Radonda Vaught Fatal Error Case Timeline

[Emergent]

Radonda's trial is supposed to start this month. This article in the Tennessean really does a good job of laying out the timeline.

Amazing that Vanderbilt escaped any consequences for what amounts to a criminal coverup. It seems that hospital executives are untouchable in our society.

The RaDonda Vaught case is confusing. This timeline will help.

[JKL33]

16 hours ago, NurseBlaq said:

Interesting how the BON let her off with no further action while there have been instances where nurses have lost licenses for far less. Something is off about this whole case.

You are darn right about that. My theory is that they thought they got rid of her relatively quietly and did their due diligence by reporting her to the BON (which I don't disagree was appropriate). Everything else on their end they covered up, including bringing the death to the proper attention of anyone else who could investigate anything about this--the coroner/ME, county and state authorities, etc. All of that is point A. Point C is where CMS showed up at their door. Somewhere in there between A and C is point B, where somebody called more attention to it (either because of being disgruntled that the BON did nothing to Radonda or because of the all-round mysteries that made this whole thing just disappear) and raised some kind of havoc and then the DA took over and charged Radonda and did jack nothing about the whole cover-up. And CMS showed up to fake-threaten Vanderbilt.

14 hours ago, Here.I.Stand said:

The C-suite occupants didn’t kill Charlene Murphey..... their actions or consequences or lack thereof isn’t anything I would waste energy on.

Disagree (respectfully, of course). Nope, that just does not fly. No they did not do the deed itself, but they run a place where someone did. When higher-ups were asked about the help-all they acted like they never heard of such a thing and tried to imply to CMS that the help-all was just some more RV rogue activity - which I don't believe for one second. [That isn't a major point that affects the case itself, perhaps, but it is very telling as to what their MO is and how they behave when something has gone wrong]. They are ultimately in charge of the service lines and they set the tone for how things run.

Their people also don't know how to report this type of event (unnatural and unexpected DEATH) to proper authorities. Apparently they also don't know how to report reportable events to CMS. Their people don't even know how to preserve evidence or have a reasonable investigation and still had the unsecured syringes etc., sitting in someone's office almost a year later. Well...I guess what else are you going to do with evidence besides totally compromise it while acting innocent/helpless and doing nothing...if you're not going to properly report the event.

The thing about how they thought they did their part because they appropriately reported RV to the BON -- no. They did not report this event to CMS or anyone else they were supposed to. They thought they got off completely free until CMS showed up almost a year later. It isn't the BON's job to investigate whether a facility is properly-run or to fully investigate a patient death.

2 hours ago, TriciaJ said:

The help-all nurse is a supernumerary nurse without a patient assignment of her own, which belies the idea of short-staffing.

I agree according to her own words she didn't feel like the staffing was inadequate. A nurse without an assignment of her own doesn't necessarily speak to this one way or the other, though. I've seen places do it both ways where if there is an extra body then everyone gets one less patient to create an assignment for the extra person, but a lot of times people's assignments are absolutely maxed and the helper goes around trying to keep everyone from all-out despair. It seems to be a personal preference/choice of management or perhaps the staff on duty. (Kind of like when there's no tech and the choice is between an RN doing the tech role or everyone having one less patient but doing total care).

Regardless of all that, I don't like the idea of the neuro ICU "help-all" running here and there for this and that (like doing swallow screens in the ED).

[BSNbound21, BSN, RN]

Terrifying that someone with this little common sense can work as a nurse.

"I thought it was odd that it was a powder."

What?? I mean... insane.

"I thought it was strange that I was firing a loaded gun into the patient instead of injecting the prescribed medication." This is what that sounds like.

[Here.I.Stand, BSN, RN]

On 7/7/2020 at 8:55 PM, JKL33 said:

You are darn right about that. My theory is that they thought they got rid of her relatively quietly and did their due diligence by reporting her to the BON (which I don't disagree was appropriate). Everything else on their end they covered up, including bringing the death to the proper attention of anyone else who could investigate anything about this--the coroner/ME, county and state authorities, etc. All of that is point A. Point C is where CMS showed up at their door. Somewhere in there between A and C is point B, where somebody called more attention to it (either because of being disgruntled that the BON did nothing to Radonda or because of the all-round mysteries that made this whole thing just disappear) and raised some kind of havoc and then the DA took over and charged Radonda and did jack nothing about the whole cover-up. And CMS showed up to fake-threaten Vanderbilt.

Disagree (respectfully, of course). Nope, that just does not fly. No they did not do the deed itself, but they run a place where someone did. When higher-ups were asked about the help-all they acted like they never heard of such a thing and tried to imply to CMS that the help-all was just some more RV rogue activity - which I don't believe for one second. [That isn't a major point that affects the case itself, perhaps, but it is very telling as to what their MO is and how they behave when something has gone wrong]. They are ultimately in charge of the service lines and they set the tone for how things run.

Their people also don't know how to report this type of event (unnatural and unexpected DEATH) to proper authorities. Apparently they also don't know how to report reportable events to CMS. Their people don't even know how to preserve evidence or have a reasonable investigation and still had the unsecured syringes etc., sitting in someone's office almost a year later. Well...I guess what else are you going to do with evidence besides totally compromise it while acting innocent/helpless and doing nothing...if you're not going to properly report the event.

The thing about how they thought they did their part because they appropriately reported RV to the BON -- no. They did not report this event to CMS or anyone else they were supposed to. They thought they got off completely free until CMS showed up almost a year later. It isn't the BON's job to investigate whether a facility is properly-run or to fully investigate a patient death.

I agree according to her own words she didn't feel like the staffing was inadequate. A nurse without an assignment of her own doesn't necessarily speak to this one way or the other, though. I've seen places do it both ways where if there is an extra body then everyone gets one less patient to create an assignment for the extra person, but a lot of times people's assignments are absolutely maxed and the helper goes around trying to keep everyone from all-out despair. It seems to be a personal preference/choice of management or perhaps the staff on duty. (Kind of like when there's no tech and the choice is between an RN doing the tech role or everyone having one less patient but doing total care).

Regardless of all that, I don't like the idea of the neuro ICU "help-all" running here and there for this and that (like doing swallow screens in the ED).

That’s very true... you make very valid points there. I’m guessing Mrs Murphey would get swifter justice too had the reporting all been more timely and thorough

[HiddencatBSN, BSN]

From what I’ve read, Vaught missed so many warnings that she was giving the wrong med (I mean really, vecuronium instead of versed? That right there, where the names are very different, should be the first clue) but the way Vanderbilt covered this up is....scary. What else have they covered up that we just haven’t heard about because there was no anonymous tipster (I have money on it being a gag-ordered family member). What a dangerous culture that speaks to.

[rockchickrn, BSN]

You know, my whole problem with this case is yes she should lose her license but I am not sure that I agree with criminal charges. The American criminal justice system is out of control...

[Wuzzie]

52 minutes ago, rockchickrn said:

You know, my whole problem with this case is yes she should lose her license but I am not sure that I agree with criminal charges. The American criminal justice system is out of control...

Have you read the other threads? There are several. Also, read the CMS and TBI reports if you haven’t already. This nurse was out of control.

[Here.I.Stand, BSN, RN]

3 hours ago, rockchickrn said:

You know, my whole problem with this case is yes she should lose her license but I am not sure that I agree with criminal charges. The American criminal justice system is out of control...

Her recklessness resulted in the death of a woman... the very definition of reckless homicide. She doesn’t get a pass based on her then-profession. I think that NOT holding her accountable for the reckless homicide of Charlene Murphey — denying that poor woman and her family a chance at justice by bringing it to a jury of her peers — would show the criminal justice system’s lack of control

[rockchickrn, BSN]

Has anyone here ever made a med error? I must admit that I don’t know the particulars in this case. However I feel it’s a bit of a frightening precedent....

[Rose_Queen, BSN, MSN, RN]

1 minute ago, rockchickrn said:

Has anyone here ever made a med error? I must admit that I don’t know the particulars in this case. However I feel it’s a bit of a frightening precedent....

Please, read the CMS report. This was not your run of the mill medication error. This was blatant disregard of the medication safety checks that every nursing student learns before they ever set foot on a nursing unit and touch a real patient.

[rockchickrn, BSN]

Where can I read CMS report? Thanks

[Rose_Queen, BSN, MSN, RN]

Here's one of the previous threads about this case:

It may be in this thread or it may be in another one of the threads. If you search "Radonda Vaught" in topic titles, you'll find the others.

[Wuzzie]

1 hour ago, rockchickrn said:

Where can I read CMS report? Thanks

Search my profile for my posts on the case. You’ll find the CMS report, the TBI report as well as my point by point breakdown. This was most assuredly not a common med error. This particular nurse displayed a breathtaking lack of good judgement and adherence to even the most basic standards of nursing. Our previous threads also addressed the idea of precedent. It simply isn’t going to happen. Juan de la Cruz did some research on that.