RaDonda Vaught Update - State Health Officials Reverse Decision and File Medical Disciplinary Charges

On 10/25/2019 at 9:38 PM, Daisy4RN said:

You sign for each individual med, that is ridiculous, I have had patients with 20+ meds for just 0900. This makes me crazy that anyone thinks this makes patients safer somehow, you are right it is for billing. I have seen nurses documenting lung sounds etc without doing the assessment and I am afraid that these ridiculous time consuming p/p are the reason why. Makes me mad and sad what is happening!

I’m not asking this in a rude tone whatsoever, but I’m curious as to how you know whether or not that nurse has listened to the patient? Also, how do you know what they’re documenting? That’s a pretty bad accusation, so I’m just wondering how you’d be able to know such a thing. Fraudulent charting is a a huge deal. Not only with the hospital, but also with Medicare, AND the BON.  

Anyone who backs up what RV did needs to read the case.

She purposely, and willfully bypassed at least seven safety checks.

Purposely and willfully is NOT a medical error, that is GROSS negligence.

Yes, she deserves criminal charges.  Yes, she deserves to be prosecuted.  Yes, she deserves to lose her nursing license.  

When you are a nurse, it is not the job of the hospital to babysit you.  You are a college-educated professional and it is $%&^@ time some nurses started acting like it.  

Want to know why you have stupid policies at work that completely discounts your training and knowledge?  Supporting people like RV is why you have them.

5 hours ago, NurseCocoBSN said:

I’m not asking this in a rude tone whatsoever, but I’m curious as to how you know whether or not that nurse has listened to the patient? Also, how do you know what they’re documenting? That’s a pretty bad accusation, so I’m just wondering how you’d be able to know such a thing. Fraudulent charting is a a huge deal. Not only with the hospital, but also with Medicare, AND the BON.  

False charting happens all the time and there are ways to pick it up. When I review vital signs and noticed that for the entire shift, for example, the patient had a HR of EXACTLY 88, and a blood pressure of EXACTLY 120/80, and EXACTLY the same weight for the last few hospital admissions?  

You can bet your bottom dollar nobody checked.  

14 hours ago, NurseCocoBSN said:

Absolutely. Hell, people who don’t have licensure also have consequences when it comes to public safety. 

Her negligence matters here. Maybe i missed it, but I’m curious if anyone thinks there is a safety measure that would have stopped her in this exact situation. Exactly what would have prevented her from giving this med? She bypassed so many of already established safety measures, and she failed to do the most basic nursing measures.

 

If there was a safety measure that could still have prevented this, I'm sure I don't know what it is.  She blew past so many stops it still makes my head spin.  As you learned from your own experience, you can be extremely conscientious and errors still happen.  That's why they're called errors.

But when we don't bother to even look at the vial that we're drawing from, what chance does the patient have?

It has been said multiple times on the pertinent threads:  this lady's death was not caused by an error.  It was caused by egregiously reckless practice.  The level of practice that is far, far below the standard of anyone who has spent a week in nursing school.  Anyone who functions this way needs to be stopped in her tracks.  

The BON initially failed miserably in protecting the people of Tennessee; that's why it fell to law enforcement to pick up the slack.  This does not set a precedent for nursing errors to be criminalized.  It just means that someone has to protect the public from those who would do harm.  Unfortunately, that has to include nurses who aren't fit to nurse.

9 hours ago, Jory said:

Want to know why you have stupid policies at work that completely discounts your training and knowledge?  Supporting people like RV is why you have them.

I agree with this.  If I had a nickel for every time a patient said "You're the only one who checks my wristband."  I thought they just weren't noticing or remembering, but when I mentioned it to a coworker (whom I thought of as a very good nurse) she said "No, I hardly ever check wristbands."

I suspect a lot of stupid policies get put into place because there are too many among us who skip important steps.  For anyone who thinks they're "too busy" for safety checks, this situation should be their Come-to-Jesus moment.

On 10/27/2019 at 6:17 AM, Jory said:False charting happens all the time and there are ways to pick it up. When I review vital signs and noticed that for the entire shift, for example, the patient had a HR of EXACTLY 88, and a blood pressure of EXACTLY 120/80, and EXACTLY the same weight for the last few hospital admissions?  

You can bet your bottom dollar nobody checked.  

I know that. But, seeing obvious bad vitals isn’t the same as saying someone isn’t listening to the breath sounds they chart. Unless I’m missing something, the only way to know that is to follow them into the room and see if they asses the patient. Or if you go in and ask the patient if they were assessed.

Also, unless you’re following someone, i don’t see how anyone knows what anyone else is charting. 

2 hours ago, NurseCocoBSN said:

I know that. But, seeing obvious bad vitals isn’t the same as saying someone isn’t listening to the breath sounds they chart. Unless I’m missing something, the only way to know that is to follow them into the room and see if they asses the patient. Or if you go in and ask the patient if they were assessed.

Also, unless you’re following someone, i don’t see how anyone knows what anyone else is charting. 

Nurses use workarounds all the time. This has been my experience and I have never worked anywhere that this did not occur. If I didn't know this for a fact I would not say it. Most prudent nurses can figure out what can be skipped and what cannot. I have had nurses tell me that they have documented things that they have not done because there was not enough time, and there are other ways to know this also. I don't know what was going on in RV's head but this should have never been a missed step (or multiple steps!) I think in her case it was not a conscience decision (workaround) but more of incompetence/not having any sense. Having gone to testing/procedures to medicate for anxiety many times I just cannot imaging pushing any med and simply walking away (basic nursing requires a re-assessment). I think she was probably feeling hurried by sups but that is (obviously) no excuse.

 

19 hours ago, TriciaJ said:

I agree with this.  If I had a nickel for every time a patient said "You're the only one who checks my wristband."  I thought they just weren't noticing or remembering, but when I mentioned it to a coworker (whom I thought of as a very good nurse) she said "No, I hardly ever check wristbands."

I suspect a lot of stupid policies get put into place because there are too many among us who skip important steps.  For anyone who thinks they're "too busy" for safety checks, this situation should be their Come-to-Jesus moment.

Exactly! I have heard these things also. It has also been my experience that management will put p/p in place (new forms to fill out!) because one knucklehead did something wrong. So instead of taking care of the problem with the individual everyone now has 1 more form (along with all the previous ones) to fill out, thus taking more time away from the patient and creating more problems in the long run creating a vicious circle. (But is this particular case I am afraid this is all on RV bc in the end she didn't even look at the vial).

6 hours ago, NurseCocoBSN said:

I know that. But, seeing obvious bad vitals isn’t the same as saying someone isn’t listening to the breath sounds they chart. Unless I’m missing something, the only way to know that is to follow them into the room and see if they asses the patient. Or if you go in and ask the patient if they were assessed.

Also, unless you’re following someone, i don’t see how anyone knows what anyone else is charting. 

Nurse who never carries a stethoscope, no disposables to be found; posterior lung sounds charted on patient who either could not he effectively rolled or at least obviously hasnt been rolled recently; documented s1s2, no murmurs documented on someone with ever-present super loud murmur (or loud obvious implanted valves/ other machinery); total collapsed lung with whiteout on xray and no useful airspace on ct, clear, loud normal lung sounds on same side documented; previous problems that are now treated and resolved obviously copied and pasted from prior charting. Etc.

You can look at what time people entered their charting and also what the previous charting says. You can note a nurse's overall M.O. and whether they cut a lot of corners. When you've been doing this job for a while, it's not that hard to figure these things out. 

2 minutes ago, Cowboyardee said:

Nurse who never carries a stethoscope, no disposables to be found; posterior lung sounds charted on patient who either could not he effectively rolled or at least obviously hasnt been rolled recently; documented s1s2, no murmurs documented on someone with ever-present super loud murmur (or loud obvious implanted valves/ other machinery); total collapsed lung with whiteout on xray and no useful airspace on ct, clear, loud normal lung sounds on same side documented; previous problems that are now treated and resolved obviously copied and pasted from prior charting. Etc.

You can look at what time people entered their charting and also what the previous charting says. You can note a nurse's overall M.O. and whether they cut a lot of corners. When you've been doing this job for a while, it's not that hard to figure these things out. 

So what you’re saying is that you’re going into patient charts you’re not covering and checking on nurses charting?

5 minutes ago, NurseCocoBSN said:

So what you’re saying is that you’re going into patient charts you’re not covering and checking on nurses charting?

I work as charge nurse, do quality improvement, investigate mishaps and various hospital acquired illnesses, etc. So yes. That's what they pay me for. 

But also, I routinely look at prior charting for those patients directly in my care. So should you.

I think we all agree that nurses do short cuts all the time..."at risk" behaviors that are considered reckless. Some of these, we do out of necessity and with full knowledge that we are breaking rules. It's a fact of everyday life. How many times do we go 10 MPH over a speed limit? do not use a turning signal? turn on red? For lack of a better word, I'm going to call it the "inner voice" that tries to snap us out of these behaviors because they are unsafe.  Sometimes it loses the battle and we do the "at risk" acts anyway because maybe we're in a hurry and maybe we convince ourselves nothing bad will happen, the coast is clear. 

RV's case involves a series of nursing mis-actions in which her "inner voice" should have kicked in and "snapped her out of it" while she was right there putting a human being in harm's way. Unfortunately for her, the outcome of her omissions led to another human being's horrible death, a person entrusted to her professional care. That's a big difference in this case from your "run of the mill med error". While I had internal struggles accepting the fact that a nursing colleague is being tried criminally for a med error because extraneous factors could have gotten in her way, the reasoning behind the criminal charge still makes a lot of sense to me because her omissions were foremost, her own doing.

Fortunately, at this point, it's not up to me. It's up a to a judge and jury to determine whether her actions were reckless -- did she proceed with one "at risk" behavior after another in a series and it led to Charlene's death? She did not intend to cause Charlene's death but that's not a requirement of that criminal charge. Tennessee law is clear about what Reckless Homicide is and yes she meets the criteria based on her actions. Now it's up to the Tennessee judicial system to give her a fair trial and decide her fate. Her case is a wake up call for all of us. I'm not religious but it's the "come to Jesus" moment some here have mentioned.

14 hours ago, NurseCocoBSN said:

So what you’re saying is that you’re going into patient charts you’re not covering and checking on nurses charting?

I follow you as relief. You seem to think I am not going to look back and compare or....as its known in Nursey World.....ASSESS whether a treatment or regimen is effective over time??

G*#^#%#&#ned right I check your charting. The fact that you are getting defensive and trying DARVO....attacking someone and becoming defensive over a practice that SHOULD BE HAPPENING and implying they should somehow feel guilty for checking your roll....

yeah,  no.

Someone should have been doing just that to RV...because I will betcha my next paycheck she was one of those holier than thou nurses that can assess lung sounds from the nurses station.

I had a preceptor in nursing school.....an Emergency Department preceptor....at a Level 1 hospital....smugly boast that he "never needs a stethoscope and doesn't carry on". He was besties with the charge nurse on nights....who also never carried ears. but they sure as s#%t had the basketball game on at the nurses station and relied completely on tele to pet them know how thwir patients were doing.

I told my preceptor, after i was off of orientation and hired at that same hospital...

how about get off your fat a$$ and check the patients before you chart that you did it...because i never saw you get up once in 4 hours yet hourly checks were completed.

i see nurses like this all the time...and i am brutally in their face. i have and do tell them that they are not to touch my patients or my faily members...and i have reported them on the internal systems for that. i have seen some quietly asked to leave or be terminated.

smug-o preceptor was one of such asked quietly to leave or be fired. do i care ? nope. do your d$%^&d job. the one the patient trusts you to DO.

 

Edited Oct 29, 2019 by SolosGirl
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