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The Anatomy of Poor Patient Outcomes: It starts with us…and ends with us

I have the privilege of presenting a blog that was recently published by a dedicated nurse who may be stripped of her license because she was doing what she was trained to do:provide safe and quality care for her patients. In order to provide the best care, systems must change and adapt and sometimes this is met by resistance from management who seek to protect their own interests over those of the patient. In this case, Amanda’s dedication to her field, was met by the full wrath of the Arizona Board of Nursing who is trying to strip her of her nursing license. Fortunately for us, Amanda is not easily frightened by these threats. However, retaliatory tactics such as these is common in the healthcare system and has been shown to be the root cause of patient harm. Until this culture of fear  is replaced by a culture of trust, patients are at risk of serious injury or death.

Merry Christmas and good tidings to Amanda Trujillo from the Arizona Board of Nursing. In this latest installment of nursing’s reality TV and social media saga I get a packet (right before Christmas of course) informing me I will be privy to a hearing before an administrative judge on January 15, 2014 where he will decide whether my nursing license is to be suspended or stripped. On the agenda: My failure to protect the interests and well-being of patients, my conduct unbecoming of a professional nurse, and  the ongoing favorite—their concern that I am a danger to the public at large. In addition to this the fact I haven’t been able to complete the ethics counseling or the psychiatric care that even the staff at this latest facility have deemed to be completely unnecessary in their professional opinion.  Yes, for the second time, mental health professionals have found me to be normal after evaluating me. On this occasion the staff went further to say that they are stunned I am still up, walking, and breathing after almost three years of this ordeal and its sequelae. Their quote was that I was “the most normal client they have seen in a very long time.” It was so heartwarming to hear I actually swooned a little, basking in the fact I wasn’t a nut case after all. But, I digress.

I feel compelled to share some things that will shed some light on what actually happened the night of April 12, 2011 when I was working on the Progressive Care Telemetry Unit, 3D, at Banner Del E Webb hospital. I had been hesitant to do this because I thought I could get into trouble for it, but the truth is the truth and these facts can be checked on and are public in nature anyway. I am writing about it now to dispel this myth that I acted on my own accord that night without asking for guidance or assistance from management figures. Before doing this I would like to emphasize the fact I had never been disciplined or written up while working at Del E. Webb. In fact, each of the new employee evaluations I received on behalf of Emem Epoch the night shift nursing supervisor and Frank Fausto the other night shift nursing supervisor—had been positive. In addition to the timeline of events I previously provided in the beginning of my social media awareness campaign I am now sharing the following so that at least this part of the complaint against me can be corrected. Note that these facts can be corroborated via the investigative report should you wish to request it from the BON.

On the night of April 12, 2011 upon discovering my client had no clue what was going on with the plan of care and noting the lack of patient education in the patient’s room pertaining to daily medications, tests and procedures they had had done, or even a copy of the patient bill of rights I became extremely concerned that this client did not have all the necessary information to make an informed choice about the path they wanted for their care. The patient indeed requested for a case manager to visit with them so they could ask questions about hospice home care—and I wrote up the care plan and placed an order for case management to come and talk to the patient further about hospice care at their request. Before educating the patient about several issues pertaining to their health condition and plan of care I consulted with my night nursing manager Frank Fausto for his guidance. I did so at the nurse’s station, where, unit secretary Linda Aust was present to hear this conversation and participate in helping me to print the patient’s education while I talked to Frank about my ethical concerns for this patient. I had even suggested that an ethics committee consult would prove appropriate to look into this case further. I requested that the day shift management be apprised of my concerns immediately so that the patient would get the education and the time needed to make the best decision for themselves and their future.

As a nurse I know the difference between a full on hospice evaluation and ordering a case manager to come and speak to a patient about hospice home care alternatives. I showed Frank every section of the book I was creating for the patient and the fact they had voiced relief to finally have something to take home and review when they had questions about medications or labs or words they didn’t understand. Frank reviewed EACH AND EVERY section of information placed in the book that the unit secretary was helping me to construct for the patient. When I asked for Frank’s feedback and whether he approved of my plan of care for the patient, Frank verbalized that he supported the plan of care and also expressed his concern about the patient’s learning assessment, stating he would speak with the dayshift nursing manager as soon as possible to ensure that the patient was given the time they had asked for to explore some different options before making a final decision about what they wanted to do. Frank further agreed with my request to ask the physician team for an extra day or so in order for the patient to figure out what was best for their care. Frank Fausto never went to the patient’s bedside to assess them personally or to look into my concerns during that shift. Is this a failure to protect the safety and well being of a patient AFTER I reported my concerns? We could all ponder that. It too is a violation of the Arizona Nurse Practice Act—BUT–he is Banner Management, therefore somehow immune to the Act.

The Arizona Board of Nursing never interviewed unit secretary Linda Aust about that night, or her involvement with the discussion. In fact, when Frank Fausto was interviewed by the board of nursing his statement was that he had no idea what I was doing with the patient’s education, nor had he seen the contents  of the educational book  I was constructing for the patient. He lied, on record, and the investigative report reflects that. My then attorney Teressa Sanzio DID interview unit secretary Linda Aust who corroborated my explanation of events that night but out of fear for her job did not sign the affidavit my attorney sent her in order for us to submit it to the Board of Nursing.

I took the liberty of writing down each of the sections within the patient’s education folder in case I’d need to discuss it someday—the list below itemizes the contents of that book. The book also included extra blank paper for the patient to write down questions, and I even offered the patient extra highlighters and pens to use. The patient was advised by me to get some rest and I asked whether they wanted me to keep the book until morning before I left or leave it on the bedside table so when they woke up throughout the night they could browse through it. The patient requested I leave it on the bedside table so it wouldn’t get lost out at the nursing station after I left my shift in the morning. The patient then advised they would write down questions for the doctor and case manager as they thought of them.Interestingly, the nurse manager on dayshift—Denise Hebert– was quoted as saying the education I had provided the patient was “above and beyond what any patient should be expected to understand.” I found this perplexing because it was information taken straight from Banner Health’s “KRAMES” patient education portal and their intranet— which also included an ENTIRE section dedicated to the education of patients being considered for solid organ transplant. Note—Their patient education materials pertaining to transplant are easily accessible on their public website as well.

HERE ARE THE CONTENTS OF THE “RESOURCE BOOK” I MADE FOR MY PATIENT–IT IS THE SAME ONE DR KENG YU CHUANG ORDERED BE REMOVED FROM THE PATIENT’S ROOM BECAUSE HE FELT THE EDUCATION WAS “CHANGING THE PLAN OF CARE” (Violation of a patient’s right to self determination? Hmmmmm. )  

  1. Understanding “    “
  2. Treating “      “
  3. Discharge Instructions for “      “
  4. Esophageal Varices (what is)
  5. Liver panel (what is)
  6. Hemoglobin and Hematocrit tests (what are)
  7. ALT/AST tests (what are)
  8. Bilirubin, B12, and Folate tests (what are)
  9. Paracentesis (what is)
  10. TIPS (What is Transjugular Intrahepatic Porotosystemic Shunt)
  11. Liver Biopsy (what is)
  12. Hepatic Angiography (what is)
  13. Common tests for “    “
  14. Abdominal Ultrasound (what is)
  15. Pulmonary Function Tests (what are)
  16. Upper and Lower GI Endoscopy (what are)
  17. Taking your blood pressure
  18. Bone Scan (what is)
  19. Computed Tomography CT (what is)
  20. Echocardiography (what is)
  21. Magnetic Resonance Imaging (what is)
  22. When is it time to consider hospice care as an option?
  23. Inpatient Hospice Home Levels of care
  24. Home Health (what is)
  25. Outreach
  26. Integrative Therapies (what are)
  27. All inpatient medications—instructions for patient understanding
  28. How the transplant system works
  29. Questions and Answers for transplant candidates
  30. Partnering with your transplant team: The patient’s guide to transplantation (contents below)
  31. ***Preparing for your transplant
  32. ***The transplant process
  33. ***Living donation
  34. ***Developing a financial strategy
  35. ***Life after transplant
  36. ***Promoting Organ and Tissue donation

The Arizona Board of Nursing states in their Nurse Practice Act that lying to any officials during an investigation is a violation of the act. When I lodged a complaint against Frank’s license for lying they closed it and tossed it out citing retaliatory actions on my part.

This is just one of quite a few examples of cases I have come across where the Arizona Board of Nursing has decided for whatever reason to just look away with some people, while choosing to relentlessly ruin and wreck the professional and personal lives of others. I’ve discussed just a few below.  I’ve made mistakes like everyone of you out there during my career, but have NEVER hurt anyone.  I’ve never once claimed perfection throughout this ordeal.

  • In spring of 2012 an LPN was found to be guilty of writing a prescription for Fentanyl for a resident at Life Care Center—a skilled nursing facility. This LPN was also found guilty of failing to render care to a patient but charted that they had indeed rendered care—which constitutes falsifying medical records and harming a patient. This LPN received one letter of concern from the state board of nursing for each violation and was left to go on their merry way back to work. A letter of concern means no discipline was ordered for these violations.
  • In 2011 an RN who repeatedly had been caught injecting IV Demerol at work was finally stripped of their license after being given chance after chance by the AZBON to work in the nursing setting. While on the State Boards substance rehabilitation program this nurse continued to use and was even allowed to work as the director of OB services at Phoenix Baptist hospital where they were ultimately caught injecting Demerol once more—this time, while allegedly pregnant.
  • On July 3, 2010 young mother Shawn Roberts Soumillas went into labor with her second child. She was to have a son whom she named Zachary. Up to this point her pregnancy had been a full term healthy one. Upon entering the labor and delivery unit Shawn was assigned a nurse whom she had concerns about. She spoke to me about the non-caring attitude of the nurse and that several times during her stay she and her baby were ignored when she called for assistance. At some point during her labor Shawn felt something wasn’t right with her baby and requested assistance. The nurse became irritated with Shawn and during this period of time sent Shawn off of the unit to the ultrasound department unmonitored. Shawn continued to seek assistance and begged for help but to no avail. Tragically, her baby Zachary died downstairs in utero. It was later discerned that had policy been followed and the nurse more attentive to both mother and baby’s physical status the baby would have lived. The nurse also had several prior documented patient complaints. This particular nurse was allowed to go on practicing after a brief probation and is now in the field working toward a Nurse Practitioner designation.  Shawn is beside herself, to this day, that the nurse has been freed by the Board of Nursing to obtain a Nurse Practitioner degree. She went before the board to ask for stronger discipline since it was determined that the baby‘s demise was due to poor nursing care.  “Also, you may want to add that the nurse completely disregarded a direct order (over the phone) from our Dr. to do a bedside BPP. (bio physical profile) This would have saved our son. Amanda, it is time to use my case.  It is all a matter of public record in regards to a nurse with a history of abusing patients and disregarding direct orders from Dr’s.  Nurse Copeland’s actions killed my child and almost killed me.  She also lied to the nurse investigator in regards to any previous reprimands for her actions.  The only reason she still has her license and has been able to move forward in her career is because we were told that if AZBON would take her license, it would create further liability for the hospital.  My case shows a complete lack of honorable intent by AZBON to protect AZ citizens from harmful nurses because their decisions are based on who the outcome benefits financially.  Use me, the board meeting, consent form and my my medical records.  It’s time.” The Nursing Board – in her words — didn’t take her seriously and she felt unheard and unwelcomed at the proceedings. Shawn wrote to me and spoke with me several times throughout the past year or so and asked that I share her story for learning purposes on my blog.

What should be of particular concern to nurses in Arizona is the fact that the State Board enjoys using the medical records of nurses against them during an investigation. Nurses are threatened with further discipline if they do not sign a medical records release allowing the AZBON to subpoena all medical and pharmacy records. Unfortunately many nurses fall prey to this (myself included)…. Physician’s assessment notes can and are often used against them in their cases. One nurse who wrote me was exasperated that a physician’s notes about their sexual health assessment and sexual habits were brought up during an investigators interrogation of the nurse and that the investigator verbally determined their sex life to be an indicator of “high risk behaviors as a nurse.” The sad truth—the SCARY truth– is that we are not covered by the federal HIPPPA law like other law abiding citizens (and criminals) in this country. Anything in those records can be used against us individually while undergoing investigative procedures by the Board—a grave (and horrifying)  injustice indeed.

We’ve got BIG problems here in Arizona… and they keep rearing their ugly heads in the media with the publicity of untimely deaths in facilities where nurses knew danger was rampant but did nothing to bring attention to it. Among them the MCSO jails and the State Mental Health Hospital. The nurses remained silent.  People died because of it. To be referred to as a danger to the public at large is something that is deeply offensive to me since this whole battle has been about protecting the public at large and promoting transparency within the healthcare system so that consumers are better prepared to protect themselves while vulnerable in patient care settings. What upsets me to no end is the fact that nurses from all over the state won’t step up now because of what they have seen happen to me for using social media as a means to highlight the injustices that occur within the walls of a hospital to the most vulnerable members of our society. To have nurses writing me and thanking me for publicizing my journey to educate them is one thing—to read that they will no longer stand and speak up for the safety of their patients out of fear is the most disappointing and heartbreaking thing of all. What greater threat is there to the public’s health, well-being, and safety than nurses who turn the other direction instead of speaking up when danger is all around threatening the lives of the people they are trusted with caring for?

A recent study that was published reported that four jumbo jets worth of people die each week as a result of medical errors that could have been prevented…..In essence, it is the Board of Nursing who has used me as an example of what will happen to nurses in Arizona should they advocate for their patients and report danger as I did. It is the Board of Nursing who has put the public at risk by instilling fear in nurses thereby suppressing their professional voices as advocates. To practice in Arizona is to practice nursing in fear. We are not protected …nor is our role as professional nurses respected here. It goes without saying I don’t recommend that travel nurses (or any nurses for that matter) come here to do it. Let me say that again: DO NOT COME TO ARIZONA TO PRACTICE NURSING.

We were all taught in nursing school about what our role is within the current healthcare system and in various patient care settings. That role includes assessing, educating, and advocating while respecting the oath and adhering to our code of ethics. When the day comes that a nurse has to wage a public battle in order to protect those very tenets that make up the foundation of our profession and to inform the public about what the realities are in a hospital— there is a problem—and it seems to be infectious . It’s happening all over the country. Here is the reality:  This is part of our duty to society. When we as nurses lie to cover ourselves instead of doing the right thing, the honest thing, each of these acts further unravels our profession — dimming its light and possibilities for a stronger future as transformative and innovative healthcare providers, healers, and nurse leaders.

I read one nurse’s post on twitter in which she posed a query about who the next great leaders and theorists will be in our profession and when would they emerge…..I thought to myself, and it’s sad to think it much less say it—-these individuals will never be allowed to emerge.  Why? Because we’ve done well in holding each other back, competing with each other for workplace klout and management positions, silencing each other, bullying each other, and drifting further and further away from who we are as a profession and what it is nurses really “do.”

The truth is—by remaining silent and complacent, allowing our unique colors to fade into grey in favor of being “like everyone else” —-the next great leaders and theorists of our profession are already lost to us.

In the perspective of someone who loves this profession so much, I find that to be the greatest crime of all…because there was so much I wanted to do….dreamed of doing, a legacy I wanted to establish that would leave the profession better than when I was sworn into it.

Maybe that will be NAASA and legislation…..if I accomplish just those two things I will have been successful as a nurse. That’s my definition….what’s yours?

The challenge I leave you with is to find the answer……….

Amanda Lucia Trujillo MSN, RN

Nurse Advocacy Awareness and Support of America

National President & Founder

fyrhoneybsn@yahoo.com

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