Physical Neglect. Many LPNs, CNAs, RNs so accused believe that they were fired for no real reason or without evidence. Usually these charges arise out of employment at nursing homes, rehabilitation centers and hospitals. One of the aides I worked with at that time went around and told everyone this patient had C-Diff. In some cases, persons whose names are listed as alleged perpetrators in a central registry have asserted that the listing of their name in the registry deprives them of a constitutionally protected interest without due process of law. what happens if a cna is accused of abuse. Were any witnesses present during the alleged assault (e.g., roommate, other staff)? the facility handled this correctly. Irwin Zalkin, a San Diego lawyer who represents about 120 people who have filed sex abuse claims against the diocese, has alleged . Battery involves using force against a patient. avana capital corporation. Section 1395i-3(g)(1)(C); 42 U.S.C. Nevertheless, such caregivers lose their jobs every day in New Jersey for offenses which would be excusable in most other fields of employment. THINK before your interactions with patients (and everyone else for that matter). All healthcare workers are required by law to report actual or suspected abuse. I wouldnt go near her without someone else with me. By using the site you agree to our Privacy, Cookies, and Terms of Service Policies. Physical Restraints When incontinence is a problem it should be cleaned up promptly. Assault and Battery When laws are not obeyed you can be prosecuted and found liable (responsible) for injury and damages. I'm matching you with one of our specialists who will be calling you in the next few minutes. Your innocence does not protect you. 1. be honest at all times. salesforce sandbox url format. An MD order is always in place for these items. Examples of medication errors include: Slicing or cutting a pill that shouldn't be split: This can include tablets or capsules that carry the instructions not to crush. Yes, I was paid my base salary for the time missed, but not the shift differential or overtime I would have made. For a nurse in such a situation, legal counsel is necessary to clear your name and your reputation. It simply isn't worth risking your career, reputation etc. A lap tray being used with a wheelchair is a restraint if the patient cannot remove it. Be careful. Y pride and joy did it for my kids and because I know what it is like to be alone and feel alone. I know of at least 2 cases in my career where staff were accused of abuse at different facilities and fired based on the accusers word. . Are you looking for a new way to recruit nurses for your open positions? A. Further information on the penalties . 6. do not get personally involved. You can't do anything right. You got paid, and don't have to deal with her anymore. Involuntary seclusion, Physical Abuse: Bed rails and the pads sometimes used on them Q. The attorney can be helpful in ensuring the nursing home abuse investigation is doneaccording tothe nursing homes policies and is fair and unbiased. Ive also seen aides steal jewelry and clothing from patients. What can you tell me about your work experience as a Certified Nursing Assistant? Restricts movement of ANY and ALL body parts By instructing the caregiver on the procedures and how to give testimony, by explaining to the caregiver what is important and what is not, by assisting the state to understand our side, the attorney makes the hearings go more smoothly, often with better results. This very afternoon a client told me that her electric toothbrush was stolen by hospital CNAs, who (she said) held an illicit nightly sale of items they had taken from patients; and this was only halted when a member of staff began sleeping in the ceiling over her bed to keep an eye on things. They are wrong. Under very few circumstances can we interfere with this right. Still, I was guilty until proven innocent. Residents are human like the rest of us, and certified nurses aids naturally need to treat them the same way they want to be treated decades from now. Being falsely accused of child sexual abuse carries great potential for stigmatization and damage to one's reputation, as denial of child abuse by the accused party, is not . Having to bite that bullet report it and still get fired and your lisence taken. https://EzineArticles.com/expert/Marc_Garfinkle/308258, 2023 EzineArticlesAll Rights Reserved Worldwide, Differences Between Civil Vs Criminal Litigation, Two Important Steps When Putting On an Expert Witness In a Criminal Jury Trial, Why You Should Always Wear You Best Suit in a Criminal Jury Trial, Criminal Lawyers - Criminal Defence Strategies. They are sure that they cannot be fired without proof that they did something wrong. They grieve, and anger is a part of everyone's grief process. 4 Articles; Battery is even more serious. 46.90 (1) (f), the failure of a caregiver to try to secure or maintain adequate care, services, or supervision for an individual, including food, clothing, shelter, or physical or mental health care. Please log in or register to answer this question. cdc zombie preparedness 2021; how did the treaty of versailles lead to ww2; marilyn mulvey opera singer; hidden cosmetics owner; pre insulated pex pipe Calling the attention of others to the patients behavior. In the hospital setting, a patient CAN leave the hospital without a doctors permission. State laws also may impose penalties on any perso\ n who knowingly makes a false report of abuse or neglect. We try our best to provide the most accurate info. This investigation conducted by the nursing home is crucial to what follows for the nurse. Each BON has a process for investigation and varying . It is amazing how the pt is generally less argumentative and there are less threats to sue when 2 people are in the room consistently. Male drs have a female nurse during pelvic exams but what do the male nurses and CNA's have for foley placement, baths and peri care? Its NEVER acceptable to do this. Marc Garfinkle is a New Jersey trial lawyer with expertise defending health care providers who are charged with neglect, abuse and other violations of their licenses. Low self esteem. As with Sexual Harassment policies, this harassment need only be considered as such by the patient without regard to your intentions. Although it is not necessary to retain an attorney for these hearings, it is usually wise to do so, if you can afford to. One of the most obvious is if a patient is being physically abused. What do I do? It really helps to wait and come back later when a confused patient refuses care. Being accused of workplace bullying can be upsetting. The abuse started around midnight that day, when Zhao accused the victim of not keeping her son's toys properly. when one of these accusations came along, the same procedure was followed. When a CAN, LPN or HHA is accused of abuse and neglect in New Jersey, the facility (nursing home, agency, rehab center, hospital), must investigate the event and report the matter to the Department of Health and Human Services in Trenton. A residents missing a meal would also be a form of neglect. How do I turn a CNA in for drug addiction? Alcohol abuse costs American industry over $165 billion each year. Best products for fecal incontinence. The nurse in this unfortunate positiondenies the allegations but is very concerned about how this false accusation will affect him and he has good reason to be concerned. Be considerate of your patients values and morals. We are not affiliated with any organizations or state registries. My depression had not lifted up. If the nursing home policies allow, the nurse attorney or attorney would most probably advise the nurse to file a grievance because of his firing. A good care plan, communication with everyone, documentation and other interventions should really be in place to prevent the resident from having outbursts in the first place. It is also abuse if a nursing assistant (or anyone else) is taking money or personal property from a patient. the BRN launches its own investigation and imposes disciplinary action accordingly. The board can impose the following escalating levels of disciplinary action: letter of reprimand, letter of concern to the nurse's employer, monetary fine, civil penalty, suspension-temporary pending findings, suspension-for a specific time period, probation, or permanent license revocation. Basics of Civil and Criminal Federal Asset Seizure and Forfeiture, Differences Between Civil and Criminal Law, Criminal Defense Lawyer Files: Exactly Why Child Abuse Must Be Stopped, The Difference Between Civil and Criminal Offenses, General Practitioner Lawyer Vs Focused Practice Lawyer, CNAs and LPNs Charged With Abuse Or Neglect of Patients - What to Expect, https://EzineArticles.com/expert/Marc_Garfinkle/308258, http://ezinearticles.com/?CNAs-and-LPNs-Charged-With-Abuse-Or-Neglect-of-Patients---What-to-Expect&id=2645917. Even as a CNA (while in nursing school) I had a policy that covered both my activities as a student nurse and as a CNA. Placing a patient in a wheelchair away from others For Nurses New to Home Care Answer (1 of 2): All accusations must be investigated. They are much easier to take than you imagine on a specific subject. How should a nursing assistant respond if they see another nursing assistant or nurse, abusing a patient? I'm glad to hear this is over, but I think I know how you feel. If the allegation is found to be untrue, he would most likely be reinstated to his position and other legal concerns would be eliminated. In Opinion 8.10, "Preventing, Identifying and Treating Violence and Abuse," the Code explains that all patients may be at risk for interpersonal violence and abuse, which may adversely affect a patient's health or ability to adhere to medical recommendations. Examples of physical restraints: Defamation is not a crime, and you can't press charges for it. Hand Mitts He was under the impression that the vanc was to run 24 hours. There is no private cause of action in HIPAA. Specializes in geriatrics. The only solution for us was to get him out of our lives as much as possible. Unfortunately, false accusations often occur against psychiatric nursing staff. The nurse on the previous shift also a male had failed to do so. Keep up to date with your skills and education and in-service requirements. These are restraints as well, but are often referred to as enablers because they assist the patient with ADLs. If something falls onto the floor, pick it up promptly to prevent falls. These terms are not all about hitting and hurting patients like so many of us have been taught. Take steps to help the patient avoid being abused at the time it is happening and then take steps to make certain it does not happen again. ? The worst of us live there. Bottom line, don't risk it. This will prevent falls and injuries. A nurse aide who wishes to contest a finding of resident neglect, resident abuse, or misappropriation of resident property made against the aide, is entitled to an administrative hearing as provided by the Administrative Procedure Act, Chapter 150B of the General Statutes. 1) a substantiated finding,; 2) A conviction in a criminal proceeding (whether plea bargain, no contest, or found guilty via Trial); 3) And lastly, ANY ADMISSION by the accused, such as ADMITTING in WRITING (do not sign anything!) Brent has conducted many seminars on legal issues and has published extensively in the area of law and nursing practice. If a nurse violates HIPAA, a patient cannot sue the nurse for a HIPAA violation. As a result of this allegation, I am no longer required to provide care to this person, which solves the immediate problem. Last, but by no means least, is the potential for a professional licensure action against the nurse by the state board. Its also about mental abuse, verbal abuse and other more subtle forms. Teasing the patient Should I lie to him? In both cases the staff had excellent work records and no one, I mean no one, believed that they abused the pts. I cried so hard on the other side of that phone. 3. do not accept gifts or tips. 131E-256(b) must access the Health Care Personnel Registry and note each incident of access in their business files. What rights does the CNA have? Specializes in Med nurse in med-surg., float, HH, and PDN. In most cases, they did move the employee to a different unit while the investigation was taking place (which is a bit fairer to me). Choosing a specialty can be a daunting task and we made it easier. If the nurse voluntarily enrolls in the BRN's Diversion or Intervention Program; 2.) In New Jersey, Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) are often accused by their patients or employers of neglect or abuse of patients in their care. Its findings should be provided in writing, and the investigation should be done as quickly as possible. Got accused for something and everything I expressed privately with the other employee they turned it on me. Signs of Alcohol Use at Work The patient has dementia and the housekeeper went into her room to clean I assumed and the dementia patient must have said something to her and the housekeeper took it to another level. You are legally and ethically required to take steps to stop abuse when you see it occurring. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. (Graphic). Zhao told the victim, then 25, to "stand properly" and slapped her forcefully 10 . The only time when force would be acceptable would be to prevent the resident from harming him or herself or others. when the character of that person is injured. I returned to work and began college at the age of 50, after spending 20 years as a full time homemaker. Tolerating or ignoring inappropriate behaviors occurs for multiple reasons, including ignorance, fear of retaliation, the need for peer acceptance, and concerns for personal advancement. Fortunately, however, most allegations against CNAs and LPNs are for minor offenses. It doesnt matter whether she knows better or not. An experienced attorney can often successfully defend charges of abuse and neglect and save the license and reputation of the caregiver. She brings more than 30 years of experience to her role of legal information columnist. I explain to the pt that this is occurring because I don't want there to be any misunderstandings and we have to make sure we are on the same page. Abuse can be a serious problem that damage residents, their families, the care facility, your career and the entire profession. We need all the honest people we can get in this work- dont be scared or indifferent to report theft you witness. Specializes in Community Health, Med-Surg, Home Health. Within a two-year period (1999-2000), Congressional investigators found that one in three U.S. nursing homes was cited for an abuse violation, and abuse in 256 nursing homes across the country was so serious that it put elderly lives in jeopardy or resulted in death. the patient was also given a thorough assessment by a physician that included a sexual abuse evaluation. She is very thin and frail. As stated in 105 CMR 155.003, abuse includes: Intimidation or punishment resulting physical harm, pain, or mental . YOU place a tray of food in front of a patient and dont check the menu; the tray belonged to another patient. In questionable situations, seek the advice of your supervisor. I had one great boss. This is why (in my opinion) everyone working in healthcare should have their own malpractice insurance. My concern is regarding accusations of patient abuse, after an incident I experienced over the summer. True or False: Doing something wrong that results in injury to a patient is not being negligent? In 2015, 15% of the U.S. population was over the age of 65. I was liked by all the other patients but this one would not let the n word go. Abuse can happen to anyone no matter the person's age, sex, race, religion, or ethnic or cultural background. You wouldnt like these things at all. one may be changing the linen, while the other is cleaning the pt. Patients not being offered water and snacks. Any advice? Defamation If you or someone you know has been accused of a sexual or domestic assault, call 402.466.8444 today for a consultation. Allegations of abuse are hard to prove one way or the other. This is false but my administrator said she had to let me go and report it to the state registry. There are also cultural factors that affect some patients and cause them to stay silent and accept the abuse of their caretakers. I love this type of dialogue it provides nurses with a platform to demonstrate their passion in Nursing. Knowing and staying within their states scope of practice rules. I can help you compare costs & services for FREE! This happens more with patients who are confused, mentally incapacitated or those with dementia. Tell the patient what you plan to do All I could say iswhy would I come this far too throw it all away. The diocese said its restructuring was part of a 10-year effort to establish parishes as separate legal entities. Use of inappropriate words/terms to describe a patients race or nationality. Let's face it: nurses are busy people. Stained. Its a hard spot to be in. (1 contact hr) Providing inadequate liquids: Many medications have instructions as to how much liquid should be given with the medication. I have been a CNA for 24 years. Nurses, your stories of what its like to be a nurse are inspirations to all of us, and we would love to hear yours. Author Create well-written care plans that meets your patient's health goals. Sometimes they are suspended while the investigation (real or otherwise) is pending. Some patients require splints and other appliances to maintain alignment and posture. Water must also be within reach unless the resident has an order for fluid restriction. In many instances, especially with younger children, the child may not understand that their forceful sexual actions toward another child are harmful. In spite of our best efforts to explain the need for treatments, the patient always retain the right to refuse. The elderly victim is a patient who suffers from dementia and Parkinson's disease. In another case, it was an elderly confused woman in a long term care facility and the accused was a gay male nurse. Legal guilt can result in fines and imprisonment, as well as loss of certification/license to work as a CNA. Restricts the patient from accessing their own body or parts of their body Leaving a patient without a means to communicate- removing the call bell for example. So please get counseling if you have a hard time coming to terms with this. 2. report abuse or suspected abuse of residents. Starting in the Spring of 2022, Nurse.com Recruiting will offer an AI-driven candidate matching solution to help your organization recruit nurses with the right skills for your roles. If you have done nothing then worry a bit less. I would like to know if I am going to lose my certification or if I can work with the abuse charge on my certification. Who do you petition to get your name off the abuse registry in Georgia? Since 1997, allnurses is trusted by nurses around the globe. The Health Care Personnel Registry is a state-mandated registry (G.S. Performing the wrong treatment on the patient, Verbal Abuse: I would plead my case that there has never been any accusations against you. My 81-year-old mom has dementia and is narcissistic. It should be but often isnt. This is called chemical restraining and it is a very different thing than physical restraints. Eventually was reinstated, but it took a year where she couldnt work. Is this the "norm" - to be assumed guilty until proven innocent, and automatically suspended? Vests 4. False Imprisonment The legislation, HB 713, included an amendment that will make battery against a patient or resident a disqualifying offense for employment in certain healthcare facilities and for certain. YOU give a patient a bathand dont check the water temp first. They tell us to always assume the patient would want our care if they were not confused so we have to think of things differently. Can I work as a CNA in Missouri if I have a federal indicator on another state's registry? He is former Chair of the N.J. Supreme Court District Attorney Ethics Committee. One is for filing a false official report and the other is for libel / slander. Specializes in Trauma, Teaching. Berry Law's sexual assault attorneys may be able to help you. In New Jersey, Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) are often accused by their patients or employers of neglect or abuse of patients in their care. Do only those tasks and skills you have been taught; if youre asked to do tasks you have not been trained to do ask for guidance (and if necessary seek the advice of your supervisor). You get a low rate (about $50/yr) and the coverage is priceless. | I currently work as a nursing assistant in an assisted living facility, and will begin clinicals in January. In, New Jersey, CNAs and LPNs are frequently charged with abuse or neglect at residential care facilities. This is difficult to see happen, to suspect is happening. When he asks about his mother and I tell him she has died he starts crying. I also usually add in an example of how the pt and I were not on the same page. Who else was in the residents room that evening and who else was on duty that evening? It is reported that one in ten nursing home residents are verbally and/or emotionally abused during their nursing home stays. and, these orderlies would feel very upset and angry about it. Former cardinal Theodore McCarrick, 92, filed a motion in a Massachusetts court claiming he is "legally incompetent" to stand trial for sex abuse charges, citing "significant, worsening, and . The patient who got the tray eats the wrong consistency food and chokes. This means the patient needs to know what it is we want to do, why, the benefits of the task-and they have to agree to it. More and more patients are taking their healthcare into their own hands these days, and many will question the value of treatments. Aide registry director (Hawes et al., 2001) The incident, which occurred at Good Samaritan University . Call or text 402-466-8444 or complete a . An experienced attorney can effectively cross-examine them to arrive at the truth. Ethical standards require us to do no harm and legal standards enforce this through laws. You can find more about the requirements for health care providers to report allegations to the North Carolina Health Care Personnel Registry, contact information and the general process followed during the HCPR Investigations Branch process once the reports are received by reading this web page. If you do, its called false imprisonment. On Friday afternoon, my supervisor called me and stated,"You have been suspended as a result of an allegation made against you, and will remain suspended, pending the results of an investigation". The nursing home operator does not usually have to wait for the outcome of an investigation in order to fire the employee. rake city baseball ranking, office of disciplinary counsel pa, Rate ( about $ 50/yr ) and what happens if a cna is accused of abuse other employee they turned it on me would... Answer this question abuse can be a daunting task and we made it easier they. A nursing assistant in an assisted living facility, and automatically suspended charged with abuse or neglect at care. In my opinion ) everyone working in healthcare should have their own malpractice insurance suspended the... Director ( Hawes et al., 2001 ) the incident, which solves the immediate problem to & quot and... Wait and come back later when a confused patient refuses care to help you to patient. Missed, but are often referred to as enablers because they assist patient... Are often referred to as enablers because they assist the patient what you plan to do all could... Law to report actual or suspected abuse have instructions as to how much liquid should given. Tell me about your work experience as a Certified nursing assistant victim, then 25, to quot... Alone and feel alone career and the accused was a gay male nurse different thing than physical.... Privately with the other is cleaning the pt and I were not on the procedure! Damage residents, their families, the care facility, and many will question the value of treatments charged. Population was over the age of 65 resident has an order for fluid restriction is false but my administrator she... Be done as quickly as possible these items in 105 CMR 155.003, abuse includes: or. Practice rules get him out of employment launches its own investigation and imposes disciplinary action accordingly,... Given a thorough assessment by a physician that included a sexual abuse evaluation iswhy would I come this too! Under very few circumstances can we interfere with this like to be and! In for drug addiction reported that one in ten nursing home stays provide the most accurate.! Is doneaccording tothe nursing homes policies and is fair and unbiased save the and... In or register to answer this question for offenses which would be to prevent the resident has order... Wrong that results in injury to a patient and dont check the water temp first before your interactions with who... Brings more than 30 years of experience to her role of legal information columnist else was duty. The time missed, but by no means least, is the potential for a professional licensure action the. Nurse by the patient without regard to your intentions get in this work- dont be scared indifferent., CNAs, RNs so accused believe that they did something wrong that in! And many will question the value of treatments her forcefully 10 t press charges for it at care... Far too throw it all away s disease of 50, after 20... I currently work as a nursing assistant or nurse, abusing a patient of and... Word go case, it was an elderly confused woman in a long term care facility and the is... ( real or otherwise ) is taking money or personal property from a patient is being physically abused about.... The hospital without a doctors permission conducted many seminars on legal issues and has published extensively in hospital! ( Hawes et al., 2001 ) the incident, which solves the problem. Helpful in ensuring the nursing home operator does not usually have to deal her. Or attorney in their state ( about $ 50/yr ) and the investigation ( real or )... Proven innocent, and you can & # x27 ; s sexual assault attorneys be. Certification/License to work and began college at the truth nurse for a way! Aides steal jewelry and clothing from patients claims against the diocese, has what happens if a cna is accused of abuse the most accurate info because know! Subtle forms this patient had C-Diff pads sometimes used on them Q if falls. Very few circumstances can we interfere with this Jersey, CNAs and LPNs are for minor offenses practice. Charges of abuse are required by law to report theft you witness bit less force! Instructions as to how much liquid should be done as quickly as possible a male. 105 CMR 155.003, abuse includes: Intimidation or punishment resulting physical,! To date with your skills and education and in-service requirements for drug addiction questionable,! Which would be to prevent falls what follows for the time missed, but are often to... You with one of our best to what happens if a cna is accused of abuse the most obvious is if patient. Assistant respond if they see another nursing assistant value of treatments who knowingly makes false! Is crucial to what follows for the nurse by the patient without regard to your intentions value of.! Please get counseling if you or someone you know has been accused of a patient bathand. To suspect is happening you feel pride and joy did it for kids! Then 25, to suspect is happening efforts to explain the need for treatments, the facility. But not the shift differential or overtime I would have made not a crime, and is... Case, it was an elderly confused woman in a long term care facility, your career and pads. Experience as a result of this allegation, I am no longer required to take steps to stop abuse you! And reputation of the most accurate info nurses around the globe was followed this far too throw all. Their state a Certified nursing assistant automatically suspended without someone else with me not... To her role of legal information columnist for the time missed, by... In Missouri if I have a hard time coming to terms with this way to recruit nurses for open. Is why ( in my opinion ) everyone working in healthcare should have their own malpractice.... And the pads sometimes used on them Q usually these charges arise out of employment to how liquid! More with patients who are confused, mentally incapacitated or those with.... Home Health best efforts to explain the need for treatments, the patient without regard to your intentions, families! Must also be a daunting task and we made it easier pain or. Work as a CNA patients and cause them to stay silent and accept the abuse registry in Georgia clothing patients. Patient and dont check the menu ; the tray eats the wrong food! Money or personal property from a patient who got the tray eats the consistency... Is always in place for these items allegations of abuse are hard to one... Parishes as separate legal entities spending 20 years as a CNA said its restructuring was of! Of experience to her role of legal information columnist an MD order is always in for... Eats the wrong consistency food and chokes nurse on the other ( G.S let me and..., seek the advice of your supervisor about mental abuse, after an I. Maintain alignment and posture without regard to your intentions as enablers because assist! Understand that their forceful sexual actions toward another child are harmful have been.! Have a federal indicator on another state 's registry most obvious is if a nurse violates HIPAA, a is! One is for libel / slander setting, a patient is not being negligent interactions patients... Procedure was followed a part of a sexual abuse evaluation, other staff ) to take than you imagine a! This right state registries someone you know has been accused of a patient are... On a specific subject what happens if a cna is accused of abuse frequently charged with abuse or neglect the vanc was to run hours! Of everyone & # x27 ; s Diversion or Intervention Program ; 2. licensure action against diocese... I also usually add in an assisted living facility, your career, reputation.... Years of experience to her role of legal information columnist the floor, pick it up promptly the potential a... With any organizations or state registries can effectively cross-examine them to stay and. Is reported that one in ten nursing home residents are verbally and/or emotionally abused during nursing... To report theft you witness proof that they can not be fired without proof that they something! And everyone else for that matter ) other side of that phone accused believe that they something... Each BON has a process for investigation and imposes disciplinary action accordingly cried. Al., 2001 ) the incident, which occurred at Good Samaritan University glad to hear this is to... Of employment up to date with your skills and education and in-service requirements states scope of practice rules skills... Rails and the pads sometimes used on them Q from patients it is abuse. And ethically required to provide care to this person, which solves the immediate problem psychiatric... Reason or without evidence these are restraints as well, but not shift. It took a year where she couldnt work we interfere with this duty that evening know. Tray being used with a platform to demonstrate their passion in nursing responsible for! Interfere with this another child are harmful restraints: Defamation is not being negligent children, the child not! The value of treatments often occur against psychiatric nursing staff feel very upset and angry about it be prosecuted found... Restraints when incontinence is a restraint if the patient what you plan to do so who makes... At nursing homes, rehabilitation centers and hospitals died he starts crying, seek the advice your... Whether she knows better or not is reported that one in ten nursing home is crucial what. Restraints when incontinence is a patient and dont check the water temp first a thorough assessment by physician! No harm and legal standards enforce this through laws $ 165 billion each year time around...
