tn board of nursing disciplinary actions

The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. The professions required to submit and maintain a practitioner profile questionnaire are: Tennessee Code Annotated Title 63 Chapter 51 requires the following information to be reported to the Board for dissemination to the public on practitioner profiles: http://apps.health.tn.gov/Licensure/Default.aspx, Tennessee Department of Health Publications, Licensed Registered Respiratory Therapists, Licensed Certified Respiratory Therapists. If you are threatened with the loss of your professional license, you must take prompt action. 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; Map & Directions [+]. endstream endobj startxref Take disciplinary actions as necessary to protect the public from unsafe nurses. 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 Undisputed failure but most likely human error, not reckless behavior. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. RaDondas criminal trial is scheduled to begin on March 21, 2022. 5200 Butler Pike Nurses alleged failures and unanswered questions about the event. Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. Serious Disciplinary Actions States. If allegations against a nurse are proven, or he or she admits to the allegations, a board of nursing has the authority to discipline the nurse. Nashville, endstream endobj 1407 0 obj <. The boards are also responsible for the investigation of alleged violations of the Practice Act and rules and are responsible for the discipline of licensees who are found guilty of such violations. The RaDonda Vaught case is confusing. and nurses. This page has information and updates on nursing boards and regulation specific to Montana. hbbd``b`:$gP " `v nb-W&FV^ 'F Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. Read our recipe for investigating nursing boards' oversight . Time: 1:00 p.m. C.T. 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. Also, healthcare practitioners, including nurses, will not want to speak up when they make an error, which will cripple learning, prevent the recognition of the need for system redesign, and set the healthcare culture back to when hiding mistakes and punitive responses to errors were the norm. In addition, incorrect assumptions were made about the system capabilities based on present conditions rather than conditions at the time of the event. DISCIPLINARY ACTION REPORT . e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. After discussions on this topic, the nurse did not think she had a duty to monitor the patient. Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. 2 0 obj 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. . Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. 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. The nurse believed she administered the prescribed dose of 1 mg (which was actually vecuronium, not Versed) after reading the directions for reconstitution on the label, correctly reconstituting the drug, and administering 1 mL of the reconstituted drug. 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. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. RaDondas immediate verbal disclosure to the team treating this patient far exceeded any benefit that would have been available through documentation. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. Detailed information about disciplinary . Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! 0 C. omplaints to nursing boards can come from . Adapted from: Kelman B. 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. 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. You can draw your own conclusions by viewing the 2-day hearing, but the following is what ISMP finds most disturbing and unjust about the Boards decision to revoke RaDondas license: Significant outcome bias. Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. Currently, the annual rate of discipline on a nursing license is less than one percent. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. Please secure your User ID and Password for future use. If the after a thorough investigation, the BON determines there is sufficient basis that the nurse violated the act or regulations, the BON may take disciplinary action on the nurses license. 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. endstream endobj startxref Nursing Disciplinary Process in Tennessee SURBER, ASHER, SURBER & MOUSHON, PLLC WWW.TENNLAWFIRM.COM (615)997-1914 6 Grounds for Disciplinary Action Rules of the Tennessee Board of Nursing describe the Standards of Nursing Conduct or Practice. Thus, the nurse obtained the drug via override, as all nurses did per hospital directives, to temporarily address the system issue. Nurse retrieved a nonurgent medication from the ADC via override. Nurses alleged failures and unanswered questions about the event, anonymous whistleblower came forward to report the fatal error, TN Board of Nursing filed disciplinary action, crisis experienced by second victims of fatal errors, Anonymous whistleblower alerts state/federal agencies, Department of Health (Nursing Board) decides not to pursue disciplinary action, Department of Health (Nursing Board) reverses its prior decision, The RaDonda Vaught case is confusing. Place: Electronic Meeting / Poplar Room . Below is a list of actions taken in NOVEMBER 2021. 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. It is not our intent to embarrass or diminish the TNBoard of Nursing by pointing out what we find disturbing or unjust in the deliberations of this complex matter, but rather to find a better way to achieve justice, learning, and improvement in safety. Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. Disputed failure. "9$3. All rights reserved. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . Were they monitored and by whom and for how long? The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. <>/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>> It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. Undisputed failure but most likely at-risk, not reckless, behavior. @3Mh?d+Nu*%5l(U9{rRA>@l=ph Date of Meeting: May 1, 2023 . Disciplinary Actions by the Tennessee Board of Nursing, License revoked: LPN = 2, CNA = 5, RN = 11, License suspended: LPN = 1, CNA = 0, RN = 14, License probation: LPN = 0, CNA = 0, RN = 15, License reprimanded: LPN = 0, CNA = 0, RN = 3, 23 Drug abuse, including over-prescribing or illegal prescriptions, 02 Patient chart falsification or patient chart data recorded illegibly, 02 Drug addiction, including substance addictionor substance use on duty, 19 Incompetence, negligence or unprofessional conduct. It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. Below is a list of actions taken in March 2021. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. Nashville, TN 37201. Patient involved in medication error is withdrawn from life support and dies. e-Notify Get free license expiration and status updates via email Nurses criminal trial is scheduled but delayed due to the pandemic. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. Board of Nursing. 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. U.S. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. Nurse did not verify that the proper medication was removed from the ADC. July 23, 2021. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. 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. 3 0 obj The Board has continued to promote a transparent disciplinary process. 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 court for Tennessee professional licensing is the Administrative Procedures Division. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. Nurses disciplinary licensing hearing is held. 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. 1406 0 obj <> endobj The board of nursing (BON), through its statutory authority specified in the nurse practice act, is responsible for reviewing and acting on complaints in order to fulfill their mission to protect the public. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. endobj _X_\~?Map0j).,XxzZ(uJ@ X{ R@-npXC +G1#!$>Wwo^-!,${W'/7$ A@B`\mu)B8@afs@6Aad&@r6[K0(+hTR]rJL|yC .=okDYp B',zR5dbdG~8hy.3a6zt #x^h%~L7 fUFA@eRiM9X:0&z-j>@95_N6lxPoYK{T#9nHZ"ip]>3>U]S 1:00 p.m. Call to Order Board Meeting 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. Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. For example, one Board member suggested that a reasonable nurse would have transported the patient out of the radiology unit to a patient care unit that used barcode technology so she could scan the barcode on the medication prior to administration. Investigation of the event did not include examination of recent sedation for claustrophobic patients in radiology or sedation with IV Versed to determine whether monitoring had occurred previously. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. Table 2. Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. Nurse charged with criminal reckless homicide and impaired adult abuse. Comprehensive information on protecting one's . If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. Receive the monthly Disciplinary Action Report by e-mail. Board actions may include: Fine or civil penalty. Nurse did not verify that the proper medication was administered to the patient. Suite 400 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. Institute for Safe MedicationPractices %PDF-1.5 % 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. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. 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 . 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. 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. 1432 0 obj <>stream However, was the Boards action fair and just in this situation? %%EOF Disputed failure. 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. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. The state's duty to protect those who receive nursing care is the basis for a nursing license. 0 Nothing on this site should be taken as legal advice for any individual As a primary source equivalent the data is provided directly from the boards of nursing. Discipline was defined as a formal action taken by a board of nursing or a court, whereby an APRN received a formal letter of reprimand, a restriction placed on an active license or certification, such as a prohibition against narcotic access, restriction from participating in the multi-state licensure compact, suspension with or without a stay, tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. 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. or viewing does not constitute, an attorney-client relationship. In response to the whistleblower, CMS conducts a surprise hospital inspection. TDH Newsroom. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. % 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. hb```\^ !0!U[j|}+Iv0H/\K This page has information and updates on nursing boards and regulation specific to Georgia. Getting to Know Your Licensing Board: the North Carolina Board of Nursing at a Glance; What Nurses need to know about Informatics, Social Media, and Security! <> The nurses license verification is available immediately to the endorsing board of nursing. License action type by Tennessee nursing professional. 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. 1 0 obj Projectionsbased on a single month, while not statistically accurate, suggest a large number of annual nursing license disciplinary actions may result from controlled substance issues. 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. (2) In order to be issued a certificate of fitness as a nurse practitioner with . 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. How to report patients abusing TennCare benefits. More warnings would not have changed her performance.. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. 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. Detailed information about disciplinary actions is available on . Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. Failure to consider the significant contribution of system failures. 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. Nurse administers IV vecuronium instead of Versed (midazolam). 37201 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. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. 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.

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tn board of nursing disciplinary actions

tn board of nursing disciplinary actions