, has a stage 3 sacral pressure injury, and flinches noticeably when the adult child approaches. The adult child states, "I keep the bedroom door locked from the outside at night so they don't wander off, and you need to show my aide how to assess that bedsore." Which of the following actions by the RN are legally required and appropriate? (Select all that apply.)
- Initiate a report to the designated state adult protective services agency regarding the suspected neglect and abuse.Answer
- Request that the adult child step into another room so the nurse can interview the client privately about their living situation.Answer
- Inform the adult child that assessing and staging the pressure injury falls strictly within the licensed nurse's scope of practice.Answer
- DPostpone contacting adult protective services until the primary healthcare provider can evaluate the client and confirm intentional neglect.
- EDelegate the task of measuring the depth and documenting the tissue characteristics of the pressure injury to the unlicensed home health aide.
- FEndorse the use of the externally locked bedroom door as an acceptable safety alternative to physical restraints to prevent wandering.
Answer
The correct actions include reporting the suspected abuse to protective services, interviewing the client privately, and clarifying that wound assessment cannot be delegated.
The registered nurse is legally mandated to report any reasonable suspicion of elder abuse or neglect directly to protective services, and doing so requires separating the client from the potential abuser to conduct a safe, private interview. Additionally, the nurse must operate within legal scope of practice guidelines, which dictate that clinical assessments—such as staging a pressure injury—cannot be delegated to unlicensed personnel.
Step-by-Step Solution
Key Concept
Legal Responsibilities: Mandatory Reporting, Proper Delegation, and Restraint Laws