6 nurses at lockup broke rules, report finds
Posted on Thursday, July 21, 2005
The Nursing Board, which was asked by state officials to investigate how the nurses dealt with Brown, now plans to investigate each nurse’s involvement in her care at Alexander Youth Services Center and could discipline them or revoke their licenses, said Deborah Jones, assistant director of nursing practices for the state.
As of Wednesday evening, all six nurses still were working at the Alexander center, said Lisa Tauser, a spokesman for Cornell Cos. Inc., the Houston-based private company that runs the lockup as a contractor for the state. The company still is trying to decide whether any of the nurses or other employees should be disciplined regarding the April 9 death. "We do take that report and its findings very seriously," Tauser said from her office in Houston. "Because of that, we are taking another look and review of our medical and nursing procedures, our staffing. We are looking to take actions that are in the best interest of our clients at the facility."
Julie Munsell, a spokesman for the state Department of Human Services, said her agency plans to work closely with Cornell, to resolve any problems at the center. Ultimately, Cornell will decide whether disciplinary action is needed. "We’ve been given a good indication from Cornell that they will be making some recommendations in the very, very near future," Munsell said.
Meanwhile, the Arkansas Medical Society, which was asked to review pediatrician Robert Choate’s involvement in Brown’s care, said it was not "possible" to do so because the nurses failed to tell Choate about her worsening condition on April 7, 8 or 9. Choate could not be reached Wednesday for comment.
Among the Nursing Board’s findings: There’s no evidence that the registered nurses on duty when Brown repeatedly collapsed before her death "supervised" the licenses practical nurses, who have less training and are required by the Arkansas Nurse Practice Act to work under RNs, physicians or other more qualified medical professionals. Three of the nurses who "assessed" Brown’s condition and made decisions about her care were LPNs. "Assessment and care planning are not within the scope of practice of the LPN," according to the report. Five nurses violated facility policy and the Board of Nursing Rules and Regulations for "knowingly or consistently failing to accurately or intelligibly report or document a patient’s symptoms, responses, progress, medications and/or treatment."
Five nurses violated center policy and Nursing Board rules and showed "unprofessional conduct" by failing to notify Choate of Brown’s condition.
A call to the infirmary at Alexander to reach the nurses named in the report — Kim Colclough, Holly Clark, Lynetta Buckley, Polly King, Penny Bruno and Karita Garcia — for comment was transferred to center director Bob Mc-Cracken. McCracken, who was asked to tell nurses they had an opportunity to comment, referred questions to Tauser.
State officials and Brown’s mother, Juana Michelle Brown, expressed gratitude Wednesday for the additional, "independent" investigation into her daughter’s medical care.
Michelle Brown said, "I’m happy. I have been comforted to know that, finally, something is going to be done."
State Sen. Shane Broadway, DBryant, who asked the state Youth Services Division to further investigate LaKeisha Brown’s death last month, said the Nursing Board investigation is vital to determining what when wrong when the girl died and what lessons can be learned from her death. "You’re talking about a lot of children’s lives," Broadway said. "The quality of care is very important. It’s important we treat each child [at Alexander] even though they have many difficulties.
" They’re still in state custody, and they are our responsibility. "
Brown collapsed repeatedly in the days before her death, complained numerous times of tiredness, chest pains and difficulty breathing, and had lost the color in her lips and fingernails, but nurses at the facility did not believe she was really ill, according to her medical records, which were provided to the Arkansas Democrat-Gazette by her mother.
A preliminary autopsy report shows that LaKeisha Brown died as a result of blood clots in her lungs.
The teenager, who had lived at Alexander for nearly two years and who had been adjudicated regarding drug possession, rape and inciting a riot, made repeated requests for medical attention earlier this year as well. Neither the nurses nor Choate found anything wrong with her and believed she was just trying to attract attention, her records show.
The Nursing Board’s report said Brown’s earlier symptoms appeared to be different from those manifested in the days before her death.
Ultimately, Choate ordered Brown to see a psychiatrist to curb her repeated requests for care. She was expecting to be released from Alexander on May 1 and was told by her therapist in mid-February that repeated requests for medical attention could" negatively affect" that release date, according to her records.
After that, Brown filed only a few requests for care.
A Youth Services Division internal investigation into her death found evidence that facility employees violated several policies in the days and hours before her death. On the day Brown died, for example, a supervisor dismissed an employee’s request to call an ambulance, and nurses did not call a doctor until Brown was unconscious.
As a result of its investigation, the state asked Cornell for a corrective-action plan. Cornell’s plan shows that the company will provide additional training for employees, require more extensive documentation about medical complaints and treatments and conduct medical emergency drills.
The company also will require nurses to consult a doctor if an inmate complaints about the same symptoms twice in a 24-hour period, as Brown did.
When Broadway learned details of the last days of Brown’s life, he called for additional investigations into her medical treatment. The Nursing Board and medical society reports released Wednesday are a result of Broadway’s request. Other legislators suggested that the state find another company to oversee the Alexander center, but no such action has been taken.
The Arkansas State Police also investigated Brown’s death and found no crime had been committed.
Broadway and Sen. Sue Madison, D-Fayetteville, did not call for immediate disciplinary action. They said the nurses should be given due process and allowed to respond to the allegations against them. Neither were overly concerned that the nurses still are caring for inmates at Alexander. "Given the scrutiny they are under right now, I think they are being extra special careful," Madison said. "We expect things to get better down there, to have better practices in place and to have people following good practices."
She was among a small group of legislators who made a surprise visit to the Alexander center last week. Madison said she saw many improvements at the campus, which has been plagued with problems over the years, but wants to ensure that proper medical procedures are in place.
Only Brown’s mother called for swift and severe disciplinary action. "I would like for them to get their licenses suspended or... revoked," Michelle Brown said. "If they do not do that, give them some additional, special training. Let them understand what they have done."
Jones of the Nursing Board said she could not talk specifically about the investigations into the nurses’ actions but described in general how the investigations will proceed. During the investigations, Jones said, the Nursing Board likely will contact businesses who previously employed the nurses.
The agency also will review the nurses’ records kept by the board.
Nurses Bruno, Garcia and Colclough have had no previous disciplinary action against them, according to the board. Information about King and Clark was not immediately available.
Buckley, who was on duty the morning Brown died, was placed on probation in 1997 for one year after she tested positive for marijuana while working at St. Vincent Infirmary Medical Center in Little Rock, according to Nursing Board records. At the time, Buckley "admitted to a 16 year history of the use of the illegal substance." No disciplinary actions have been taken against Buckley since then.
Munsell has said that the Human Services Department, which oversees the Youth Services Division, was not aware of Buckley’s history but Cornell was. Tauser said Wednesday that she did not know if any of the nurses were drug-tested after Brown’s death.
The Nursing Board investigations could take months to complete, Jones said. The nurses could be sent a letter of reprimand, required to take additional training courses, be placed on probation, have their licenses suspended or have them revoked.
Though Cornell has not made any personnel decisions, Tauser said the company is learning from what happened. "We are, first of all, very sorry about Keisha’s death. It is an awful thing to happen," she said. "We certainly take responsibility where we need to and are making corrections and revisions to our policies and procedures and staffing that ensure the quality care that these children need."