tn board of nursing disciplinary actions tn board of nursing disciplinary actions

Speak with an attorney as soon as possible. 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. Adapted from: Kelman B. 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. Please secure your User ID and Password for future use. 3 0 obj But mistakes were made. This information is not intended to create, and receipt 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 Comprehensive information on protecting one's . 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. Nurses can verify their licenses by completing the Nursys verification process for $30 per license type, per each board of nursing where the nurse is applying. Please include your name, title/position, organization name, office phone and . There may have been gross oversight defects in controlled substance dispensing and verification procedures on the part of a hospital or pain management clinic. %PDF-1.5 % To determine what a reasonable nurse would do, the Board used a null hypothesis (suggesting no differences between nurses working in different systems) with a rigid lens in a vacuum, not actual nurses who were similarly situated, often leading to unreasonable expectations of a nurse. Late in 2018, the hospital was investigated by the Centers for Medicare & Medicaid Services (CMS) after an anonymous whistleblower came forward to report the fatal error. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. Board of Nursing Complaint Process: Investigation to Resolution. Nurse retrieved a nonurgent medication from the ADC via override. 1432 0 obj <>stream Listed below are the meetings held for the past year. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. e-Notify Get free license expiration and status updates via email ~\W3o3Vq~;?+|_y[OFCP"!$"1 fNr]E Xxo?_OxW/$w;~p.)}(z!% mR:muv P" NT/T*?UlaP=:> 3paRh ZC! Listings are sorted by the year of original Board action issued then by last name, first name. The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. %%EOF 2023 Institute for Safe Medication Practices. 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. 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 Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) She said through tears at the hearing, I wont ever be the same person. Look up, verify and monitor your nurse licenses anytime, anywhere. The location of the licensee's primary practice setting; A description of any criminal convictions for felonies and, as determined by the board, serious misdemeanors, within the most recent ten (10) years. endobj Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. Adherence to the physicians order is oddly linked by the prosecutor to the nurses alleged failure to monitor the patient. 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. Discipline Meeting . As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. Disputed failure. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. Patients, coworkers, members of the public, or employers can call the board of nursing, put complaints in writing, or complete a board of nursing Web site complaint form. To make changes to or update the Practitioner Profile, please do so via the web at:https://lars.tn.gov/datamart/mainMenu.do. Disciplinary Action. 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. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. 5200 Butler Pike 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. 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. Nashville, TN 37201. If you applied for initial license online, you can use the same account to renew your license. Time: 1:00 p.m. C.T. ); 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). The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Available for institutions Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. 1406 0 obj <> endobj 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. 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. Nurse failed to document vecuronium administration to the patient in the EHR. 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. 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. Complaints. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. <> Information Required to be Reported on Practitioner Profiles. You must have JavaScript enabled to use this form. When an individual is engaged in at-risk behavior, their internal risk monitor is silent. As RaDondas defense attorney said during the hearing, Rather than revoking this good nurses license, there needs to be another way. If we dont find it, we risk jeopardizing the opportunity to recruit talented people into the healthcare fieldthey wont want to join a profession where an unintended mistake could end in the loss of their license or even jail time. 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. 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. 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. Furthermore, the answers to these questions at the time of the event appeared to be unknown to the prosecution. 0 This page has information and updates on nursing boards and regulation specific to Montana. TN Lack of a thorough investigation. Detailed information about disciplinary actions is available on . Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. You must be logged in to view and download this document. 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. Make a User ID that you can remember, such as your email address. 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. We believe this is what happened here. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. 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. (2) In order to be issued a certificate of fitness as a nurse practitioner with . 466 0 obj <>stream It seemed the Board was holding a disciplinary hearing primarily because the patient had died, so there was a significant outcome bias. 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 information on this website is for general information purposes only. hbbd``b`:$gP " `v nb-W&FV^ 'F Drug prescription errors, while serious events are not necessarily intentional. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. hb```\^ !0!U[j|}+Iv0H/\K _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 0 National Council of State Boards of Nursing, Inc. All Rights Reserved. 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 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. National Council of State Boards of Nursing, Inc. All Rights Reserved. Unreasonable expectations. 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. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act (NPA) and the state rules/regulations. Every state and territory in the US set laws to govern the practice of nursing. 63-7-115. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . a number of sources. Didn't find what you are looking for? Date of Meeting: May 1, 2023 . Were they monitored and by whom and for how long? You can read the details of the error in three of our 2019 newsletters (January 17, 2019;February 14, 2019; March 14, 2019). 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. 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. But the five rights are merely broadly stated goals or desired outcomes of safe medication practices that offer no procedural guidance on how to achieve these goals. A nurse can be disciplined for "unprofessional conduct, and negligence, endstream endobj startxref Map & Directions [+]. U.S. stream Read our recipe for investigating nursing boards' oversight . %%EOF However, this failure is substantively unimportant relative to the wrong drug error. The mission of each board is to safeguard the health, safety and welfare of . For the purposes of this subsection (a), a person shall be deemed to be convicted of a crime if such person was found or adjudged guilty by a court of competent jurisdiction. Board revokes the nurses professional license and fines her $3,000. Nurse did not verify that the proper medication was removed from the ADC. Receive the monthly Disciplinary Action Report by e-mail. To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. 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. 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. In response to the whistleblower, CMS conducts a surprise hospital inspection. Currently, the annual rate of discipline on a nursing license is less than one percent. How to report patients abusing TennCare benefits. 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. Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . Nurses disciplinary hearing is scheduled but delayed due to the pandemic. The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. Any change to information is required to be reported within 30 days of the change. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. 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. Place: Electronic Meeting / Poplar Room . If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. C. omplaints to nursing boards can come from . Development of Sanctioning Guidelines for Public Discipline in Nursing Regulation: The North Carolina Board of Nursing Journey; What Could Happen: The Consequences of "Practice Drift" 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. The RaDonda Vaught case is confusing. Undisputed failure but most likely at-risk, not reckless, behavior. Monday, May 1, 2023 . 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. {dhF`g)Ut9`6XX:WaVUR!@Z! Also, disciplinary sanctions are not imposed for at-risk behaviors, including not following the rules; any system design failures that may have contributed to not following the rules must be examined and factored into the judgment of the behavior. Nursing professionals have the right not to respond verbally or in writing to any nursing license board communication without their counsel present. <>/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>> If you are threatened with the loss of your professional license, you must take prompt action. 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 . Select Begin Here For Sign-up under New User to create your account. 37201 The state's duty to protect those who receive nursing care is the basis for a nursing license. (The patient involved in the error received 20 different medications obtained by various nurses via ADC override during her hospitalization.). Plymouth Meeting, PA 19462. Hospital settles with patients family, requiring them to not speak about the error publicly. The Administrative Procedures Division is the administrative court for the State. Contact us with any comments or questions. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. 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 $60,000 in prosecution costs. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. While the vast majority of nurses are competent and caring individuals who provide care according to the standard, violations of the nurse practice act do happen. For example, the Board considered neuromuscular blocking agent warnings on the ADC screen and shrink wrap sleeves over the vials to be red flags overlooked by RaDonda, when both had been added to improve the warning system after the event occurred. .`jh L@ b All rights reserved. Request monthly Disciplinary Action Report by e-mail. July 23, 2021. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. Fifty states, District of Columbia and 4 United States (US) territories . Suite 400 Nurse was distracted while talking to an assigned orientee while retrieving the medication from the ADC. 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, 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. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. Nurse did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. The court for Tennessee professional licensing is the Administrative Procedures Division. The court for Tennessee professional licensing is the Administrative Procedures Division. These laws are defined in the Nursing Practice Act (NPA). Without your 214 2nd Avenue N. Questions posed to witnesses were also misleading as they were directed at current conditions and not correlated to the conditions that existed in 2017. Nursys is the only national nurse licensure and disciplinary database. See what boards of nursing are currently participating. 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. Nurse charged with criminal reckless homicide and impaired adult abuse. 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. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Nurse License Verification service enables nurses to verify their license(s) from a Nursys verification participating board when applying for endorsement into another state. 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. 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. 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. Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Information concerning paid medical malpractice claims shall be put in context by comparing an individual licensee's medical malpractice judgment awards and settlements to the experience of other providers within the same specialty. Tennessee Department of Health Publications. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. Contact Info Montana State Board. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. 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. and nurses. Nashville, Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. Undisputed failure but most likely human error, not reckless behavior. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. See Table 1 for a more detailed timeline of events. Nurses disciplinary licensing hearing is held. Read our recipe for investigating nursing boards' oversight . Undisputed failure. e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. Table 2. Institute for Safe MedicationPractices The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. Below is a list of actions taken in July 2020. 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. Hospital fires nurse for not following the five rights of medication administration. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. Professional nursing license action report. Below is a list of actions taken in NOVEMBER 2021. Once enrolled, a nurse will get automatic notifications about license status, license expiration, license renewal or publicly available disciplinary actions or alerts. 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. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. The Board relied on an incomplete investigation of the event, particularly related to the question, What normally happens in similar circumstances? For example, the investigation had failed to examine prior patients who were anxious about radiology scans due to claustrophobia to see what normally happensdid these patients receive oral anxiolytics or IV sedatives? . However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. 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. Receive the monthly Disciplinary Action Report bye-mail. @3Mh?d+Nu*%5l(U9{rRA>@l=ph "9$3. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . 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. Nurse administers IV vecuronium instead of Versed (midazolam). Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. Take disciplinary actions as necessary to protect the public from unsafe nurses. Below is a list of actions taken in March 2021. As a primary source equivalent the data is provided directly from the boards of nursing. For Institutions. 2 0 obj 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. 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. or viewing does not constitute, an attorney-client relationship. Undisputed failure but most likely at-risk, not reckless, behavior. Inability to differentiate between human error, at-risk behavior, and reckless behavior.