Those of you who are school nurses know the many challenges you face on a daily basis surrounding the health of your students. I have written about several of these challenges, including assessing if a student is well enough to drive home from school and when your actions can breach a student's privacy. One particular challenge is when you care for an insulin-dependent diabetic student. This challenge can take many forms, and in the following case, the school district and the school nurses' conduct surrounding a student resulted in liability under several federal laws.
Details of Luke's Treatment
Eight-year-old Luke required two types of insulin to manage his diabetes while at school. During his first year at school, the school's nurses administered his insulin injections. Luke's mother requested that pictures of the prepared syringes be sent to her via a text message so she could see that the correct dose was given. On many occasions, the nurses did not send the requested messages, or when they did, the picture was blurred. Luke's care continued as he progressed through the school. One day in 2018, Luke's mother was unable to receive transmitted readings from her son's glucose monitor. She rushed to the school and did not stop at the main desk (which was school policy) before entering the school. Luke's mother received an email from the school district about her violation of school policy and was informed if such "improper" school visits continued, she would have limited access to the school. The school resource officer was informed of the incident.
Luke's mother's concerns continued during the school year. She requested alternative options for her son's insulin administration, including that she pre-fill syringes at home for the school nurses to administer. This request was denied by the school.
Another request was that Luke be allowed to carry and self-administer syringes that were "pre-filled with home-diluted insulin" to manage diabetes. Luke's doctor agreed with this plan, as did his parents. This request was also denied. Due to the inability to resolve the disagreements over Luke's treatment, the school district placed Luke on "home hospital status" for his education and was denied from attending school with his classmates for a year. Luke's mother filed a complaint against the school district in the Federal District Court alleging:
- Five causes of action for violations of the Americans with Disabilities Act (ADA)
- Two causes of action for violations of the Rehabilitation Act of 1973
- One cause of action for a violation of 42 United States Code Section 1983
- Two causes of action for violations of the Equal Protection Clause of the 14th Amendment of the US Constitution
The school district filed a Motion to Dismiss all counts on the complaint.
District Courts' Holdings
The District Court's opinion considered each of the causes of action raised by Luke's mother. The school district's Motion to Dismiss was denied and several of her causes of action were dismissed. Specifically, the court held that under the ADA or the Rehabilitation Act, five of the 10 causes of action were sufficiently pled by Luke's mother concerning discrimination. The school district knew of her son's disability but refused to make accommodations or modifications to its existing policies. Thus, these counts were adequate enough to overcome the Motion to Dismiss. The court pointed out that the mother's requests for changes in the policies at the school could be considered a "protected activity" under the ADA. Also, the email she received warning her about further "improper visits" to the school could be considered an "adverse action" under the ADA. However, she was not a party to the suit, only her son was a party [the plaintiff]. Moreover, the court continued that her complaint lacked specifics regarding whether adverse actions were taken against Luke. Therefore, the court ruled that these two causes of action would be dismissed with leave to allow her to amend those counts. Luke's mother's allegations that the school violated her son's rights under Section 1983 were dismissed. The court's decision rested on case law holdings that a Section 1983 action cannot be used to vindicate rights created by the ADA or the Rehabilitation Act. Consequently, those allegations must be dismissed. As to Luke's mother's claims of a violation of the Equal Protection Clause, the Court also dismissed her claims. It pointed out that she did not allege the identity or characteristics of similarly situated students and how those students were treated differently. Accordingly, those causes of action were dismissed.
Implications for School Nurses
The case clearly underscores how important the specific federal laws used by the mother to file her suit are. Keeping up to date with these laws as they relate to your school nursing practice and role is vital.
The communication by the school and the school nurses with Luke's mother is unusual. There was never an attempt to resolve the mother's concerns nor provide the son with any reasonable alternative to the difficulties that were experienced in administering the required insulin to the diabetic student.
Rather, it appears that the character of any communication by the school was defensive and threatening, resulting in a clear violation of Luke's protected rights as a disabled student. It is not known if Luke had an individualized healthcare plan (IHP). If not, he should have had one. Developed by the school nurses in collaboration with Luke's mother and Luke, an IHP appropriately crafted and considering Luke's specific needs could have avoided the necessity of filing a lawsuit to obtain those specific needs. In my opinion, it is important to point out that the school's refusal (and I am assuming the school nurses' refusals) to administer Luke's insulin in syringes prepared at home by his mother was one refusal that was appropriate. As you know, one of the basic principles of medication administration is that you never administer a medication that you did not personally prepare. This "accommodation" could result in the school nurses' being reported to the state board of nursing by anyone who learned of its existence, including a teacher or a parent of another diabetic student. The nurses could face disciplinary proceedings for failure to uphold standards of nursing practice. I believe the accommodation of choice would have been the ability of Luke to carry and self-administer his own insulin. Doing so would have supported the concept that Luke should be helped to be responsible for his own care, with guidance from the school nurses as needed. It would also have allowed Luke to stay in school, take part in school activities, and be with his fellow classmates.
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