Showing posts with label Elder Care Nurses. Show all posts
Showing posts with label Elder Care Nurses. Show all posts

Saturday, December 10, 2011

Geriatric Nurses, Eldercare Nursing, #NurseFriendly #eldercare #caregivers #nursing #nurses #geriatrics #seniorcare

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Friday, November 4, 2011

#Elderly #Patient Repeatedly Injured In #NursingHome "Accidents." #Negligence, Coincidence? http://bit.ly/sFOyRe #nursefriendly

See also: Medical, Legal Nurse Consultants, Clinical Nursing Case of the Week, Clinical Charting and Documentation, Nurses Notes, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:

Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Attorneys, Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material.

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Summary:  As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes.  When a family member is placed in a facility, a certain standard of care is expected.  In this case, a resident was injured repeatedly while under their care.  When the patient died a few days after being "dropped" the family sued.

The patient was a 95 year old woman who was placed in a Missouri nursing home when the family was no longer able to care for her needs.

"Approximately 1.5 million people live in the nation's 17,000 nursing care facilities. . .The typical nursing home resident is a woman in her 80s displaying a mild form of memory loss and dementia. Although physically healthy for a woman her age, she needs help with approximately 4 of 5 activities of daily living (eating, transferring, toiletting, dressing, and bathing)."2

During her admission the patient would sustain  multiple injuries over the course of her stay.  In 1993, on two occasions, the patient's legs were broken with fractures diagnosed.  Each time the patient was transferred to the hospital for treatment and then returned to the nursing home.

Each time the documentation would show that the family had been "made aware."  This was reflected in incident reports that had been filed.  The incident reports did not specify which family members had been notified.

A third injury took place in 1995 when the patient was being transferred from her bed.  Documentation of the incident stated that the patient had been "dropped" during a transfer.  The charted notes documented that a head injury was sustained and that family members were notified.

The patient was again transferred to the hospital and was evaluated in the Emergency Department.  Interestingly, when examined by a physician, the day after the incident, the physician stated that there was no evidence of head injury.  Five days following this examination, the patient died.

The family would sue the nursing home.  They would allege that standards of care had not been met.  They would accuse the nursing home of rendering negligent care.

It is no secret that nursing home abuse occurs.  It can take many different forms and have devastating consequences on residents and their families.

"The United States Department of Health and Human Services researchers identified seven categories of abuse. Ninety-five percent of those surveyed said they felt that all seven are problems for nursing home residents:

Physical abuse --infliction of physical pain or injury.

Misuse of restraints --chemical or physical control of a resident beyond physician's order or outside accepted medical practice.

Verbal/emotional abuse --infliction of mental or emotional suffering.

Physical neglect --disregard for the necessities of daily living.

Medical neglect --lack of care for existing medical problems.

Verbal/emotional neglect --creating situations harmful to the resident's self-esteem.

Personal property abuse --illegal or improper use of a resident's property for personal gain."3

The basis of the family's lawsuit centered on the assumption that a certain standard of care, and a "duty" is owed to nursing home residents.   This duty it was assumed, included safe living conditions, freedom from harm and timely medical treatment.  They alleged that these standards had not been observed by the nursing home.

In the initial trial, a review of the charting and documentation showed that in each "incident," facility protocols had been followed.  Upon discovery of the injuries, medical treatment and family notification had been provided.

The Defense moved to have the charges dismissed.  The court agreed.

The family appealed.

Questions to be answered.

1. Was there clear evidence of either neglect or abuse on the part of the nursing home staff in either of the three documented incidents of injury?

2. Had standards of care been met in regard to treating an injured patient and providing safe and reasonable care.

Chiefly due to the timely documentation of the incidents, the records were used to demonstrate adequate care being given.

The family's lawsuit chiefly targeted the "handling" of the incidents rather than the "cause" of injury.  The documented interventions and notifications on the part of the nursing staff provided sufficient proof that standards were upheld.

It is common knowledge that documented nurses' notes and the medical chart are legal records.  They should be written and treated at all times as if a jury will later examine them.

Had the incident not been documented as thoroughly or had incident reports not been filled out, it might have been a different story.  It was the clear and concise charting of the nursing homes staff's handling of the incidents that saved the facility from a potentially costly lawsuit and trial.

This was particularly evident when the family accused the nursing home staff of "failure to notify" the family members.  As long as efforts were documented in the notes to notify the family, the facility was covered.

It is a bit strange that the specifics as to "who" was notified was not included in the chart.  Under a different set of opinions, this could easily be interpreted as a "red flag."  In this case it was not.

This documentation of  "notification" could have been seen as the nursing home staff charting to cover themselves regardless of whether a family member had been contacted.

To minimize suspicions of impropriety it is suggested that when a family member is contacted, the name and phone number also be documented.  All evidence is subject to interpretation.  This can be applied to physician notification as well.

When a patient has an attending, consulting physicians and residents responsible for their care, "MD made aware" leaves much room for debate as to who was notified.  If the name of the physician is noted, the guesswork is removed and accountability easier to establish.

What was not addressed in this case was the nature of the "accidental" injuries.  It is not difficult to imagine a 95-year-old patient falling as she tries to get out of bed.  It is common for patients to fall on their way to or from the bathroom.  The pertinent question is "could the injuries have been avoided."

It is clear from published studies that indeed many can be.

""We found that neither complaint investigations nor enforcement practices are being used effectively to assure adequate care for Nursing Homes residents and the prevention of nursing home abuse and neglect. As a result, allegations or incidents of serious problems, such as inadequate prevention of pressure sores, failure to prevent accidents, and failure to assess residents' needs and provide appropriate care, often go uninvestigated and uncorrected."4

Lawsuits against nursing homes are common and on the rise.  If you are working in a nursing home, you need to be aware that you are responsible for documenting adequate care.  You are equally responsible for prevention.  If a dangerous condition or "accident waiting to happen" is identified, steps must be taken and documented to correct it.

If a patient is at risk for falling they may refuse to call for assistance.  If they try to get out of bed anyway, it should be documented that the patient was instructed to "call for assistance," and did not.

If a patient is clearly a danger to himself or herself and others, restraints may be indicated.  The family or the physician may refuse to allow or write an order for them.  The nurse must document that the need for them was communicated, to whom and the response.

Even with adequate care being given accidents can happen with legal consequences.  Nursing homes are currently the focus of intense governmental supervision and regulation.  The effectiveness of the regulation is debatable.  There are many that feel that the only "solution" to correcting problems are legal actions against nursing homes.

If this approach is to be paralleled to eliminating medical malpractice, a solution may be a long way off.  What can be anticipated is increased pressure from the government, from consumers and the courts.  This will result in increased litigation and increased pressure on nursing home staff and facilities.  Each member of the nursing staff would be wise to document carefully daily care and especially incidents that result in injury.

Related Case Studies:

June 13, 1999: Felony Child Abuse Conviction, Made Possible Thanks to Nurse's Documentation.
State v. Gillard, 936 S.W. 2d 194 - MO (1999).
http://www.nursefriendly.com/nursing/clinical.cases/061399.htm

June 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Gordon v. Lewiston Hospital, 714 A.2d 539 - PA (1998)
http://www.nursefriendly.com/nursing/clinical.cases/060699.htm

May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)
http://www.nursefriendly.com/nursing/clinical.cases/053099.htm

Related Link Sections:

Abuse:
http://www.nursefriendly.com/nursing/directpatientcare/abuse.htm

Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Emergency Department Nurses on the Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/ed.html

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Head Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htm

Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Nursing Homes, Long Term Care Links:
http://www.nursefriendly.com/nursing/nursing.homes.long.term.care.htm
 

Sources:

1. 40 RRNL 1 (June 1999)

2. American Health Care Association.  September 1998. Profile: Nursing Facility Resident: Retrieved June 27, 1999 from the World Wide Web:  http://www.ahca.org/secure/nfres.htm

3. Seniors-Site.  No date given.  Nursing Home Abuses to Senior Citizens.   Retrieved June 27, 1999 from the World Wide Web: http://seniors-site.com/nursing/abuses.html

4. United States Senate.  March '99. Excerpts from Committee On Aging Hearings.  Retrieved June 27, 1999 from the World Wide Web: http://www.jeffdanger.com/

The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/062799.htm

Send comments and mail to Andrew Lopez, RN

Created on Saturday May 23, 1999

Last updated by Andrew Lopez, RN on Saturday, September 17, 2011

via nursefriendly.com

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Sincerely,

Andrew Lopez, RN
Nursefriendly, Inc. A New Jersey Corporation.
38 Tattersall Drive, Mantua New Jersey 08051
http://www.nursefriendly.com info@nursefriendly.com ICQ #6116137
856-415-9617, (fax) 415-9618

Visit our network of sites. Over 150,000 + Nurse Selected, Approved Nursing & Healthcare Resources:

For Health Information you can use, Follow, Connect, Like us on Facebook, Google +, LinkedIN, Twitter, StumbleUpon (Most Invites Accepted):
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4nursing.com:"In this Nursing Portal you'll find information on Nursing Jobs, Nursing Schools, Nurse Degrees, CNAs, LPNs, RNs, Travel Nursing, Prescriptions Drugs, Medications, Nursing Associations and much more."
http://www.4nursing.com

InspirationalNursing.com:"InspirationalNursing.com. Touching Poems, and Inspiring stories that touch the heart and occasionally bring a tear to your eye. Affection, Ambition, Angels In Our Lives, Animals, Babies, Bereavement, Caring, Caring, Children, Christian Stories, Christmas, Computers & The Internet, Death, Dependability, Determination, Dying, Easter, Emergency Medical Services (EMS), End of Life, Etc., Friendship, God's Creatures, Grief, Holiday Thoughts, Honesty, Hospice Poems, etc."
http://www.inspirationalnursing.com

Jocularity.com (Former home to the Journal of Nursing Jocularity (JNJ)):"Nursing & Medical Humor. Find hundreds of jokes and links to sites that will make you smile. Therapeutic Humor Associations, Battle of the Sexes, Bedside Nursing Humor, Brain Teasers, Clowning, Clowns, Therapeutic Humor & Comedy Links, Dental Humor, Emergency Department Humor, General Nursing Humor, Geriatrics, Senior Citizen, etc."
http://www.jocularity.com

Legalnursingconsultant.com:"This website is intended to be a resource for Legal Nurse Consultants, Attorneys looking to use their services, and nurses looking to enter the field of Legal Nurse Consulting. On our site you'll find a directory of LNCs by state and specialty."
http://www.legalnursingconsultant.com

Nursefriendly.com:"Nationwide Nursing Resources: In this Nursing Portal you'll find information on Nursing Jobs, Nursing Schools, Nurse Degrees, LPNs, RNs, APNs, Nursing Associations and much more."
http://www.nursefriendly.com

Nursinga2z.com:"It is our intent for this Alphabetical, A to Z index to be a comprehensive listing (In Progress) of Nursing-related resources on the Internet. It is indexed by Google and fully searchable."
http://www.nursinga2z.com

Nursingdiabetics.com:"Welcome to NursingDiabetics.com. Here you will find information on all aspects of Diabetes, a disease that afflicts millions of people world wide. I'll be adding pages as fast as I can research the information so remember to bookmark this page and return."
http://www.nursingdiabetics.com

Nursingdiscussions.com:"This website will be a portal to Nursing Discussion boards throughout the Web. If your site has a discussion board we don't have listed here, please contact us."
http://www.nursingdiscussions.com

Nursingentrepreneurs.com:"Nationwide Nursing resource to nurse entrepreneurs looking to nework and start home based businesses. On it you will find links to small and large business related resources."
http://www.nursingentrepreneurs.com

Nursinghumor.com:"Nursing & Medical Humor. Find hundreds of jokes and links to sites that will make you smile. Therapeutic Humor Associations, Battle of the Sexes, Bedside Nursing Humor, Brain Teasers, Clowning, Clowns, Therapeutic Humor & Comedy Links, Dental Humor, Emergency Department Humor, General Nursing Humor, Geriatrics, Senior Citizen, etc."
http://www.nursinghumor.com

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Monday, June 20, 2011

Most Baby Boomers are Unprepared to Care For Aging Parents | The Intentional Caregiver

Yesterday, I was fortunate to be able to interview Mr. Jeff Huber, President of Home Instead Senior Care, the largest provider of in-home care services for seniors in the world and was the first company to offer franchise opportunities.

Most professionals involved with eldercare are aware that adult children are not prepared to care for their parents when they receive “that call” that throws them into the caregiving role.  But the Home Instead Senior Care network  wanted to learn more about that and so in conjunction with The Boomer Project, a study of 600 baby boomer aged adults was conducted. 

The results surprised me:

  • Less than 50% were knowledgeable about their parents’ medical history
  •  49% were unable to name any of their parents’ current medications
  • More than 30% did not know just how many medications their parent(s) was taking
via takingcareofthefolks.com

Thank you Shelley for bringing attention to this critical topic. It is a phone call we will each be getting eventually. It is much better to be prepared.

Click on the "VIA" link to read the full article.

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Sincerely,

Andrew Lopez, RN
Nursefriendly, Inc. A New Jersey Corporation.
38 Tattersall Drive, Mantua New Jersey 08051
http://www.nursefriendly.com info@nursefriendly.com ICQ #6116137
856-415-9617, (fax) 415-9618

150,000 + Nurse-Reviewed & Approved Nursing Links

http://www.4nursing.com
http://www.inspirationalnursing.com
http://www.legalnursingconsultant.com
http://www.nursefriendly.com
http://www.nursingcasestudy.com
http://www.nursingentrepreneurs.com
http://www.nursingexperts.com
http://www.nursinghumor.com

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Tuesday, May 17, 2011

Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?

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See also: Medical, Legal Nurse Consultants, Clinical Nursing Case of the Week, Clinical Charting and Documentation, Nurses Notes, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:

Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Attorneys, Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material.

For a free subscription to our publication:
Please send a blank e-mail to: clinicalnursingcases-subscribe@topica.com

Summary: Nursing homes are frequently a patient's destination for
rehabilitation following surgery.  Common conditions fitting
this bill include large bone fractures, hip replacements and stroke.
Following these acute episodes, the patients are too unstable to
go home and not "sick" enough to have their hospital stays
reimbursed by insurance companies.  The purpose of admission
to a nursing home is to help the patient regain lost function,
strength and health.  In this case, the patient would remain in the
Nursing Home till her death of complications.

The patient was admitted to a state owned nursing home
following repair of a femoral fracture.  Her treatment plan
emphasized Physical, Occupational therapy and Nursing care
to provide for rehabilitation.

She had successfully undergone surgery to repair a fractured
femur.  The length of stay projected was six weeks.  During
this time, the patient's condition would worsen rather than
improve.

This is not an isolated incident.  Media attention is continuously
focusing on conditions in nursing homes.

"A TIME investigation has found that senior citizens in nursing
homes are at far greater risk of death from neglect than their
loved ones imagine. Owing to the work of lawyers, investigators
and politicians who have begun examining the causes of
thousands of nursing-home deaths across the U.S., the grim
details are emerging of an extensive, blood-chilling and for-profit
pattern of neglect."2

The patient's skin was intact and she was continent on admission.
She would develop multiple pressure ulcers on her bony
prominences.  These are frequently the consequence of inadequate
turning and poor nutrition.  Monitoring of both of these factors
are direct responsibilities of nurses and nursing home personnel.
If either is inadequate, a duty is owed to the patient by the nurse
to inform the physician.  The physician, once made aware, is
then charged with taking additional measures as needed.

The patient would have a Foley catheter inserted supposedly
for urinary incontinence.  Documentation would later show
that need for catheterization had not been established.

The patient had been fully continent on admission.  Her
rehabilitation plan called for her to ambulate to the bathroom
when needed.  An assessment of her ability to go on her own
was nowhere to be found at the time of her Foley catheter
insertion.  Development of a urinary tract infection is a known
complication of catheter use.  The patient would develop a
UTI soon after.

"In the last year, complaints against nursing homes in Texas
are up over 60%. Medication errors, under-staffing, unsanitary
conditions, neglect, lack of care, substandard care and injuries
from dangerous products, are but a few of the dangers. The
administrators of these facilities contend that the level of care
is excellent in Texas nursing homes but, state investigators and
Texas juries have been sending a different message."3

On the initial trial, the court dismissed the claims.  They based
this on the fact that the nursing home personnel were "state"
employees and supposedly immune from liability.

The patient's family appealed.

Questions to be answered:

1. Could the nursing home personnel in a public facility be
held liable for negligence in the care of the patient?
Specifically, could they be sued for not maintaining the
standards of care required by the state?

2. Were the "incidents" leading up to the patient's deterioration
reasonably "foreseeable" by a prudent caregiver in a
similar situation?

On appeal, the plaintiff presented multiple pieces of evidence
documenting neglectful incidents.

This documentation included fractures during transfers (one
requiring re-hospitalization and extensive surgical repair),
the development of skin breakdown, the development of
infections of the respiratory, urinary and gastrointestinal tract.

Each of these events suggested that care for the patient could
be falling below accepted standards.  Each of these events
could be identified as necessitating further therapy and
increasing the patient's length of stay.

In reviewing the Tort Immunity Acts of Illinois, it was
determined that liability could be assessed for acts of
negligence or omission in the patient's care.

It was clear from physical, mental and health status changes
that the patient was deteriorating.  These changes, specifically
the multiple injuries during transfers, development of skin
breakdown and infection could be traced to negligence in the
omission of required care.  Any time the treatments prescribed
by the physician are not carried out, or if it is not documented
that they have been carried out, the possibility of omission and
negligence is raised.

It is highly unlikely that if the treatments and care prescribed
had been given that the gross deterioration would have occurred.
In this case, documentation of care was not present.  Documentation
of "likely results of neglect" was present.

This underscores the necessity of properly documenting the care
you give.   Many facilities are adopting "charting by exception"
policies.  These are dangerous in that they may not account for
basic care given.  In saving time and nursing costs for a facility,
not fully charting care given can raise the question of a nurse's
omission and negligence later in court.

If the temptation to chart care that is not given is present, keep
this in mind.

If time for giving proper treatments and care is not there,
falsifying records is patently illegal.  It is an offense that
could cost you your license if reported to the State Board.

In the case of a lawsuit, it is much cheaper for a facility to
scapegoat a nurse, than defend one.  If reporting you to the
State Nursing Board, or threatening to will give their attorney's
a bargaining chip to keep an employee "quiet," about existing
conditions they'll use it.

"Generally, the nursing-home industry likes to settle lawsuits
quietly and often hands over money only in exchange for
silence."2

A nurse must decide if saving facility money by spending
less time charting or on patient care is worth possible liability
or loss of licensure down the road.  It is highly unlikely that
a nursing home or hospital will defend a nurse named in a
lawsuit.  This chiefly will happen only when the facility's
assets are at stake.

If conditions in a nursing home are visibly substandard, a
nurse must ask if it is wise to continue working in the facility.
Ask yourself.  Is the administration receptive to suggestions
for improvement?  Do they raise concerns over overtime and
time involved to complete care and charting?

As media attention and lawsuits increase, more nurses will
find themselves involved in legal actions.  If it's determined
that poor conditions existed yet nothing was done about
them, the cost in liability could be high.

"Palo Alto attorney Von Packard has studied the death
certificates of all Californians who died in nursing homes
from 1986 through 1993. More than 7% of them succumbed,
at least in part, to utter neglect--lack of food or water,
untreated bedsores or other generally preventable ailments.
If the rest of America's 1.6 million nursing-home residents
are dying of questionable causes at the same rate as in
California, it means that every year about 35,000 Americans
are dying prematurely, or in unnecessary pain, or both."2

Many states have "elder abuse" legislation mandating abuse
be reported.  Whistle blower legislation is slow in coming.
Currently the employer's interests are put first rather than the
patient's or employees in most cases.  Protections for nurses
that do report abuse are questionable in their effectiveness.
The risk of employer retaliation is high.

The chances of a nursing home or hospital defending you
against the State Board of Nursing when your license is
at stake over an incident are almost none.  In fact, it is
common for complaints to be filed by the facility where
a nurse has worked.

Unless you have a personal malpractice insurance policy,
you will be forced to pay for this representation out of pocket.
For less than the cost of a typical day's pay (around $70-$90
per year), most personal policies will provide representation at
no additional cost to you.

Related link Sections:

Direct Patient Care Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Foley Catheterization:
http://www.nursefriendly.com/nursing/directpatientcare/foley.catheterization.htm

Informed Consent:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.co...

Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Operating Room (Surgical) Links on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directory/spec/operatingroom.htm

Nursing Homes, Long Term Care Links:
http://www.nursefriendly.com/nursing/nursing.homes.long.term.care.htm

Wound Care:
http://www.nursefriendly.com/nursing/directory/business/woundcar.htm

Sources:

1. 39 RRNL 12 (May 1999)

2. Time Magazine.  October 27, 1997. Fatal Neglect. Retrieved July 11, 1999 from the World Wide Web: http://cgi.pathfinder.com/time/magazine/1997/dom/971027/nation.fatal_neglect....

3. Law Offices of James K. Burnett, P.C. 1999.  Nursing Home Negligence. Retrieved July 11, 1999 from the World Wide Web: http://www.nursinghomenegligence.com/
 

The Uniform Resource Locator (URL) or Internet Street Address of this page is
http://www.nursefriendly.com/nursing/clinical.cases/071199.htm

Send comments and mail to Andrew Lopez, RN

Created on July 11, 1999

Last updated by Andrew Lopez, RN on Monday, February 28, 2011

via nursefriendly.com

--

******************************************************
For Health Information you can use, Follow, Connect, Like us on (Most Invites Accepted):
http://www.nursefriendly.com/social/

Twitter!
http://www.nursefriendly.com/twitter

Facebook:
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What's New:
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Blogger:
http://4nursing.blogspot.com/

Linked In:
http://www.linkedin.com/in/nursefriendly

Nursing Entrepreneurs, Nurses In Business
http://nursingentrepreneurs.ning.com/

StumbleUpon,
http://www.nursefriendly.com/stumbleupon
******************************************************

Sincerely,

Andrew Lopez, RN
Nursefriendly, Inc. A New Jersey Corporation.
38 Tattersall Drive, Mantua New Jersey 08051
http://www.nursefriendly.com info@nursefriendly.com ICQ #6116137
856-415-9617, (fax) 415-9618

150,000 + Nurse-Reviewed & Approved Nursing Links

http://www.4nursing.com
http://www.inspirationalnursing.com
http://www.legalnursingconsultant.com
http://www.nursefriendly.com
http://www.nursingcasestudy.com
http://www.nursingentrepreneurs.com
http://www.nursingexperts.com
http://www.nursinghumor.com

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