Element Causing Negligence
Each of the following five elements must be present for the patient to have an appropriate civil action cause for the waiver of wrongdoing:
1. Health care is discontinued unreasonably.
2. Termination of health services against the will of the patient or without the patient’s knowledge.
3. The health care provider fails to properly arrange for care by another skilled health care provider.
4. Health care providers must reasonably estimate that harm to the patient will result from discontinuation of treatment (proximate cause).
5. Patients actually suffer losses or losses due to discontinuation of treatment.
Doctors, nurses, and other health care professionals have an ethical, as well as legal, obligation to avoid patient neglect. Health care professionals have an obligation to provide their patients with all the necessary attention during a case requiring it and must not leave a patient in a critical stage without giving reasonable notice or making appropriate arrangements for the presence of another person. 
Abandonment by Doctor
When a doctor treats a patient, treatment must be continued until the patient’s condition no longer requires treatment, the doctor and patient both agree to end treatment by the doctor, or the patient discharges the doctor. In addition, the doctor may unilaterally terminate the relationship and withdraw from the patient’s care only if he/she gives proper notification to the patient of his intention to withdraw and the opportunity to obtain suitable substitute treatment.
In the home health setting, the doctor-patient relationship does not end simply because patient care moves from the hospital to the home. If the patient continues to require medical services, supervised health care, therapy, or other home health services, the treating physician must ensure that he or she is doing a good job with the patient.
Nearly every situation where home care is approved by Medicare, Medicaid, or an insurance company will be one where the patient’s need for care continues. The hospital’s existing doctor-patient relationship will continue unless formally terminated with notification to the patient and reasonable efforts to refer the patient to another appropriate physician.
Otherwise, the doctor will maintain his obligations to the patient when the patient is discharged from the hospital to his home. Failure to follow up on the part of the doctor will constitute a tort of neglect if the patient is injured as a result. This negligence may hold doctors, hospitals, and home health agencies liable for such negligence.
The hospital treating physician must ensure that appropriate referrals are made to the physician who will be responsible for the patient’s home health care as long as the care is provided by the home health care provider, unless the doctor intends to continue to personally supervise home care. . More importantly, if a doctor in a hospital arranges for a patient’s care to be carried out by another doctor, the patient must fully understand these changes, and must be carefully documented.
As supported by the case law, the types of action that would result in liability for patient negligence would include:
• early discharge of the patient by the doctor
• failure of doctors to give proper instructions before the patient is discharged
• the doctor’s statement to the patient that the doctor will no longer treat the patient
• the doctor’s refusal to respond to calls or further treat the patient
• the doctor leaves the patient after surgery or fails to follow up on postoperative care. 
Generally, abandonment does not occur if the physician in charge of the patient arranges for a substitute physician to take his place. These changes can occur due to vacation, doctor relocation, illness, distance from the patient’s home, or the doctor’s retirement. As long as treatment by a person who is trained, knowledgeable about the patient’s particular condition, if any, has been arranged, the court will usually not find that a waiver has occurred.
 Even if the patient refuses to pay for the treatment or is unable to pay for the treatment, the doctor is not free to unilaterally terminate the relationship. Physicians still have to take steps to have the patient’s care taken over by someone else  or to allow a reasonable period of time to find another before discontinuing treatment.
Although most of the cases discussed concern the doctor-patient relationship, as indicated earlier, the same principles apply to all healthcare providers. Furthermore, because the care provided by the home health institution is provided according to the doctor’s treatment plan, even if the patient demands the doctor to be left because of the action (or the inaction of the home health agency staff), the doctor can claim compensation. from a home health provider. 
EXPENDITURES BY NURSES OR HOME HEALTH AGENCY
Principles similar to those that apply to physicians apply to home health professionals and home health providers. Home health agents, as providers of direct care to patients who stay at home, may have the same legal obligations and obligations to provide care that meets the needs of patients as physicians. Furthermore, there may be a legal and ethical obligation to continue to provide care, if the patient has no other alternative. Ethical obligations may still exist for patients even if the home health care provider has fulfilled all legal obligations. 
When a home healthcare provider provides care to a patient, the task of continuing to provide care to the patient is a task that should be performed by the agency itself and not by any professional individual who may be an employee or contractor of the agency.
Home health care providers have no obligation to continue to provide the same nurses, therapists, or assistance to patients during treatment, as long as providers continue to use appropriate and competent personnel to administer treatment consistently with the treatment plan.
From the point of view of patient satisfaction and continuity of care, it may be in the best interest of the home health care provider to try to provide the same individual practitioner to the patient. The development of personal relationships with provider personnel can improve communication and greater levels of patient trust and compliance. This will help alleviate many of the problems that arise in healthcare settings.
If a patient requests a replacement nurse, therapist, technician, or certain home health assistance, the home health care provider remains under an obligation to provide care to the patient, unless the patient also specifically states that he or she no longer wants the provider’s services.
Home health institution supervisors should always follow up on the patient’s request to determine the reasons for dismissal, to detect “problematic” employees, and to ensure that no incidents occur that could result in liability. The home health agency must continue to provide care to the patient until the patient is definitively told not to.
OVERCOMING PATIENTS WHO BLAME
Home healthcare personnel can sometimes deal with abusive patients. This major abuse may not be the result of the medical condition for which the treatment is given. The personal safety of the individual healthcare provider must be paramount. If the patient poses a physical danger to the individual, he must leave the premises immediately.
The provider should document in the medical record the facts surrounding the inability to complete treatment for the visit as objectively as possible. Management personnel must notify supervisory personnel at the home health provider and must complete internal incident reports.
If it turns out that a criminal act has occurred, such as physical assault, attempted rape, or other such acts, these actions must be reported immediately to local law enforcement officials. The home care provider must also promptly notify the patient and physician that the provider is terminating his relationship with the patient and that an alternative provider to this service should be obtained.
However, other, less serious circumstances may cause the home health care provider to decide that he or she should cut ties with a particular patient.
Examples might include a patient who is extremely abusive, a patient who asks a professional at-home healthcare provider to break the law (for example, by providing illegal drugs or providing services and equipment that is not covered and billing it as something else), or a patient who consistently disobedient.
However, once treatment is in place, the home health care provider is usually obligated to continue providing services until the patient has had a reasonable opportunity to find a replacement provider. The same principle applies to the patient’s failure to pay for the services or equipment provided.
As healthcare professionals, HHA personnel must have training in how to handle difficult patients responsibly. Emotional arguments or comments should be avoided. If it becomes clear that a particular provider and patient are unlikely to be compatible, a replacement provider should be tried. If it appears that the problem lies with the patient and the HHA needs to cut ties with the patient, the following seven steps should be taken:
1. The situation should be documented in the patient record.
2. The home health care provider should provide or send a letter to the patient explaining the circumstances surrounding the discontinuation of treatment.
3. The letter must be sent by official letter, return receipt requested, or other measures to document the patient’s acceptance of the letter. A copy of the letter should be placed in the patient record.
4. If possible, the patient should be given a certain period of time to get replacement treatment. Usually 30 days is enough.
5. If the patient has a life-threatening condition or a medical condition that may worsen without further treatment, this condition must be clearly stated in the letter. The patient’s need for health care in a surrogate home should be emphasized.
6. Patients should be informed of the location of the nearest hospital emergency department. Patients should be told to go to the nearest hospital emergency department in the event of a medical emergency or to call the local emergency number for ambulance transport.
7. A copy of the letter must be sent to the doctor treating the patient by official letter, requesting a return receipt.
These steps should not be taken lightly. Before such steps are taken, the patient’s case should be thoroughly discussed with the home health care provider’s risk manager, legal counsel, medical director, and the patient’s treating physician.
Inappropriate discharge of patients from health care coverage by home health care providers, whether due to termination of entitlement, inability to pay, or other reasons, can also lead to liability for wrongful waivers. 
Nurses who passively stand by and observe negligence by a doctor or other person will be personally liable to patients who are injured as a result of that negligence… Health care facilities and their nursing staff owe independent duties to patients beyond the obligations that physicians have to perform . When the doctor’s orders to go home are not appropriate, nurses will be responsible for following orders that they know or should know are below the standard of care. 
Similar principles may apply to holding home healthcare providers accountable.
Liability to the patient for wrongful neglect can also result from the failure of the home health care professional to observe, examine, assess, or monitor the patient’s condition.
 Liability for neglect may arise from failure to take timely action, as well as failing to call a doctor when a doctor is needed.
 Failure to provide adequate staff to meet patient needs may also be considered a waiver on the part of HHA.
 Ignoring a patient’s complaint and not following the doctor’s orders can also be considered illegal because it is abandoned by a nurse or other professional staff member.
1. Lee v. Dewbre, 362 S.W.2d 900 (Tex. Civ. App. 7th Dist. 1962).
2. Kattsetos v. Nolan, 368 A.2d 172 (Continued 1976).
3.61 am. Jur. 2d, Doctors and Surgeons 237 (1981).
4. See, for example, Tripp v. Pate, 271 S.E.2d 407 (N.C. 1980 Application).
5. Ricks v. Budge, 64 P.2d 208 (Utah 1937).
6. M.D. Nathanson, Home Health Care Answers Book: Legal Issues for 212 Providers (1995).
7. See, in general, E.P. Burnzeig, The Nurse’s Liability for Malpractice (1981).
8. Sheryl Feutz-Harter, Nursing Caselaw Update: In Discharge of Appropriate Patients, 2 J. Nursing L. 49 (1995).
9. Number, 53.
10. See, for example, Pisel v. Stamford Hosp., 430 A.2d1 (Continued 1980) (nurse held responsible for failing to monitor patient condition).
11. See, for example, Sanchez General Hospital v. Bay, 172 Cal. Rp. 342 (Cal. Application 1981); Valdez v. Lyman-Roberts Hosp., Inc. 638 S.W. 2d 111 (Text. 1982).
12. Czubinsky v. Doctor Hosp., 188 CA. Rp. 685 (1983).