tn board of nursing disciplinary actions

<> ISMP believes the TN Board of Nursings disciplinary processes and judgment of RaDondas actions during this event are NOT aligned with the tenets of a Just Culture. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. In cases of this type, a nursing professional's legal counsel may get a dismissal or reduction of charges by exposing weaknesses in the board's case. Take disciplinary actions as necessary to protect the public from unsafe nurses. Contact Info Georgia State Board. 2 0 obj hbbd``b`:$gP " `v nb-W&FV^ 'F Nurses can verify their licenses by completing the Nursys verification process for $30 per license type, per each board of nursing where the nurse is applying. e-Notify Get free license expiration and status updates via email Adapted from: Kelman B. 214 2nd Avenue N., e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Board actions may include: Fine or civil penalty. When I started being a nurse, I told myself that I wanted to take care of people the way I would want my grandmother to be taken care of. Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. I know the reason that this patient is no longer here is because of me. Unfortunately, the Board members seemed to interpret this only as a clear admission of guilt and did not appear to acknowledge the psychological pain RaDonda is still experiencing as a second victim of a fatal error. There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. Together the NPA and rules/regulations guide and govern nursing practice. 457 0 obj <>/Filter/FlateDecode/ID[<4E10B6721FA6774B905977532A094C83><1EEB8E14ED3DC44691B1AA4AE180590B>]/Index[437 30]/Info 436 0 R/Length 99/Prev 185930/Root 438 0 R/Size 467/Type/XRef/W[1 3 1]>>stream July 23, 2021. Consequences range from moderate to severe, including permanent license revocation and significant fines: In certain areas, such as alleged chart falsification or chart illegibility, the Tennessee Board of Nursing presumes the nursing professional acted with intent. Filing Complaints and Researching Disciplinary Actions . Below is a list of actions taken in NOVEMBER 2021. Also, it cannot be asserted that the failure to document in the EHR contributed to the patients harm or denied her any opportunity for recovery. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. Nurse could not carry out the physicians order to repeat the first dose if insufficient because she did not monitor the effectiveness of the first dose. 4 0 obj here are three Nursys services publicly available via nursys.com: e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Disputed failure. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). Plymouth Meeting, PA 19462. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. Please secure your User ID and Password for future use. Believing the best in everyone, ISMP has faith that the TN Board of Nursing likely had the right, albeit misguided, intention to protect the citizens of TN. How to report patients abusing TennCare benefits. Comprehensive information on protecting one's . Request monthly Disciplinary Action Report by e-mail. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. Read our recipe for investigating nursing boards' oversight . These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. Disciplinary action taken by the institution or organization if action pertains to the Board's grounds for disciplinary action (see related content below) Minnesota Statutes Section 148.261 . But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. Disciplinary hearings are conducted in accordance with the "Open Meetings Act" NMSA 1978, Chapter 10, Article 15 and all disciplinary actions are listed on the Board website and published in the Board newsletter quarterly. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. . Nurse did not verify that the proper medication was administered to the patient. In fact, the Board has not filed disciplinary action against all TN nurses who have not read a medication label carefully, obtained a nonurgent medication from an ADC via override, drawn an incorrect conclusion, failed to monitor a sedated patient, or failed to document a medication error in the patients record. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! endobj Dispositions of paid claims shall be reported in a minimum of three (3) graduated categories indicating the level of significance of the award or settlement. Nurse could not know the dose of the drug she administered if she had not read the label and knew the concentration. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Nothing on this site should be taken as legal advice for any individual However, was the Boards action fair and just in this situation? nunsirg ce nli es. The Division of Health Related Boards provides administrative support to the boards, committees, councils and one registry that are charged with the licensure and regulation of their respective health care professionals, as well as the Office of Consumer Right to Know. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. The standards are very broad. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. 37201 <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 13 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Table 2. ); Names of medical schools or professional and training schools and dates of graduation; Graduate medical education or other graduate-level training; Specialty board certification as determined by the relevant board; Names of the hospitals where the licensee has privileges; The identification of any translating services that may be available at the licensee's primary practice location; An indication of which managed care plans in which the licensee participates; An indication of TennCare plans in which the licensee participates; Appointments to medical school faculties and indication as to whether a licensee has a responsibility for graduate medical education within the most recent ten (10) years; (optional), Information regarding publications in peer-reviewed medical literature; (optional) and, Information regarding professional or community service associations, activities and awards; (optional). Nurses criminal trial is scheduled but delayed due to the pandemic. Disputed failure. While searching for information on a particular health care professional, consumers should be aware that there are several locations available to aid them with their research. Any actions taken by the boards must be filed with the Administrative Procedures Division of the Secretary of States Office in which effective dates will be assigned. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. She said through tears at the hearing, I wont ever be the same person. Below is a list of actions taken in July 2020. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. endstream endobj startxref The NPA is then interpreted into regulations by each state and territorial nursing board with the authority to regulate the practice of nursing care and the power to enforce the laws. This information is not intended to create, and receipt To view your current profile, please go tohttp://apps.health.tn.gov/Licensure/Default.aspxand enter your license number and profession, then click on the Practitioner Profile link. endstream endobj 1407 0 obj <. C. omplaints to nursing boards can come from . Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. endobj The mission of each board is to safeguard the health, safety and welfare of Tennesseans by requiring those who practice health care professions within this state to be qualified. The boards interpret the laws, rules and regulations to determine the appropriate standards of practice in an effort to ensure the highest degree of professional conduct. As ISMP knows well from the vast number of error reports received, even the most careful and competent practitioner might make these mistakes or drift into unsafe practice habits without recognizing the risks. Furthermore, the Board did not determine whether RaDonda saw the risk associated with her behavior as substantial and disregarded it, and whether her internal risk monitor firedthat little voice that creeps into our conscious thoughts and lets us know we are in danger. Nashville Tennessean. {dhF`g)Ut9`6XX:WaVUR!@Z! . Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. Also, the nurse was used to scanning the barcode on drug labels for verification and tried to locate a scanner to do so while in radiology, but to no availbarcode scanning technology was not available in radiology. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. These laws are defined in the Nursing Practice Act (NPA). There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. NASHVILLE, Tenn. Tennessee Code Annotated, Section 68-- 1-114 requires the Tennessee - Department of Health to issue a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Please include your name, title/position, organization name, office phone and . By the time she arrived back in the intensive care unit (ICU), she learned of her error and immediately reported it and completed an event report. %%EOF 437 0 obj <> endobj You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. Also, hospital policy did not require monitoring after Versed administration, and the drug was not mentioned in the moderate sedation policy or the hospitals high-alert medication list. U.S. Disciplinary action against her license was then filed. National Council of State Boards of Nursing, Inc. All Rights Reserved. %PDF-1.5 % 466 0 obj <>stream In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. endstream endobj startxref And while RaDonda made a conscious decision to not monitor the patient or scan the medications barcode, she was told that monitoring was not required, and barcode scanning technology was not available in radiology. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . However, RaDonda also testified that the error was made because of flawed procedures at the hospital, particularly the lack of timely communication between the pharmacy computer system and the ADC, which led to significant delays in accessing medications and the hospitals permission to temporarily override the ADC to obtain prescribed medications that were not yet linked to the patients profile in the ADC. Place: Electronic Meeting / Poplar Room . Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. Failure to recognize self-blame in second victims. During the hearing, RaDonda appeared to fall on the sword of guilt, remorse, self-doubt, loss of confidence, and a wish to make amends. This page has information and updates on nursing boards and regulation specific to Montana. The nurses license verification is available immediately to the endorsing board of nursing. Nurse charged with criminal reckless homicide and impaired adult abuse. To SEARCH and find an individual, press Control and 'f' keys, and type in name. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. case or situation. While the Board believed it was conscious disregard to not read the label, this is likely human error, as it happened inadvertently when she saw that the drug was a powder and quickly turned the vial over. Undisputed failure. endobj Available for institutions While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. While the vast majority of nurses are competent and caring individuals who provide care according to the standard, violations of the nurse practice act do happen. The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. Drug prescription errors, while serious events are not necessarily intentional. Nursysis the only national database for verification of nurse licensure, discipline and practice privileges for RNs,LPN/VNs and APRNs licensed in participating jurisdictions, including all states in theNurse Licensure Compact (NLC). This timeline will help, Medication Safety Officers Society (MSOS). and nurses. RaDonda was involved in a fatal medication error after entering ve in an automated dispensing cabinet (ADC) search field, accidentally removing a vial of vecuronium instead of VERSED (midazolam) from the cabinet via override, and unknowingly administering the neuromuscular blocking agent to the patient. Information concerning all settlements shall be accompanied by the following statement: Settlement of a claim may occur for a variety of reasons which do not necessarily reflect negatively on the professional competence or conduct of the provider. Currently, the annual rate of discipline on a nursing license is less than one percent. Hospital settles with patients family, requiring them to not speak about the error publicly. Each provider licensing board shall set by rule adopted pursuant to the Uniform Administrative Procedures Act, compiled in title 4, chapter 5, a threshold amount below which judgments or settlements shall not be reportable; provided, such threshold shall, for chapter 6 or 9 of this title licensees, be set at seventy-five thousand dollars ($75,000), for doctors of chiropractic, regulated pursuant to chapter 4 of this title, be set at fifty thousand dollars ($50,000), for dentists, regulated pursuant to chapter 5 of this title, be set at twenty-five thousand dollars ($25,000), and for all other licensees under this title be set at ten thousand dollars ($10,000). Nursing Licensure for Internationally Educated Nurses, See what boards of nursing are currently participating, Enhance communication between member boards, Retrieve discipline and various other reports. RaDonda could not have consciously disregarded a substantial and unjustifiable riska requirement for reckless behaviorbecause she had no idea that she had made a mistake. An outcome bias often results in over-reacting to a singular event with unwarranted disciplinary action, or under-reacting to a system design flaw if the outcome is not harmful. Date of Meeting: May 1, 2023 . Nursys is the only national nurse licensure and disciplinary database. This timeline will help. Registered Nurse Licensed Practical Nurse Clinical Nursing Specialist Nurse Practitioner Contact: Sylvia Tamayo-Suijk, (804) 367-4502 , sylvia.tamayo-suijk@dhp.virginia.gov For: Nurse Aide Medication Aide Licensed Massage Therapist Contact: Cathy Hanchey, ( 804)367-4481 , cathy.hanchey@dhp.virginia.gov Virginia Board of Nursing TDH Newsroom. Nurses disciplinary licensing hearing is held. Nurse did not verify that the proper medication was removed from the ADC. Accountability for not following the five rights. What is NOT in dispute is that the hospital could have made barcode scanning technology a priority in radiology, given its high reliability for managing the risk of a competent, caring nurse showing up with the wrong drug in hand, as happened here. Listings are sorted by the year of original Board action issued then by last name, first name. A payment in settlement of a medical malpractice action or claim should not be construed as creating a presumption that medical malpractice has occurred. (Pending malpractice claims shall not be disclosed by a board to the public. Filing Complaints and Researching Disciplinary Actions. NASHVILLE, Tenn. -- Tennessee Code Annotated, Section 68-1-114 requires the Tennessee Department of Health to issue a monthly media release listing all disciplinary actions taken by the health-related boards during the prior month. Late in 2018, the hospital was investigated by the Centers for Medicare & Medicaid Services (CMS) after an anonymous whistleblower came forward to report the fatal error. This page has information and updates on nursing boards and regulation specific to Georgia. a number of sources. To determine what a reasonable nurse would do, the Board used a null hypothesis (suggesting no differences between nurses working in different systems) with a rigid lens in a vacuum, not actual nurses who were similarly situated, often leading to unreasonable expectations of a nurse. May 20-21, 2020 Vaught's professional discipline hearing is scheduled at a quarterly hearing of the Tennessee Board of Nursing. Please click the link below to access the licensure renewal page. She did not read the front of the medication label due to either a momentary distraction (error) or an unsafe practice habit (at-risk behavior). Yet, the primary way to determine the differences between at-risk and reckless behavior is to carefully consider the system-based causes that might have contributed to the behavioral choices. The system provides licensure and publicly available discipline data directly to you as the information is entered into the Nursys database by participating boards of nursing. Patient involved in medication error is withdrawn from life support and dies. @(!1a1Cv:KM60v#.MKbCg&b&pkaK:dplbvY)Z.9-U*AP%k]Y2Tud=xD"Q,|q]iv Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Tennessee Department of Health Publications. Board of Nursing Complaint Process: Investigation to Resolution. Disputed failure. If you are threatened with the loss of your professional license, you must take prompt action. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. Yet, a failure to follow the five rights is often cited as a performance deficit when a medication error occurs, clearly perpetuating the mistaken belief that healthcare practitioners can be held individually accountable for achieving these goals. Although many questions regarding RaDondas alleged failures and the event remain unanswered (Table 2), the Board still voted unanimously to strip RaDonda of her nursing license and levy the full monetary penalties allowed, noting that there were just too many red flags that RaDonda ignored when administering the medication. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. July 13, 2020 Vaught's criminal trial is scheduled to begin. or viewing does not constitute, an attorney-client relationship. The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Speak with an attorney as soon as possible. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. The RaDonda Vaught case is confusing. Unreasonable expectations. On September 27, 2019, in a stark reversal of a 2018 decision to take no licensing action against the nurse, the TN Board of Nursing filed disciplinary action against RaDonda that focused on three violations: Unprofessional conduct related to nursing practice and the five rights of medication administration, Abandoning or neglecting a patient requiring nursing care, Failure to maintain a record of interventions. The nurse was surprised that the medication was a powder, so she turned the vial over quickly to look at the reconstitution directions on the back of the label, without looking at the front of the label (and product name). Inability to differentiate between human error, at-risk behavior, and reckless behavior. `g"H>O|oD)svT>VZ9,VP{PVy9[K. Monday, May 1, 2023 . Detailed information about disciplinary actions is available on . The National Council of State Boards of Nursing (NCSBN) is a not-for-profit organization whose purpose is to provide an organization through which boards of nursing act and counsel together on matters of common interest and concern affecting the public health, safety and welfare, including the development of licensing examinations in nursing. The Office of Consumer Right to Know is charged with seeking and collecting this information and providing it to consumers via the Departments web site. Contact the board at (615) 532-5166. Only cases that have occurred within the most recent ten (10) years shall be disclosed by the department to the public; All medical malpractice court judgments, all medical malpractice arbitration awards in which a payment is awarded to a complaining party and all settlements of medical malpractice claims in which a payment is made to a complaining party beginning with reports for 1998 and each subsequent year; provided, such reports shall not be disseminated beyond the most recent ten-year period, but shall include the most recent ten-year period for which reports have been filed. Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Serious Disciplinary Actions States. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. 1419 0 obj <>/Filter/FlateDecode/ID[<7C1E6885F79A2840B3CD3D4380937611><607411345D04C24E89F3B328005C117C>]/Index[1406 27]/Info 1405 0 R/Length 73/Prev 82019/Root 1407 0 R/Size 1433/Type/XRef/W[1 2 1]>>stream <> 1432 0 obj <>stream Below is a list of actions taken in March 2021. Misdemeanor convictions later expunged by a court of competent jurisdiction shall be stricken from the provider's profile; A description of any final board disciplinary actions within the most recent ten (10) years, which actions shall include final board action as defined by 4-5-314, and reprimand action taken pursuant to a board practice act; A description of any final disciplinary actions of licensing boards in other states within the most recent ten (10) years; A description of revocation or involuntary restrictions of hospital privileges for reasons related to competence or character that has been taken by the hospitals governing body or any other official action of the hospital after procedural due process has been afforded, or the resignation from or nonrenewal of medical staff membership or the restriction of privileges as a hospital taken in lieu of or in settlement or a pending disciplinary case related to competence or character in that hospital, all as taken pursuant to procedures promulgated by the board for licensing health care facilities. The Board has continued to promote a transparent disciplinary process. A nurse can be disciplined for "unprofessional conduct, and negligence, ISMP was shocked, discouraged, and deeply saddened to learn that the Tennessee (TN) Board of Nursing recently revoked RaDonda Vaughts professional nursing license indefinitely, fined her $3,000, and stipulated that she pay up to $60,000 in prosecution costs. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. Board members, with few exceptions, are appointed by the Governor. Board of Nursing. In the end, the prosecutor made the statement that, Nothing [the hospital] could have done would have made the respondent [RaDonda] meet the standards of nursing practice She admitted to alarm and warning fatigue. Undisputed failure but most likely human error, not reckless behavior. See Table 1 for a more detailed timeline of events. If you applied for initial license online, you can use the same account to renew your license. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. 3 0 obj After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. x|83"n lNb:;U}#(jW5m?{8}q~;.>>vK}s[M^^\8_r%N){\~A9aH\9c$f#;_z5]m3g`utfpub>WdU_8WD,(Qs>qhD"63P22.3d|`zKA(%#PIA$1q?JwDU;G\-; Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. License action type by Tennessee nursing professional. Nurse claims that after failing to find the order in the patients profile in the ADC, she called the charge nurse to make sure the order had been placed, and then entered an empty room and checked the patients electronic health record (EHR) to verify the physicians order before returning to the ADC to withdraw the drug via override. Nor did anyone consider if the nurse recognized the risk associated with talking to the orientee while pulling medications from the ADC at the time of the error. DISCIPLINARY ACTION REPORT . DISCIPLINARY ACTION REPORT NASHVILLE, Tenn. -- Tennessee Code Annotated, Section 68-1-114 requires the Tennessee Department of Health to issue a monthly media release listing all disciplinary actions taken by the health-related boards during the prior month. In a Just Culture, inadvertent behavior (human error) is not worthy of disciplinary sanction, regardless of the outcome, and the quality of behavioral choices made during an event are thoroughly examined to determine whether there was conscious disregard of significant risks. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Lack of a thorough investigation. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative.
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