tn board of nursing disciplinary actions

The nurse questioned the need to monitor the patient, which was framed around the need to bring monitoring equipment along for use in radiology. More warnings would not have changed her performance.. Patient involved in medication error is withdrawn from life support and dies. 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. Serious Disciplinary Actions States. PDF Professional Licensure: Investigation and Disciplinary Action The graphic below demonstrates the disciplinary process from receipt of complaint to resolution and reporting. This timeline will help. 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. Nurse did not verify that the proper medication was administered to the patient. The nurse claims that she questioned the need for monitoring the patient and was told that monitoring was not required. C. omplaints to nursing boards can come from . Nursing Practice Act - StatPearls - NCBI Bookshelf (2) In order to be issued a certificate of fitness as a nurse practitioner with . Board actions may include: Fine or civil penalty. How to report patients abusing TennCare benefits. Click here to go to the live stream site. 7oM~/dc`xb7T206 )5F{w0Q ( During the hearing, RaDonda was given an opportunity to testify and defend herself; however, she never shrank from admitting her mistake. <> July 23, 2021. Nurse failed to verify the physicians order for Versed and administered the drug based on the primary nurses oral directions. To cite another example, the prosecutor stated that a reasonable nurse would have seen that the ADC defaulted to searching by the generic drug name, not the brand name (which was difficult to notice at the time), rather than recognizing that the capability of the ADC to simultaneously search by brand and generic names would have been so much more effective. 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. The same Board member said a reasonable nurse would have brought appropriate monitoring equipment and oxygen to radiology to monitor the patient, despite repeated discussions with the primary care nurse who explicitly noted that no monitoring was required. Tennessee Board of Nursing shall be subject to disciplinary action by the Board of Nursing in accordance with the provisions of T.C.A. tzHhn(`d4H&e `Hhe/bFi 1a33$LQLR00m]2b6Q ]j@ZiSf7\D@ hY. Nursing Disciplinary Action Explained | NurseJournal.org These laws are defined in the Nursing Practice Act (NPA). Together the NPA and rules/regulations guide and govern nursing practice. Boards of nursing have replaced a punitive approach to nurses with substance use disorder with treatment alternatives that help nurses return to practice. Disciplinary Actions by the Tennessee Board of Nursing Montana: Nursing Board Tracker - ProPublica Filing Complaints and Researching Disciplinary Actions . The Board seemed to hold RaDonda accountable for not overcoming any of the hospital system failures that, in turn, set her up for failure. 5200 Butler Pike 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 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. %%EOF endobj 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. Filing Complaints and Researching Disciplinary Actions. Name of Board: Tennessee Board of Nursing . When a BON disciplinary process is based on substance use disorder The court for Tennessee professional licensing is the Administrative Procedures Division. Time: 1:00 p.m. C.T. 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" Disputed failure. 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. Suite 400, Information concerning the existence of a court-sealed settlement shall be reported in cases involving such a settlement. THE TENNESSEE BOARD OF NURSING CHAPTER 1000-04 ADVANCED PRACTICE NURSES AND CERTIFICATES OF FITNESS TO PRESCRIBE . hb```\^ !0!U[j|}+Iv0H/\K To be clear, nurses cannot be held accountable for achieving the five rights; they can only be held accountable for following the processes that their organizations have designed and held out as the best way to verify the five rights. In December 2017, RaDonda made a fatal medication error when administering vecuronium rather than Versed to a patient in radiology. 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. However, ISMP believes her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. License action type by Tennessee nursing professional. 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? Below is a list of actions taken in July 2020. 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. And mistakes have consequencesbut apparently not for those lucky enough to avoid patient harm. According to her defense attorney, her acceptance of responsibility for the error was immediate, extraordinary, and continuing. RaDondas criminal trial is scheduled to begin on March 21, 2022. Look up, verify and monitor your nurse licenses anytime, anywhere. 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 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. Any change to information is required to be reported within 30 days of the change. Lists of nurses disciplined since 2004 (NOTE: Nurses are included with other professionals regulated by the state.) 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. Undisputed failure but most likely at-risk, not reckless, behavior. hbbd```b``+@$4XD'A$X|-XXV!`L^ +2$cXW l/#QF @ Disciplinary Actions - New Mexico Board of Nursing Hospital fires nurse for not following the five rights of medication administration. case or situation. However, this failure is substantively unimportant relative to the wrong drug error. Nothing on this site should be taken as legal advice for any individual Disciplinary action against her license was then filed. Resignation of a nurse before conclusion of any disciplinary proceeding or in lieu of discipline. 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. Read our recipe for investigating nursing boards' oversight . She said through tears at the hearing, I wont ever be the same person. U.S. Disciplinary Action Report Page 1 of 11 . 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. Information Required to be Reported on Practitioner Profiles. Board members, with few exceptions, are appointed by the Governor. Were they monitored and by whom and for how long? Last month, the TN Board of Nursing disciplinary hearing was held on July 22and July 23, 2021. Professional boards must publish disciplinary license action each year by month per Tennessee Code Annotated, Section 68-1-114. There can be latitude in interpretation of intention and evidential proof of alleged misbehavior tovigorously defend nursing professionalsagainst the board's rulings. Professional nursing license action report. However, the nurse was unable to document medication administration in the EHR or electronic medication administration record (MAR) while in radiology. 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. Georgia: Nursing Board Tracker - ProPublica 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. 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. A nurse can be disciplined for "unprofessional conduct, and negligence, Receive the monthly Disciplinary Action Report by e-mail. Fifty states, District of Columbia and 4 United States (US) territories . 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 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. After CMS released its report, RaDonda was indicted, arrested, and charged with criminal reckless homicide and impaired adult abuse. Links to various Internet sites are available from the Department of Health Websitehome pageand from the Health Professional Boards Website. What Discipline Can a Board of Nursing Impose Against a Nurse Licensee The purpose of the discipline imposed is remediation; in other words, "to correct practice and promote safety". Select Begin Here For Sign-up under New User to create your account. July 13, 2020 Vaught's criminal trial is scheduled to begin. 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. 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. Tennessee: Nursing Board Tracker - projects.propublica.org Lack of a thorough investigation. The state's duty to protect those who receive nursing care is the basis for a nursing license. Listed below are the meetings held for the past year. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. During the investigation, it was never determined whether other nurses would talk to an orientee while pulling medications from an ADC. 4 0 obj Although terminology may differ, board disciplinary action affects the nurse's licensure status and ability to practice nursing in the jurisdiction. or viewing does not constitute, an attorney-client relationship. 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. 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. 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. Unreasonable expectations. PDF Rules of The Tennessee Board of Nursing Chapter 1000-04 Advanced Adapted from: Kelman B. 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. 0 This information is not intended to create, and receipt 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 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. TN Detailed information about disciplinary actions is available on . <> 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. `g"H>O|oD)svT>VZ9,VP{PVy9[K. 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. Disciplinary action against her license was then filed. In addition to suspending or revoking a nursing license, state boards of nursing may issue fines or warnings and possibly require a nurse . Nurses disciplinary licensing hearing is held. Licensure QuickConfirm is a free service that allows employers and recruiters to retrieve licensure and any applicable discipline documentation in one convenient location. Take disciplinary actions as necessary to protect the public from unsafe nurses. Nurse did not monitor a patient who had received an IV sedative that is sometimes used for moderate sedation. If you applied for initial license online, you can use the same account to renew your license. Disputed failure. 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. Nursys Table 2. 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. 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. 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. The nurses license verification is available immediately to the endorsing board of nursing. As a primary source equivalent the data is provided directly from the boards of nursing. DISCIPLINARY ACTION REPORT . The standards are very broad. WHEN Melissa Welsh*, a certified nurse assistant (CNA), renewed her CNA certificate, she self-reported her arrest and conviction for delivery of cocaine. 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\-; As one Board member noted, I feel like, as humans, every one of us make mistakes, none of us are perfect. Contact us with any comments or questions. 63-7-115. 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. RaDonda's criminal trial is scheduled to begin on . 1406 0 obj <> endobj 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. Without your 214 2nd Avenue N. PDF DISCIPLINARY ACTION REPORT - Tennessee 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. Currently, the annual rate of discipline on a nursing license is less than one percent. Request monthly Disciplinary Action Report by e-mail. 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. 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 Tennessee Department of Health Health Related Boards Memorandum Listings are sorted by the year of original Board action issued then by last name, first name. 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. NCSBN members utilize Nursys via nursys.org to: Receive automated license expiration reminders and status updates. Last month, the TN Board of Nursing disciplinary hearing was held on July 22 and July 23, 2021. But mistakes were made. Nurse retrieved a nonurgent medication from the ADC via override. 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. Contact the board at (615) 532-5166. 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. 37201 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. See what boards of nursing are currently participating. The process is also summarized in the NCSBN videoBoard of Nursing Complaint Process: Investigation to Resolution. The Board has continued to promote a transparent disciplinary process. Institute for Safe MedicationPractices Nurse failed to document vecuronium administration to the patient in the EHR. Both the disciplinary hearing against her license and the criminal trial were delayed due to the coronavirus disease 2019 (COVID-19) pandemic. <>/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 a licensed professional and have been arrested for a crime, your license to practice may be on the line. 0 .`jh L@ b You must be logged in to view and download this document. 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. 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. . 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. Licensed Nurses and Unlicensed Registrants Disciplinary action taken by the Board against an individual is listed below. Below is a list of actions taken in March 2021. If you are threatened with the loss of your professional license, you must take prompt action. The information on this website is for general information purposes only. {dhF`g)Ut9`6XX:WaVUR!@Z! 1432 0 obj <>stream 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. While the prosecutor noted that RaDonda did not act with bad intent, he alleged that she did act recklessly. Nurses alleged failures and unanswered questions about the event. Also, the degree to which distractions were tolerated by the nurse, as well as by other hospital nurses, was never determined. 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. Undisputed failure but most likely human error, not reckless behavior. 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. endstream endobj startxref The Administrative Procedures Division is the administrative court for the State. Hospital settles with patients family, requiring them to not speak about the error publicly. TDH Newsroom. PDF Nursing Disciplinary Process in Tennessee - Surber, Asher, Surber e-Notify for Institutions is a free of charge innovative nurse licensure notification system where you receive real-time notifications about nurses you employ. ); 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). PDF Disciplinary Action Report Page 1 of 18 - Tennessee The Board of Nursing meets 12 times a year and takes disciplinary actions during each meeting. Find Your Nurse Practice Act | NCSBN Furthermore, we recognize how difficult it is to be conferred with the responsibility of protecting the public. 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 . But whether this happened due to human error or at-risk behavior, or reckless behavior as alleged by the Board, is at odds. e-Notify for Nurses helps nurses easily manage their licenses at no cost to them. 2023 Institute for Safe Medication Practices. TN Board of Nursing's Unjust Decision to Revoke Nurse's License
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