Anonymous865

Once again the Tennessee Board of Nursing has failed to protect patients. In July 2021 Johnson City Medical Center in Johnson City, TN, found that someone had tampered with vials of dilaudid and returned the vials to the omnicell. The tampered vials were linked to Jaqueline Brewster, a travel nurse. “She was removing the Dilaudid and replacing it with another substance that looked clear like Dilaudid, and replacing the vials in the Omnicell system,” Levine said. “One of our other nurses noticed that something looked different in one of the vials and notified the pharmacy immediately.” Ballad Health fired Brewster and alerted law enforcement and the Tennessee Department of Health, according to a statement from the company. It sent five Dilaudid syringes to the Tennessee Bureau of Investigation’s crime lab, which confirmed the amount of medication within was “inconsistent with the manufacturer’s label,” according to the nursing board documents." Ballad Health notified about 100 patients that they may have been exposed to blood-borne diseases and recommended that they be tested for Hep C and HIV. The nurse was fired by JCMC. She had a compact license, so she started working at Raleigh General in West Virginia. In March of 2022, that hospital discovered dilaudid vials had been tampered with and reported Brewster to the West Virginia BON. West Virginia suspended her license on 3/22/2022. The Tennessee Department of Health filed the professional disciplinary case against Brewster with the Board of Nursing on March 31. She is scheduled to appear Aug. 24 at a board hearing and risks losing her nursing license. If the TN BON had acted, they could have protected patients in WV. They did not act until after West Virginia suspended her license. https://khn.org/news/article/travel-nurse-opioid-tampering-investigation-jacqueline-brewster/

Unfortunately a lot of people have read the CMS report and see it as proof that all fault falls squarely on the hospital. To them the fact that CMS issued "a 50+ page deficiency report" to the hospital is proof it's the hospital's fault.

Great news. <<sarcasm>> You can now get an "I stand with RaDonda" t-shirt!! One was even designed by RaDonda! All the proceeds to to RaDonda. https://istandwithradonda.com/ Am I the only one who thinks this is in terrible taste? Does she grasp that she killed someone? This must be terribly painful for the family of her victim.

I don't know of a transcript. The 2nd time the board considered the complaint against her, the board meeting was live streamed. The links to the live stream are here https://www.tn.gov/content/dam/tn/health/healthprofboards/nursing/meeting-schedule/Nursing Public Notice July 22-33, 2021.pdf It was 2 days long. The first day was testimony. The 2nd day was the board discussing the case. Radonda Vaught starts testifying about 3:50 on the first day.

In her testimony to the 2nd BON investigation, it sounds even worse. They asked when was the last time she had given Versed. Radonda answered the day before the incident. BON: isn't Versed a controlled substance Radonda: Yes BON: Doesn't the ADC require you to count and confirm controlled substances? Radonda: Yes. BON: When you pulled Vecuronium did you have to do a count? Radonda: No BON: Did that not raise a red flag for you? Radonda: No BON: was the vial a different size and color from the versed vial from the day before? Radonda: Yes BON: Did that not raise a red flag for you? Radonda: No BON: When you gave Versed the day before did it have to be reconstituted? Radonda: No BON: When you saw it was a powder, did that not raise a red flag for you? Radonda: No BON: Did you read the label to determine the concentration of the reconstituted powder Radonda: No BON: How did you know how much to give Radonda: well when we give versed it is usually 1mg/ml They also asked about her going to ED to do the swallow assessment. It sounded like ED was next to radiology. When she got to ED, her patient wasn't there. BON: what did you do when you found the patient wasn't there? Radonda: went back to the neuro ICU and check with various nurses to see if they needed any help BON: why didn't you go back to check on your patient in radiology before returning to the unit? Radonda: uh There were so many opportunities for her to think wait something isn't right here.

Grossly negligent docs are also being criminally charged. https://kdvr.com/news/local/geoffrey-kim-rex-meeker-plastic-surgery-death/ "Dr. Geoffrey Kim faces charges of first-degree aggravated assault and criminally negligent homicide in Emmalyn Nguyen’s death, according to the Arapahoe County Sheriff’s Office. Nurse anesthetist Rex Meeker also faces a charge of manslaughter." An 18 year old went for breast augmentation in a free standing plastic surgery center. She was anesthetized but apparently not monitored for 15 minutes before surgery started. When found she was in cardiac arrest. She was resuscitated, but they didn't call 911 for 6 hours. She suffered an anoxic brain injury and died a year later. https://www.thedenverchannel.com/news/local-news/19-year-old-dies-14-months-after-going-under-for-breast-implants-that-left-her-incapacitated

I've been looking at sentencing guidelines for Judges in TN, and it looks like she'll get probation. They say, "A defendant has the presumption of an alternative sentence if he/she is convicted of a C, D or E felony as a Range One standard offender." She was convicted of a Class E felony. They continue "Where a defendant is entitled to the statutory presumption of alternative sentencing, the State has the burden of overcoming the presumption with evidence to the contrary." and "Guidance as to what constitutes evidence to the contrary may be found in the following sentencing considerations contained in T.C.A. § 40-35-103(1): (A) Confinement is necessary to protect society by restraining a defendant who has a long history of criminal conduct; (B) Confinement is necessary to avoid depreciating the seriousness of the offense or confinement is especially suited to provide an effective deterrence to others likely to commit similar offenses; or (C) Measures less restrictive than confinement have frequently or recently been applied unsuccessfully to the defendant." I don't think the state will argue that these apply. The only thing that might cause her a little problem is this "She was also charged last year with perjury in Sumner County. According to an affidavit, Vaught was trying to purchase two AR-15 firearms. She checked a box on a federal form required to get the guns saying that she was not under indictment on felony charges." The guidelines can be found here https://www.tncourts.gov/sites/default/files/docs/what_every_judge_should_know_about_criminal_law-ppt__handouts.pdf

She told the TBI that she thought it was weird when the vial contained a powder, because Versed was a liquid. She took the time to read how to reconstitute the med, but didn't bother to read what med she pulled. She was the "help all nurse." The help all nurse doesn't have a patient assignment. The role is to act as an extra set of eyes, ears, hands, and brain for the nurses with an assignment as well as covering for other nurses, so that every nurse got their breaks and meals. The TBI asked if she was really busy or stressed that day. She said no. They asked if she was really tired. She said no. She was on her 2nd day after 7 days off. The pharmacy was apparently not short staffed that day either. Per the ADC report the order was entered at 2:47 pm, verified by pharmacy at 2:49 pm. She pulled vecuronium at 2:59 pm a full 10 minutes after versed had been verified.

I think she is guilty of reckless homicide. She acted in a way contrary to what a reasonable person with similar training and education would act. No reasonable nurse would act in the careless manner she did. This resulted in another's death. That is the very definition of reckless homicide. A drawbridge operator is facing the charge of manslaughter by culpable negligence in Florida. It sounds like it is a similar charge to Tennnessee's reckless homicide charge. It refers to causing another's death due to the omission to do something which a reasonably careful person would do, or the lack of the usual ordinary care and caution in the performance of an act usually and ordinarily exercised by a person under similar circumstances and conditions. In the Florida case the drawbridge operator closed the gates leading onto the bridge, sounded the warning, but did not walk out and make sure no one was on the bridge. A woman walking her bike across the bridge fell to her death when the bridge opened while she was on it. https://www.cnn.com/2022/03/18/us/florida-bridgetender-manslaughter-charge/index.html I feel some sympathy for Radonda, but 99% of my sympathy goes to Charlene Murphy and her family.

I've been watching this hoping that someone would provide some good advice, since I too need to find a good surgeon. I've learned you can't trust the recommendations of your physicians anymore. It seems that most physicians no longer have a private practice. They are employees of hospital owned practices. As such their contract specifies who they can refer to. No physician will ever criticize another physician even if they think he is a hack. The best you might get is a comment like, "It's always a good idea to get a second opinion." Like you I'd consider flying back to your previous state to see a surgeon that you personally know is awesome. I considered going out of state too, and looked into the insurance situation. What I found out is that the surgeon and hospital will probably be "out-of-network", so you will be responsible for more of the cost and possibly all of the cost. Most insurance plans are only applicable to your state. The state insurance commissioner has to approve all the plans for that state. Even if you have a national insurance company like Cigna, United, Blue Cross, etc. the plans will probably vary by state. When I was considering going out of state, I had Blue Cross. Only physicians and hospitals within my state were in-network. I logged into their website and read the detailed literature on my plan. I found that I could petition to go out of state and be treated as in-network on one of the Blue Cross plans authorized in the other state. The Blue Cross in the other state and the Blue Cross in my state had to work it out between them. The physician/hospital would bill the Blue Cross in the other state. The Blue Cross in the other state would pay the claim. The Blue Cross in my state would reimburse them. The plan in the other state might have a higher co-pay or deductible, but it could be done. I didn't pursue it, so I don't know how difficult it would be to get it approved. If you want to see the surgeon that you know in the other state, call your insurance or get on their website and look at the detailed plan literature. Find out if you can go out of state. After 3 unsuccessful surgeries, you would think the insurance company would be very interested in making sure you have an excellent surgeon for the next surgery. I hope your next surgery goes smoothly and is successful.

Wow. Attempting to purchase firearms while you are awaiting trial does seem to indicate questionable judgement. Lying on a federal application where there is usually some wording that by signing the form you are attesting under oath that you have answered all questions truthfully is a whole other level of dumb.

I'm glad you said all that. That was my response too. I have heard all those excuses and explanations in many articles. I was starting to wonder if I expected too much.?

I don't think that VUMC got the DA on board to help them out. I have cousins who are lawyers in Nashville. They know the DA. He spent probably 30 years of his career as a defense attorney. He ran for office because he wanted to clean up the DAs office. My cousins know him professionally not socially. They say he is highly respected in the legal community by both defense and prosecution. I would say it is more likely that the DA pursued this because the TBON took no action at all. You had a nurse who carelessly caused a death and the TBON didn't even require a few hours of CE on safe medication administration. She still had an unencumbered license. DAs feel obligated to act if they feel their community is at risk.

The news coverage made a big deal about the override function. I don't remember VUMC or CMS making that an issue. Perhaps you are thinking of the news coverage? CMS was tipped off. Initially they said they were alerted by an anonymous source. Later I read that it was a physician. Then a short time later the name of the physician came out.

Yes. She was charged with reckless homicide and abuse of a vulnerable adult. Here's a decent timeline of the events. https://www.tennessean.com/story/news/health/2020/03/03/vanderbilt-nurse-radonda-vaught-arrested-reckless-homicide-vecuronium-error/4826562002/