tn board of nursing disciplinary actions

National Council of State Boards of Nursing, Inc. All Rights Reserved. RaDondas criminal trial is scheduled to begin on March 21, 2022. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. Undisputed failure but most likely at-risk, not reckless, behavior. Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. hb```\^ !0!U[j|}+Iv0H/\K Board actions may include: Fine or civil penalty. These are all common symptoms of the deeply personal, social, spiritual, and professional crisis experienced by second victims of fatal errors. 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. Listed below are the meetings held for the past year. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. Disputed failure. 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 Tennessee Department of Health issues a monthly media release listing all disciplinary actions taken by the health related boards during the prior month. Referral to an alternative to discipline program for practice monitoring and recovery support (drug or alcohol dependent nurses, or in some other . 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. Time: 1:00 p.m. C.T. Tennessee law mandates that specific health care professionals submit information to the Department regarding details of their training, specialty certification and practice. 1:00 p.m. Call to Order Board Meeting 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. The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. endstream endobj 1407 0 obj <. Nurse retrieved a nonurgent medication from the ADC via override. 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 prosecutor acknowledged that the hospital had various system failures that contributed to the error; however, he stressed that the Board is not here to look at the system and is instead looking at individual conduct. Thus, the Board judged RaDondas behavior in isolation of the contributing system failures. National Council of State Boards of Nursing, Inc. All Rights Reserved. Nashville Tennessean. %%EOF Please include your name, title/position, organization name, office phone and . Read our recipe for investigating nursing boards' oversight . 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. 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. Currently, the annual rate of discipline on a nursing license is less than one percent. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. 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. 5200 Butler Pike 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. I would have never wanted something like this to happen to her, or anyone that I loved, or anyone that I dont even know. Please click the link below to access the licensure renewal page. The state's duty to protect those who receive nursing care is the basis for a nursing license. Board of Nursing Complaint Process: Investigation to Resolution. Board members, with few exceptions, are appointed by the Governor. 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). 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. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. Please secure your User ID and Password for future use. For example, in the case of suspected theft or misappropriation, were there other professionals or employees present who had access to the alleged misappropriated items? Board revokes the nurses professional license and fines her $3,000. Nurse did not verify that the proper medication was administered to the patient. %PDF-1.6 % Date of Meeting: May 1, 2023 . 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. 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 did not see or heed the warning on the vial cap/ferrule, , Undisputed failure but most likely human error, not reckless behavior. U.S. Below is a list of actions taken in March 2021. See Table 1 for a more detailed timeline of events. What Discipline Can a Board of Nursing Impose Against a Nurse Licensee Read our recipe for investigating nursing boards' oversight . 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? .`jh L@ b This page has information and updates on nursing boards and regulation specific to Georgia. Discipline Meeting . Click here to go to the live stream site. Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. If you are a licensed professional and have been arrested for a crime, your license to practice may be on the line. PDF DISCIPLINARY ACTION REPORT - Tennessee 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" 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. 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. Disciplinary action against her license was then filed. While the Board accepted the state prosecutors recommendation to revoke RaDondas nursing license, ISMP doubts that the Boards action was just, and we believe it set us back 25 years in patient safety. Contact Info Georgia State Board. The information below represents a single month of 51 Tennessee Board of Nursing professional license actions in November 2018. The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. 214 2nd Avenue N., 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. Nursys is the only national nurse licensure and disciplinary database. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ A nurse can be disciplined for "unprofessional conduct, and negligence, Contact the board at (615) 532-5166. News Releases; Calendar of Events; Health Advisories; TDH History Milestones; Tennessee Department of Health . hb```@( g0A2kC.)3gZZN.qY{IU!FIP!DCA vs5 The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". 0 Nurses disciplinary hearing is scheduled but delayed due to the pandemic. Any change to information is required to be reported within 30 days of the change. Monday, May 1, 2023 . 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. 437 0 obj <> endobj 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. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. 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. According to the prosecutor, the Board has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. Nurse did not verify that the proper medication was removed from the ADC. 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. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. {dhF`g)Ut9`6XX:WaVUR!@Z! Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. This timeline will help. Find Your Nurse Practice Act | NCSBN Comprehensive information on protecting one's . 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. If reading the front of the medication label was the best way to confirm the drug in hand, then RaDonda failed in that regard. 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. For Institutions. Also, during investigation of the event, it was not determined whether previous patients in radiology had been monitored after receiving an IV sedative. 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). %PDF-1.7 Serious Disciplinary Actions States. Institute for Safe MedicationPractices The mission of each board is to safeguard the health, safety and welfare of . 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. Reporting Obligations - Minnesota Board of Nursing When a BON disciplinary process is based on substance use disorder Select Begin Here For Sign-up under New User to create your account. Health Professionals Boards Disciplinary Actions - Tennessee Request monthly Disciplinary Action Report by e-mail. 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. endobj 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 . To make changes to your profile, log in to your account at:https://lars.tn.gov/datamart/mainMenu.do. You must have JavaScript enabled to use this form. Health Professional Boards - Tennessee 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. Nurse failed to document vecuronium administration to the patient in the EHR. 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 by e-mail. The information on this website is for general information purposes only. Filing a Complaint; Monthly Disciplinary Action Report; Social Media; . Lack of a thorough investigation. During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. TDH Newsroom. The Administrative Procedures Division is the administrative court for the State. The professions that are required to submit information are: alcohol and drug abuse counselors, audiologists, certified nurse practitioners, chiropractors, clinical pastoral therapists, dentists, dietitian or nutritionists, dispensing opticians, electrologists, marital and family therapists, massage therapists, medical doctors, medical laboratory personnel, nursing home administrators, occupational therapists, optometrists, osteopathic physicians, pharmacists, physical therapists, physician assistants, podiatrists, professional counselors,psychologists, registered nurse anesthetists, respiratory care practitioners, social workers, speech pathologists and veterinarians. The nurse was distracted (talking to an orientee) while preparing the medication and failed to read the full medication label. Practitioner Profiles - Tennessee 3 0 obj SD Nursing Board - Disciplinary Actions - SD Dept. of Health Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) 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. Information for health professionals regarding the COVID-19 response. Nursing Practice Act - StatPearls - NCBI Bookshelf Information Required to be Reported on Practitioner Profiles. 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. 37201 When an individual is engaged in at-risk behavior, their internal risk monitor is silent. More warnings would not have changed her performance.. As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. Disciplinary Actions Log | North Carolina Board of Nursing RaDonda's criminal trial is scheduled to begin on . Listed below are the monthly summaries of disciplinary actions taken against health professionals and/or unlicensed individuals. It is unlikely that the nurse perceived a significant or unjustifiable risk associated with obtaining medications via override. 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. The Board called for the revocation of RaDondas nursing license and fines of up to $3,000. Detailed information about disciplinary . NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. 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). Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. 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. Health Professionals Boards Disciplinary Actions, Tennessee Department of Health Publications. This page has information and updates on nursing boards and regulation specific to Montana. <>/Metadata 1427 0 R/ViewerPreferences 1428 0 R>> Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. Disciplinary Action Report Page 1 of 11 . 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. endstream endobj startxref 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 Accountability for not following the five rights. RaDonda Vaught's trial has ended. This timeline of the case explains

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