Sunday, June 14, 2015

Guise? Guise? I need advice.



All drama, all joking, all silliness aside: I need srs advice.

Keith did two things in the past week that were so boneheaded, so arrogant, so overstepping-of-boundaries, so completely idiotic, that I feel like it's getting to be a quandary just working with him.

(And yes, before we go any further, he's been written up and counselled and so on, and has returned from those meetings with a halo of righteousness.) (It's nearly impossible to fire anybody at Sunnydale.)

I'm going to look up my legal responsibilities tomorrow, once I've metabolized the bottle of wine I just drank to get over this day, but I have a question about ethics, to wit:

What is my ethical responsibility to patients who are not my own, when I know that the nurse who is caring for those patients is at least minimally competent and at worst actively dangerous?

I have never had to ask this question before. I hope I never have to ask it again.

I'm baffled. If it were up to me, Keith would be gone before the start of the shift tomorrow. Not only has he done some incredibly dangerous shit, he's lied about it, and about other stuff, and even falsified his charts. Lesser things got somebody fired from a Planned Parenthood clinic I worked at.

And I do not know what to do.

Rated on a scale of one to ten, with one being stuck in a nice, comfortable elevator equipped with chaise longue and Benedict Cumberbatch and several bottles of good Scotch, and ten being told I have CANSUH, this is over and beyond and way past ten. At least with CANSUH, I had somebody who told me "you're not gonna die from this" and somebody else who said "you're not even gonna have to be trached."

I am, in short, worried that something that Keith does will make me lose my license because I didn't act on my own prior to his injuring-or-worse somebody. Legal stuff I can look up. What's the ethical take on this?

Anybody?

Bueller?


36 comments:

JAB said...

Ooh, that is a good question. Especially with the Texas BON being a particularly punitive board (so I am told). And you know the hospital isn't going to cover your back. Maybe time to get/up the malpractice insurance?

Jacqueline Bennetts said...

Here is NZ I could call my union and most likely get some legal advice before I acted, and I think I can make a report to the licensing board to report my concerns. And document/diary every lame brain thing and also your response ie incident reports etc all done in an ethical legal manor. I would imagine that if you have repeatedly bought it to managements attention that you yourself should be covered. but of could I'm a nurse not a lawyer. I know you folks in the state practice in a very different environment to us here in NZ and Australia. I have to say though crappy co worker nurses are everywhere, but I think Keith takes the cake!
Jacqui

Anonymous said...

Report him to the BON.

(Which is not advice I give often and I've never done it myself).

He isn't safe, he's proven it multiple times and your employer isn't acting.

Reporting him will fulfill your duty to the patients on your unit. I know that it sounds harsh and can feel like you are ruining someone's life (taking away their livelihood and all) but you *do* have an ethical responsibility to those patients.

Imakebelieveitsreal said...

Is there a state board of nursing you can contact?

Anne said...

I am appalled that you have to deal with this situation.
The following is brainstorming only, and feel totally free not to post it. I do not know what is best.

Maybe you need to talk with as many doctors as you can. Surely they do not want to be sued. Document that you spoke with them--like, make it obvious that you are taking notes as you speak with them. Date your notes, and keep the notes.
Does the hospital have a board? Can you speak with a board member?
Maybe--and I have never been in this situation--you do really need to talk with a lawyer, who can advise you how best to make it clear to the doctors/the board how they are risking their reputations--and can tell you what risks/liabilities you are taking if you do not speak up.
And shouldn't you speak with family members whose loved ones are at risk? As in, "It isn't true that your grandma is getting the right treatment."
From an ethical standpoint, are you willing to watch the car fly off the bridge if it is in your power to flag it down instead?

Alison said...

Jeez Louise, this is rough. I know nothing about the professional ethics of the situation, but it sounds like you have to at least try to act in the way you think is best for the patients. Who else can be told about him? Sunnydale's legal department? The guy sounds like a major potential liability. Is there a licensing body that deals with these types of complaints? Again, I'm way outside the nursing profession, but having relied on some amazing hospital-based nurses in recent years, I hate the thought of people like you and them having to deal with this dangerous asshat.

lilbets said...

Its a horrible situation to be in. I started in a new unit 18 months ago and had problems working with a RN. There are only 2 of us plus an assistant on at nights. I was in charge and found her skills and care to be dangerous and if we had a code could not rely on her. I had to put my complaint in writing to the Nurse Manager and there were lots of dramas involved and my Nurse Manager ended up on 9 months stress leave!!!!!!
It was hard to be the force behind it all as this RN had been there for months and everyone complained to each other but wouldnt put it in writing.
I was not going to have her mistakes cause harm to any of the patients and ultimately maybe affect my registration. Ethically I believe that you have to do as much as you can to have Keith dismissed. Could you forgive yourself if something happened to his patient and you were in charge and could have prevented it.

Nurse Dee said...

You know - this is something that just recently we had to have a discussion board post about for my BSN program - we are ETHICALLY and legally obligated to report him to the employer and the state board of nursing - ensure that you write dates and info down so that you have it available as "evidence". Remember, who the hell cares about his license if yours is at risk!

Eatin Butter said...

I think the correct thing to do is to follow your chain of command. Start with your immediate supervisor and explain the areas of concern and if these are not addressed you move up the chain. I do believe the first encounter should be face to face and if you feel the matter is handled correctly you do nothing else, but if not then you have to put it in writing and move up the chain.

By reporting to your immediate supervisors you place the responsibility on them and what happens next - should an unfavorable outcome occur you have done your part to correct.

jimbo26 said...

Talk to Administration about what's happened , if they take no notice , tell them it's on their heads if they don't do anything . If you talk to them , have a witness present . Also , if you have a recorder on your cell , switch that on . Hope this helps .

Laura said...

O.O Falsified charts? Um, don't charts count as a legal document, which means that what he's doing is so illegal it hurts?

(Not what you were asking about, but I needed to goggle a moment.)

As long as you're not Keith's supervisor, you don't have direct foreknowledge of him about to go do something stupid, and you can document that you've raised serious concerns about Keith's competence to management (with additional documentation to support your claims of his ineptitude), then you should be off the legal/ethical hook. If you do not have the power to move him somewhere he can't hurt a patient, if not outright fire him, then what are you supposed to do, duct-tape him in a closet for the duration of his shift? (hmmm....) So long as you can show that you did everything within your scope of what your hospital will let you do, then your license should be safe. I'm sure you know this, but document EVERYTHING. Get things in writing. Emails are good, because they're timestamped. CC everyone and her mother on those emails.

As for the squishier side of ethics, I think it comes down to what you can live with. What level of involvement do you need in Keith's patients to feel like you did everything you reasonably (i.e. without risking your own patients or yourself) could to prevent his ineptitude from causing harm?

Gretchen said...

My line in the sand with my old boss (not medical field or anything serious) was when it got to the point where I felt like I needed to fix her mistakes so *I* didn't get the fallout, when I realized I was covering for her, when she was obviously not doing things she said she was, I had to speak out. And document. And she ended up retiring under pressure. And I hated every minute of it and hope I never have to do that again. You have to be able to protect your own job and live with yourself. Honestly, if it was me I'd start documenting and reporting everything. PITA but you need to be able to live with yourself.

RehabNurse said...

jo:

Good luck! Outside of a JC or state report, there may not be much (state laws vary) you can do.

But I'm all for asking experts to weigh in. Just be sure this one is VERY familiar with how hospitals work and nursing.

Anonymous said...

I worked with an LPN at one point in my career that I felt this strongly she was dangerous. I did write a letter to my state board of nursing stating my concerns about her practice. It felt awful, but I also felt that strongly that she shouldn't be practicing. I continued to bring my concerns forward to the manager, so that there was documentation of what was going on the whole time. She was suspended shortly after pending investigating concerns about her learning disability that she had neglected to mention at any point up until she was getting in trouble. The board did remove her licence conditionally, and I check back about every year or so, and she's not come back to nursing. I still feel like it was the right thing to do for the patients, and my own practice.

Anonymous said...

Re: the suggestion to document via recording conversations: Check the laws in your state on this. They vary widely - in some states only one party to the conversation (you) needs to know it is being recorded, in others all parties must be informed or the recorder is breaking the law and/or the recording is inadmissible as evidence.

Anonymous said...

All I can add to the advice to "document, document, document" is to get a receipt for the notices that you give. If it's a face-to-face, get a signature (and make a copy) acknowledging the meeting and its substance. If you mail a notice to the state BON, send it via registered mail. If you do an on-line report, print the "processed" notice...you get my drift. After 25+ years with DOD, I don't believe there is such a thing as over-documenting
As for the ethical take, I'd like to hear that you kicked this guy squarely in his most-precious taint (particularly after his Josh Duggar pronouncement), but that's just non-nurse me.

bobbie said...

Document, document, document. Take it up the ladder, and if you get no no response or action, take it to the BON.

Document, document, document.

BT,DT.

bobbie RN

CrowsCalling said...

I would argue you are obligated as an nurse to continue to bring your concerns up the chain. You have written up each incident and have expressed your concerns to management. Yet, Keith still has not shown improvement and does not seem to be on any remedial pathway, and continues to endanger patients. I assume you have started and are maintaining documentation about each incident at this point. I do not recall the process for submitting incidents to peer review and at a few places I have worked that can only be done by (or with) your mangers assistance.

It seems you are left with reporting these incidents directly to the Board of Nursing. I would hope you can do so annonymously as to avoid any backlash from Keith or manglement. Management will look to avoid scandal or a lawsuit.



bybike said...

I'm not in the medical world (except as an occasional patient) but I do have a lot of experience in the insurance world, and (you may think this is incompatible) put enormous importance on ethical and caring behavior. Which, by the way, makes you one of my blogging heroes! Anyway, on the legal side, I'd agree that what you need to do is document like crazy. On the ethical side, I'd hope that you and all the other wonderful co-workers you described in a recent post could quietly keep an eye on his patients to be sure they are as safe as you can make them. And I'd get those other co-workers to document like crazy, too, so you'll soon (too soon, sadly for the patients)have such a heap of reality to provide to Sunnyside that it will pretty much have to listen if it does not want to lose its license, standing in the community, insurability, and a whole bunch of money when the inevitable really ugly case happens.

Swifty K said...

Oh, Jo, that sucks. I am a psychologist, and don't know what the ethical code of nursing says. I just scanned the psychologists' code and found nothing specific, except maybe "don't do any harm,and minimize harm when harm is unavoidable". In training, I remember something along the lines of "ya gotta speak up". In any case, I would consult your ethics code, and more importantly, get in touch with the ethical committee of your state nursing association. Someone there should listen anonymously to your tale, and advise you on how you need to proceed. Be sure to get their name, and document your discussion. That will help CYA. Good luck.

Shawn Stratton said...

Ethically you have a responsibility. I know in the PT code of ethics we are responsible for "monitoring" our peers practice, I would guess nursing carries the same type of responsibility. Also it should be part of your hospital compliance compliance program, at least the falsifying charts. That's a tough position to be in. Don't worry if it looks if you're CYA, you've got your pets to protect. HANG TOUGH!!

Lynda Halliger Otvos (Lynda M O) said...

Oh wow, Jo. Nothing to add except that I will send extra energy your way as you travel this path. Get solid advice, protect yourself, but Yeah, those patients.... It's a hard hard call but you have to do what will keep you sleeping at night; and licensed. Best of luck with this one. Keep us posted.

Scrub Ninja said...

Falsifying charts? Hooooly shit. I don't know about Texas, but in my state, doing that just one time is a felony, and is grounds for having your license revoked at the least. You need to report this dude to your state board. Hopefully, they'll investigate him and confirm your allegations, and then make sure he's not anybody's nurse ever again.

Unfortunately, board investigations may take months. That's not going to help on your next shift. In the short term there are some other things you can try.

Does your hospital have an ethics hotline? Most places I've worked have had a number you can call to anonymously report patient safety issues. Their whole job is to handle situations like this, where you see a problem and your management isn't taking care of it.

If you haven't got a hotline, talk to your risk management department. I think every hospital must have one of those. Their job is to make sure the hospital doesn't get sued. They take a very dim view of careless employees who flout good practice, and of the managers who fail to correct them.

In the meantime, if you're concerned about your own professional liability, pick up some malpractice insurance of your own. It's dirt cheap for nurses. A million dollars of coverage costs about a hundred bucks a year.

Lisa G said...

Our hospital system has a direct link to Risk Management (I think they call it Enterprise Complaint Management System or some such) on our intranet page. It allows you to submit a concern for investigation, either signed, or anonymously. It skips the chain, and goes straight to the risk management department, basically allowing folks who are not getting what they need out of their managers to get to somebody who hopefully will investigate. Perhaps your hospital system has something like that? Otherwise, I wouldn't feel the least bit of guilt about reporting him to the BON, especially if you believe that he's endangering lives. Because, frankly, if your hospital fires him finally, he's just going to go someplace else and be a danger to others there; at least (hopefully) the BON will get him off the street, so to speak.

Sorry you're in such a sucky situation. Keep us posted.

Anonymous said...

I am mixed about this....on one hand if you see something this nurse is doing is wrong you should step in right there and have a one on one discussion with the bloke. Does he know he has messed up? Does he know someone saw his mistake? Every person deserves the face to face and then if he is doing something wrong with intent you report it.

However, there are always three sides to every story yours, his and the truth and it is almost never as black and white as one person explains. I have been director of a unit for many years and people make claims against each other for many reasons, some valid and some not. However, if you go behind back to report him without the face to face I would seriously wonder what your true motives are...that is without know the nature of the mistakes.

Jo said...

To give you all some idea of what we're dealing with--and thank you all for your advice thus far--there have been three incidents which I've been witness to. I don't want to go into too much detail, but here are the basics: the first was a med error, which anybody can make. That was something I dealt with face-to-face, and our manager dealt with it as well, informally. I figured it was just unfamiliarity with the procedure and a lack of supervision on my part, and that that would be it.

The second was trickier: Keith went over the heads of a patient's care team to recommend a patient be moved to the med/surg critical care unit when that was totally inappropriate. Again, no detail, but it got everybody on both care teams very upset. That was dealt with by the various MDs and management.

The third was straight-up idiocy: he went against the recommendations of another discipline, and in doing so, put his patient at risk for serious complications. In other words, he didn't follow orders or charted recommendations or even common sense.

There have been other things that I haven't seen, but that have resulted in multiple meetings with family members, other nurses, and--again, and I'm sure they're getting very tired of it--managers.

As you can imagine, rumors are flying, and there's lots of chatter. I'm not all that interested in rumors or chatter. What I *do* know is that I spend a fair amount of time correcting misconceptions, explaining things that were wrong that he told various patients and/or family members, and following up to be sure that no harm came of his actions. I'm not the only one, either: the shifts that follow Keith have started splitting up his patients, as they've come to discover that one moderate-to-major screwup will have to be dealt with by the nurse following him.

We do have a risk management division, as well as a compliance hotline, but neither of those allows a reporter to be anonymous. That makes me nervous. I'll need to hunt around for other options. In the meantime, it's going to be another meeting with another manager the next time I'm at work.

Scrub Ninja said...

It sucks that they won't let you complain anonymously. But because Keith is providing unsafe care, I think you still have an ethical obligation to complain.

Whenever you think a non-anonymous complaint could come back to haunt you, one workaround is to get lots of people to complain at once. That makes it really hard for a bad manager to get vindictive against anyone in particular. It sounds like a bunch of others also understand how Keith is screwing up, so you should be able to find some others to go in with you.

Getting many people to report separately can be a pain to organize, so if possible you'd want everybody to aver the same complaint.

The most straightforward thing is for one person to type up a letter on paper, and have it physically signed by as many agreeable coworkers as possible. In order to maintain an audit trail, don't just hand over your only copy. Scan it to an image or PDF first, and then after you go physically hand in the paper, send that scan by email as well. That way you've got something to fall back on if anybody claims the paper was lost.

Anonymous said...

Jo,
After being a nurse for 13 years in TX, I'd really reccomend calling it in to the BON. You know as well as I do that if you're the unit lead that when he finally severely injures someone, they'll ask where you were and why you didn't properly assist him. I've seen too many crappy nurses sent for "retraining" while the unit lead got hung out to dry by manglement in order to avoid problems with the state.
Good luck! CYA darlin' cause nobody else will,

CatherineMarie said...

What about talking to the patient advocate office? Can his patients report him? Or the doctors? If he is messing up this consistently with this many people... Can you talk to the supervisor of the following shifts to document that he has screwed up consistently with A,B,C? Sometimes patients and family of patients can make a big enough fuss to cause an investigation. And while i'm not saying "throw him under the bus", maybe you can make sure that the people he has fucked with have an appropriate number to call and complain about him?

Elle said...

Could you approach Risk Management with the information about the shift following Keith's having to split up his patients simply to triage his errors? That might be a way of saying, "Hey, I've noticed some other nurses having to deal with something that you might need to know about, if you haven't heard of it already." Or would that seem to be throwing the other nurses under a bus? It seems pretty extreme if an informal protocol is developing for *knowing* there will be screwups by a particular person.

clairesmum said...

If u don't have malpractice insurance please get it. Then ask them for guidance. You may not want to share all details with them but enuf to get some guidance. Their job is to protect YOUR license. Ethically you need to keep documenting and speaking up. Maybe report to Board but be sure you are protected in what u do and say. Good luck. This is a stinker.

Anonymous said...

Ethically, you have to report it. Do you have a Compliance Hotline at your hospital? Would suggest you could call and report annonymously. Make sure you give details someone can look up, like patient names, data falsified, etc.

Janey Hakanson said...

New reader of your blog *waves* Vet Nurse for 8 years but not (yet) in the human care medical profession. Everyone else has given you good legal and covering your arse advice.

I would also like to say - being a nurse is not his RIGHT. It is a job. A passion and career for some people to, but most importantly it is a job. A very important job that you have to be doing properly, you can't do half arsed, and is a part of a big team. So if someone isn't doing that right, especially after being pulled up multiple times... he does not "deserve" to have his job and licence.

You are not being a mean person for going down the path that will lead to him losing his job. Sometimes making a complaint about someone, especially a serious one, can make us feel like we are a jerk. But this dude has had all the opportunities to change his behaviour and be humble and learn and potentially continue and become an amazing nurse. He's not doing that.

So don't feel bad. Maybe you don't, but I just wanted to make that point. If other people are digging their heels in because they don't wanna be the bad guy, remind them that they are being an amazing and responsible professional for reporting this guy and escalating the situation.

JG said...

I'm a little late to the party, but I thought I'd weigh in. If he's endangering patients despite counseling, and manglement doesn't seem to want to take decisive action, then it's time to report him to the BON. Seriously, it sounds like he's going to end up killing someone or causing real harm. A med error, well, it happens. But it sounds like he needs to be stopped.

If you'd rather take a stab at getting it handled in-house, I agree with the suggestion that you get a lot of people to complain at once. Then it looks less like a personal thing. But I'd recommend the BON at this juncture, because I'd be worried that the incompetence would just find a new playground.

Anodyne said...

Long-time reader, first time (I think) commenter: document like crazy, and get as many other people as you can to complain at once to the official reporter line. It's unfortunate that you can't be anon while doing it, but it's a due process thing - you can't recommend someone for the most severe penalty in a workplace based on anonymous tips. Especially not in a unionized one.

But absolutely report it to the BON as well - that way, he can't go on to pull this shit at other hospitals.

@ CatharineMarie: based on what Jo has said previously, a lot of her patients are not really in a place, either physically or mentally, where they're capable of reporting what's going on. And it'd be...problematic, to recommend that patients or family report Keith, because that'd involve telling them straight-up that he is doing things he should not. And that's too likely to backfire on whoever does it.

Anonymous said...

I thought JCAHO required anonymous reporting. You could make anonymous complaints via email to the hospital risk team noting that you saved a copy if no investigation happens. The risk team would be obligated to investigate because they would not be able to go into any kind of hearing and say that they never investigate anonymous complaints because treating all complaints seriously is the standard of care.