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Board of Nursing Investigation for System Charting Error

Nurses   (9,542 Views | 76 Replies)

Terry Bow has 3 years experience as a BSN, RN.

1,025 Profile Views; 17 Posts

I received an email from the BON compliance officer about wanting me to participate in an investigation. When I spoke with them, they stated it was about a med error for suboxone many months prior that 15 other nurses at the facility made. They stated it was minor and wouldn't result in suspension or loss of license, just disciplinary action at the very most. I told them I was concerned and may seek legal counsel. They continued to state that it was minor and they just wanted to get my take on the situation regarding safe medication administration. They want to schedule a time to interview. Do I accept the interview or consult an attorney? Should I speak to my unit first? Nobody has written me up or informed me of any med error regarding this. I also have not heard of our entire unit being under investigation, either. I have only been a nurse for 3 years and have never had this happen. My state nursing board has a reputation for being notoriously aggressive. What's the best way to proceed? 

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Sour Lemon has 9 years experience.

3 Followers; 4,485 Posts; 33,686 Profile Views

I would speak to a lawyer first. It might also be a good idea to change your name and picture to something more anonymous.

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Terry Bow has 3 years experience as a BSN, RN.

17 Posts; 1,025 Profile Views

Thank you. I will postpone the interview. I contacted an attorney and they said to see what they want first then provide minimal information, then to call them back. 

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

2 Followers; 1 Article; 2,623 Posts; 43,874 Profile Views

Unless you go to Boards to chat with one of your old pals about life in general, do not utter a word with them without your lawyer. However innocent it might really look like or they might want to present it, just do not do that. Any mistake can be too costly. 

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TriciaJ has 39 years experience as a RN and specializes in Psych, Corrections, Med-Surg, Ambulatory.

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If 15 nurses all made the same error, then it's a systems error.  Your facility Risk Management Department should be wanting interviews with everyone to figure out how best to adjust the system.

How on earth did the Board of Nursing get involved in this?  It makes no sense.  Add that to your statement of them being notoriously aggressive, and telling you up front it will possibly lead to disciplinary action, and you were right to lawyer up.

If your lawyer won't attend a meeting until the Board tips its hand then it sounds like you'll have to attend a meeting first without him/her.  You could contact another lawyer to see if that person will attend an initial meeting with you; it will prevent possible mistakes and let the Board know that you take your reputation seriously.

Otherwise, be up front with the Board.  Tell them you agree to an initial meeting where they tell you what information they want.  Let them know that you will provide NO answers until you can present their questions to your attorney.  Their idea of "minor" and your idea of "minor" aren't necessarily the same thing so  accept no vague assurances from them.

I have the feeling that once they're made  aware that a lawyer is involved and that you will not proceed without one, the whole thing goes away.  Sounds like there are currently some power-trippers at the Board of Nursing.

Good luck and keep us posted.

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KatieMI has 6 years experience as a BSN, MSN, RN and specializes in ICU, LTACH, Internal Medicine.

2 Followers; 1 Article; 2,623 Posts; 43,874 Profile Views

4 minutes ago, TriciaJ said:

If 15 nurses all made the same error, then it's a systems error.  Your facility Risk Management Department should be wanting interviews with everyone to figure out how best to adjust the system.

How on earth did the Board of Nursing get involved in this?  It makes no sense.  

Easy. One of former (or current) employees was suspected of diversion (or caught red-handed, or reported for a clear breaking of the rules of charting/administration of narcs, the latter is most possible if the case is about Suboxone), Boards were informed and initial investigation found multiple similar mistakes done by the person in question and every nurse in the facility. 

Less possible that State surveyor or DEA found something. DEA cooperates very closely with professional Boards in every state. 

One SNF I was frequently discharging patients into was known to request two copies of each script for "controls" written with one day difference, with "this is OUR POLICY!!" single rationale for that strange request. Their policy lasted till one beautiful day a rural pharmacy in the middle of nowhere accidentally got both scripts, written for a large amount of narcotics for the same patient with one day difference. The scripts were immediately flagged by pharmacist and duly reported to DEA as "double scripting",  the State and Feds people descended in the SNF in their full power shortly thereafter and found  several hundreds of scripts written by half of local providers of all specialties,  signed by every nurse who worked there, all unfilled and kept openly in patients' files. 

After all was said and done in about a year, the SNF quickly became known for exceedingly polite and accomodating nursing administration. 

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Terry Bow has 3 years experience as a BSN, RN.

17 Posts; 1,025 Profile Views

The officer specifically told me that another nurse gave 2 suboxone to a patient that I cared for when they were supposed to give one. She told me I didn’t do that but wanted to check to see what I would do in a certain situation etc. She did not specify what situation. She DID say that she thinks it’s a systematic error because of the amount of nurses involved. I do not want to talk or “accidentally admit” to anything beyond my knowledge that could make me guilty. However, I am surprised that my facility has not notified me of this first! Also, this happened many months ago last year! 
Thank you for the feedback. 

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5 Followers; 37,751 Posts; 104,490 Profile Views

Stinks that you are not hearing about this first from your facility. Shows who is not on your side. I would not attend meeting without attorney for this reason alone.

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Terry Bow has 3 years experience as a BSN, RN.

17 Posts; 1,025 Profile Views

Thank you. I know. I work PRN at the facility while in school so I’m usually just there a couple days a week at the most. 

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526 Posts; 2,377 Profile Views

Why would the BON want to know what you would do in specific situations?  What does that matter?  If 15 nurses made the same error then obviously there's a problem. And if you say you'd do the same (wrong) thing they did, what will happen to you?  Quite frankly I would just ignore the whole issue till they call back, and maybe ignore till they call back again.  

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Terry Bow has 3 years experience as a BSN, RN.

17 Posts; 1,025 Profile Views

I don’t know. Somewhere there’s an issue. I am just upset that I never heard anything outstanding from my facility at the time. I haven’t worked there in over 2 months. Do you recommend bringing this to their attention? 

I don’t know. Somewhere there’s an issue. I am just upset that I never heard anything outstanding from my facility at the time. I haven’t worked there in over 2 months. Do you recommend bringing this to their attention? 

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Terry Bow has 3 years experience as a BSN, RN.

17 Posts; 1,025 Profile Views

I don’t know. Somewhere there’s an issue. I am just upset that I never heard anything outstanding from my facility at the time. I haven’t worked there in over 2 months. Do you recommend bringing this to their attention? 

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