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TRIAGE    

INVESTIGATION    

CASE  RESOLUTION  

Valerie Smith Arizona Mary Blubaugh Kansas Barbara Damchick-Dykes Minnesota Lisa Ferguson-Ramos Ohio Lisa Griffitts Oklahoma Eric Holsapple Iowa Chris Sansom Nevada Lori Sheidt Missouri Mary Trenton Arkansas

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National Council Discipline Effective Practices Subcommittee

Case  Resolu=on

• Disciplinary  Matrix  

• Criminal  Conduct  Grid  

• Consent  Agreement  Wording  

Change  is  inevitable!  

SITUATION  -­‐  True  Statement    Previous  Applica/on  wording:    Have  you  been  convicted  of  a  misdemeanor  or  felony,  other  than  a  minor  traffic  viola/on?    •  Solely  self  disclosure  •  “Deferred  AdjudicaOon”  is  a  curse      

December  of  2002,    Dallas  Morning  News  ar6cle    

Texas  Board  of  Nursing  licenses  known  felons,  rapist  and  drug  addicts  

Revised  Screening  QuesCons  •  Have  you  ever,  for  any  criminal  offense,  including  those  pending  appeal:  

•  Been  convicted  of  a  misdemeanor  or  felony  

•  Pled  nolo  contendere,  no  contest,  or  guilty”  •  Received  deferred  adjudicaOon?  •  Been  placed  on  community  supervision  or  court  ordered  probaOon,  whether  or  not  adjudicated  guilty?  

•  Been  sentenced  to  serve  jail  or  prison  Ome?  Court  ordered  confinement?  

•  Been  granted  pre-­‐trial  diversion?  •  Been  arrested  or  have  any  pending  criminal  charges?  

•  Been  cited  or  charged  with  any  violaOon  of  the  law?  

•  Obtain  federal  and  state  criminal  histories  through  fingerprint  on  all  applicants  for  licensure  and  current  licensees  •  Changes  to  the  criminal  code  grid  •  Modify  Ques/ons  to  include:    

   

December  of  2002,    Dallas  Morning  News  ar6cle    

RESULTS  -­‐    2004  LegislaCon  authorized  the  Board  to:    

Texas  Board  of  Nursing  licenses  known  felons,  rapist  and  drug  addicts  

•  The  nature  and  seriousness  of  the  crime,  i.e.  the  presence  or  absence  of  criminal  plan  or  premeditaOon,  the  presence  of  contribuOng  influences,  

•  Evidence  of  immature  thought  process/judgment  at  the  Ome  of  acOvity,  and  classificaOon  of  offense  as  felony  or  misdemeanor,  etc.;  

•  A  person’s  failure  to  disclose  a  criminal  offense  to  the  Board;  •  The  actual  damages,  physical  or  otherwise,  resulOng  from  the  criminal  acOvity;  

•  The  extent  and  nature  of  the  person's  past  criminal  acOvity;  •  If  the  person’s  conduct  evidences  a  lack  of  truthfulness  or  trustworthiness;  

•  The  age  of  the  person  when  the  crime  was  commibed;  •  The  amount  of  Ome  that  has  elapsed  since  the  person's  last  criminal  acOvity;  

•  The  work  acCvity  of  the  person  before  and  acer  the  criminal  acOvity;  

•  Evidence  of  the  person's  rehabilitaOon  or  rehabilitaOve  effort  while  incarcerated  or  acer  release*;  

•  A  record  of  steady  employment  and  whether  the  person  has  supported  his  or  her  dependents;  

•  If  the  person  has  paid  all  outstanding  court  costs,  supervision  fees,  fines,  and  evidence  of  resOtuOon  to  both  vicOm  and  community;  

•  If  the  person’s  conduct  indicates  an  inability  to  pracCce  nursing  in  an  autonomous  role  with  paOents/clients,  their  families  and  significant  others,  and  members  of  the  public  who  are  or  who  may  become  physically,  emoOonally  or  financially  vulnerable;  

•  Evidence  of  the  person's  present  fitness  and  professional  character,  including  leUers  of  recommendaCon  from  prosecutors,  law  enforcement,  and  correcOonal  officers  who  prosecuted,  arrested,  or  had  custodial  responsibility  for  the  person;  the  sheriff  or  chief  of  police  in  the  community  where  the  person  resides;  and  any  other  persons  in  contact  with  the  person;  

•  Evidence  of  remorse;  •  Evidence  of  current  maturity  and  personal  accountability;  •  Evidence  of  having  learned  from  past  mistakes;  •  Evidence  of  current  support  structures  that  will  prevent  future  criminal  acOvity;  

•  evidence  of  current  ability  to  pracOce  in  accordance  with  the  NPA,  Board  rules,  and  generally  accepted  standards  of  nursing;  

•  the  extent  to  which  a  license  might  offer  an  opportunity  to  engage  in  further  criminal  acCvity  of  the  same  type  as  that  in  which  the  person  previously  had  been  involved;  

•  the  relaOonship  of  the  crime  to  the  ability,  capacity,  or  fitness  required  to  perform  the  duOes  and  discharge  the  responsibiliOes  of  nursing  pracOce;  

•  if  imprisonment  followed  a  felony  convicCon,  felony  community  supervision  revocaOon,  revocaOon  of  parole  or  revocaOon  of  mandatory  supervision*;  

•  if  the  person’s  conduct  resulted  in  the  revocaCon  of  probaCon/community  supervision*;  evidence  of  the  person’s  safe  pracOce;  

•  successful  compleOon  of  probaOon/community  supervision;  •  if  criminal  acCvity  is  due  to,  associated  with,  or  related  to  substance  abuse  or  chemical  dependency,  including  alcohol,  evidence  of  evaluaCon  by  a  Board  approved  evaluator,  treatment  (wriUen  verificaCon  of  compliance  with  any  treatment),  a[er  care  and  support  group  aUendance,  and  evidence  of  random  drug  screening;  and  

•  if  criminal  acOvity  is  due  to,  associated  with,  or  related  to  mental  illness,  evidence  of  evaluaOon  by  a  Board  approved  evaluator,  including  prognosis,  evidence  of  treatment  (wriben  verificaOon  of  compliance  with  any  treatment),  and  any  medicaOon  regime.  

The  Criminal  Conduct  Grid The  following  list  includes  some  of  the  factors  the  Board  may  use  in  its  case-­‐by-­‐case  analysis:    

Sunset  Advisory  Commission    

The  Matrix  2007  Sunset  recommended  crea/on  of  a  tool  to  facilitate  greater  transparency  so  the  public  and  stakeholders  could  beIer  understand  the  agency’s  decision  making  process  regarding  discipline    

Timeline  •  April  2008–the  Board  adopted  a  pilot  version  of  the  Matrix  

•  October  2009–the  Board  adopted  a  revised  version  of  the  Matrix  

•  February  2010–the  Board  adopted  t  he  final  version  of  the  Matrix  

•  The  Matrix  requires  the  Board  to  consider  3  things:  1.  The  threat  to  public  safety  2.  The  seriousness  of  the  violaOon  3.  AggravaOng  or  miOgaOng  factors  

The  Content  of  the  Matrix

AggravaOon  • mulOple  offenses  •  intent  •  seriousness  of  harm  or  potenOal  harm  • miOgaOon  •  internal  facility  systems  issues  • parOcipaOon  in  remediaOon  

TIER  3    -­‐  Involves  serious  harm,  serious  risk  of  harm  

or  death  

TIER  2  –  Generally  has  some  harm  or  risk  of  harm  

component  

TIER  1  –  Isolated  event    (no  harm)  

Case  Study:    Nurse  Reyes

Matrix Analysis: §  Harm occurred which kicks it out of the

Tier 1 category §  Harm was more than general–patient

died §  Tier 3

•  Threat to public evident §  Seriousness of the violation §  Violation resulted in death §  Aggravation

•  intentionally negligent •  coughing up blood and required

him to continue in strenuous bootcamp exercises

§  Mitigation •  Bootcamp environment /similar to

a prison •  Melingerer

Formal Charges cited: §  Between December 26, 2000 and January 7,

2001, while employed with Tarrant County Community Correctional Facility, Mansfield, Texas, Respondent:

§  Failed to appropriately assess and intervene in the care of an eighteen year old inmate in the boot camp who had requested to see Respondent due to symptoms of illness including loss of appetite, sore throat, shortness of breath, and coughing up blood;

§  Required the teenager to continue doing strenuous exercise after exhibiting the aforementioned symptoms:

§  Failed to appropriately communicate with the physician regarding the status of this teenager;

§  Failed to transfer this teenager to a hospital in a timely manner.

Outcome  •  Nurse  Reyes’  license  was  Emergently  Suspended  on  February  13,  2001  •  She  Voluntarily  Surrendered  her  license  on  May  23,  2001  •  Convicted  of  Criminally  Negligent  Homicide  on  August  30,  2002  

Case  Study:    Nurse  Reyes

Consent  Agreement  Wording

•  Informal  seblements    

 Informal  seblement  conferences,  alternate  dispute  resoluOon,      and/or  mediaOon    

   Openly  consider  miOgaOng  and  aggravaOng  factors  

   Avenue  for  Omely  resoluOon  

Promising  Prac=ce  Discussion  on  Consent  Agreement  Wording

•  Specify  what  the  violaOon  of  the  law  was  by  statute  and  narraOve.    

•  For  example,  Arkansas  states  in  the  Conclusion  of  Law  that  the  conduct  described  in  Finding  of  Fact  4  consOtutes  a  violaOon  of  Ark.  Code  Ann.  SecOon  17-­‐87-­‐309(a)(6)  which  consOtutes  unprofessional  conduct.  

   

Promising  Prac=ce  Discussion  on  Consent  Agreement  Wording • When  does  the  Ome  for  monitoring/probaOon  begin?  

•  Not  unOl  the  nurse  returns  to  pracOce.  

•  If  2  years  of  monitoring  is  ordered,  the  2  years  begins  acer  the  Order  becomes  effecOve  and  acer  the  nurse  obtains  employment.      

•  The  2  years  is  not  met  unOl  the  nurse  obtains  2  full  years  of  pracOce.  

Promising  Prac=ces  Discussion  on  Consent  Agreement  Wording •  Substance  Use  Disorder  Agreements  

•  Reference  NCSBN’S  Substance  Use  Disorder  in  Nursing;  A  Resource  Manual  and  Guidelines  For  AlternaOve  And  Disciplinary  Monitoring  Programs  

Promising  Prac=ce  Discussion  on  Consent  Agreement  Wording • Remedial  EducaOon  

•  Should  be  required  for  the  deficiencies  cited  in  Findings  of  Fact.  

•  MedicaOon  Errors—MedicaOon  Course  •  DocumentaOon  Errors—DocumentaOon  Course  •  Failure  to  assess  and  intervene—Physical  Assessment  Course