What Threatens One Arizona RN Threatens Us All

January 24th, 2012

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By , BSN, RN

Just recently in Notes from the Nurses' Station I have written about scope of practice and about hospice and palliative care nursing. This topic has all come together in what appears to be the unjust firing of a nurse in Arizona named Amanda Trujillo. Her story is sweeping the nursing sites and I want to add my voice to the chorus. It is time for nurses to pull together and defend one of our own.

The very short version is Trujillo advocated for one of her patients, used hospital approved teaching materials, stayed with the scope of practice routinely used at her facility and dictated by the Arizona State Board of Nursing, suggested to her patient that they might want to get information on alternative treatments from the surgery proposed by the patient's physician and followed through on the patient's request to have a hospice consultation. For that, she seemingly angered a physician by disrupting his plans, he pursued having her fired and her hospital did not stand up for her practice. She is now threatened with losing her license and has, for the most part, lost her livelihood. 

I have included the transcript of the investigative questionnaire wherein Trujillo's complete description of events is recorded by her attorney. It is yours to read, to contemplate and to decide whether or not to act. If you are so inclined after reading the below posting, email or call the Arizona State Board of Nursing at arizona@azbn.gov or 602-771-7800. Tell them you are following the case and they are setting a dangerous precedent if they punish this nurse for doing her job, as we are all taught to do our jobs, advocating for and educating our patients for their own health and well being.

(as obtained from Vdutton’s posterous)

BEFORE THE Arizona STATE BOARD OF NURSING

In the Matter of Registered Nurse License No. RN137552 issued to:

Amanda Trujillo, Respondent. )

RN/LPN INVESTIGATIVE QUESTIONNAIRE

DESCRIPTION OF EVENTS

(Nurse Practice Consultant, Ann Schettler)

Respondent Amanda Trujillo, by and through undersigned counsel, submits this Description of Events in response to a complaint filed against her in June of 2011 with the Arizona State Board of Nursing (“Board”) by Banner Del E. Webb Medical Center (“Webb”).

Description of Relevant Events

The allegations contained in the complaint arise from events that occurred when Ms. Trujillo was caring for a patient with end stage liver disease.  Ms. Trujillo had been a registered nurse with Webb for approximately six months prior to the date of the alleged conduct and she normally worked the night shift from 7 a.m. to 7 p.m.

After assessing and communicating with the patient, Ms. Trujillo’s evaluation led her to believe that the patient did not fully understand what she had consented to when (pt) agreed to go forward with an intensive transplant evaluation scheduled to begin at Banner Good Samaritan Medical Center the following day. Based on her nursing assessment,  Ms. Trujillo gathered patient education materials and spoke with the patient regarding the transplant evaluation, the waiting period and the commitment needed in following a lifelong self-care regimen.  After their discussion, the patient expressed a desire to learn more about hospice care because (pt) was uncertain she was willing to take the necessary steps to maintain a successful organ transplant.  Thus, the patient inquired into whether (pt) could speak with a hospice representative.  Ms. Trujillo then placed an “order” for a case management consult with a hospice representative.  Ms. Trujillo did not believe that requesting a case management consult was a medical order requiring physician permission; she believed the consultation was for educational purposes in order to give the patient a broad understanding of her options.

As a result of the additional information given by Ms. Trujillo, the patient determined (pt) did not want to go through with the liver transplant evaluation or resulting transplant procedure.  When the doctor treating the patient found out about the patient’s wishes to forgo the evaluation he was unhappy that the patient had changed (pts) mind and determined that the education given by Ms. Trujillo was the underlying cause of the patient’s change of heart.  He accused her of going beyond her scope of practice by entering a physician order without permission  (“ordering” the case management consultation).  As a result of the accusation, Ms. Trujillo was placed on administrative leave by her nursing director, Venus Gaines, and was eventually terminated by Webb.

Ms. Trujillo believes she was well within her scope of practice to assess the patient’s understanding of (pts) plan of care.  She was not acting outside her scope of practice by educating the patient (deferring all questions outside of her scope to the medical team), once she determined the patient had a gross misunderstanding of what (pt) had agreed to participate in.  Ms. Trujillo believed that the case management  “order” she placed on the patient’s behalf was not a medical order that needed physician permission.  Each step of the treatment provided by Ms. Trujillo to the patient will be analyzed below.

Patient Assessment

It is standard practice for Ms. Trujillo to ensure her patients understand their medications, plan of care and treatments.  While fully reviewing the patient’s medical record Ms. Trujillo read a progress note entered by the patient’s primary care physician from earlier in the day that noted a “transplant evaluation is the only viable option outside of Hospice.”  Utilizing the standard nursing process of patient assessment (assessment, diagnosis, planning, intervention, evaluation), Ms. Trujillo asked the patient a number of open-ended questions regarding (pts) hospital stay, medications, liver disease, procedures, etc.  Ms. Trujillo asked the patient if (pt) had received any information or teaching regarding the proposed transplant evaluation.  The patient, to Ms. Trujillo’s surprise, responded that (pt) did not understand (pts) disease, plan of care or what a transplant evaluation entailed. The patient asked Ms. Trujillo if she could provide some information regarding the disease and any less invasive choices that would allow (pt) to go home and be with (pts) family. Based on this request Ms. Trujillo determined the patient had a knowledge deficit regarding (pts) disease and the choice to receive palliative care.

Patient Education

Having assessed the knowledge deficit related to the patient’s routine medications,  disease process, associated tests and procedures, the plan of care for transplant evaluation and palliative care options, Ms. Trujillo proceeded to print out patient educational material from Banner’s website that addressed those areas.  Additionally, she printed out education materials from Banner’s transplant website pertaining to what to expect during a transplant evaluation and what to expect after a transplant.  Ms. Trujillo also provided materials related to hospice care per the patient’s request.  Ms. Trujillo, concerned about the patient’s lack of understanding of (pts) treatment regimen and the option for comfort care, discussed her education of the patient with her clinical manager, Frances Fausto, who readily supported Ms. Trujillo’s plan of care and interventions.

Ms. Trujillo and the patient reviewed the materials over the course of the night.  After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.”  The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries.  Ms. Trujillo then explained hospice care services and the differences between symptom relief care and end of life care.  The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.”  The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.

Ms. Trujillo placed a note in the chart pertaining to the assessment of knowledge deficit, the specific education provided and the palliative care discussion, in addition to, the patient’s request to see a case manager from hospice.  She used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in Banner policy when she handed off care of the patient to the dayshift nurse, alerting the nurse that the patient requested more information prior to being transferred to another facility for a transplant evaluation.  She also alerted the dayshift nurse that there was a nursing note in the record for the doctor to read that detailed what occurred over the course of Ms. Trujillo’s shift with the patient.

Case Management Consult

As a relatively new nurse to Banner, Ms. Trujillo self-educated in order to work within Banner’s policies and procedures.  She found no specific policy or procedure regarding end of life care that prohibited her from obtaining case management consultations for her patients. She also could not find any policy or procedure that gave a formal definition of a “physician order” or what nurses could order and what they could not. In fact, Ms. Trujillo had ordered hospice consultations for her patients on numerous occasions prior to this incident without any objections from other physicians or Webb administration.  She entered the “order” with a note stating, “per patient request, patient wants to visit with hospice representative for more information.”  In fact, the computer system in place at Webb allows her to click a box that further specifies “Nurse Ordered,” which she did on this occasion.

The only reason Ms. Trujillo’s actions turned into allegations of unprofessional conduct is because the primary care physician on this case, The Dr. initiated an angry public display when he found out that the patient had changed (pts) mind regarding the transplant.  Ms. Trujillo was surprised when the nursing director, Venus Gaines, went so far as to tell Ms. Trujillo that the physician was angered because she had, “messed up all of the work they had done, and that the doctors were nowhere near going down the hospice route.”

Conclusion

This was not a medical order.  This was a nurse trying to help a patient become better informed about a life changing procedure and (pts) right to choose what direction (pts) care would go.  Ms. Trujillo’s actions were well within her scope of practice and she conscientiously kept her line of teaching within the boundaries of her scope of practice by taking care to utilize the proper channels to obtain patient teaching materials and advising the patient to ask the doctors about more complex questions she was unable to answer as a registered nurse.

The patient had the absolute right to self-determination regarding her course of treatment, as illuminated in Senate Bill S. 1052, the Bipartisan Patient Protection Act, after receiving additional information regarding her disease.  Ms. Trujillo, working within her scope of practice and the nurse’s code of ethics, honored and protected that right when she abided by the patient’s requests to the best of her ability.

Accommodating a patient’s request for a consultation with a hospice case manager does not require a physician’s order.  No medication was requested, no equipment was needed, and no procedures were required.  A patient simply wanted to speak with an expert regarding her options for comfort care and end of life care, so that (pt) could make the best decision about (pts) future.

It is standard knowledge that the Cerner electronic health records system in place at Webb contains a box that states, “Nurse Ordered.”  Why would this box exist if nurses were never allowed to “order” anything?  The Complainant contends that Ms. Trujillo overstepped her scope of practice by ordering the consult; however, it is standard practice of the hospital to allow nurses the freedom to do the exact thing alleged in the Complaint.

Ms. Trujillo was allowed to order case management consults on numerous occasions prior to this and was never told by the hospital that this practice was not allowed or outside the scope of her practice.  It is apparent that the hospital is simply trying to appease and placate an angry physician by filing this Complaint against Ms. Trujillo.

She looks forward to discussing this matter with the Board, if necessary, and hopes to conclude this matter expediently.

SUBMITTED: July 11, 2011

ROBERT CHELLE LAW

By: ______________________

Robert Chelle

Attorney for Amanda Trujillo


16 Responses to “What Threatens One Arizona RN Threatens Us All”

  1. Andrew Lopez, RN Says:

    Thank you for publishing this story :) What happened to Amanda is happening every day in hospitals and is having a chilling effect on the ability of Nurses to act as Patient Advocates. Something needs to be done. Stay tuned :)

  2. christine esquivel Says:

    This is a travesty. Ms Trujillo was well within her scope of practice by ordering a hospice consultation. The MD was way out of line and was probably upset over loss of revenue. As nurses we see this happen all the time and should be addressed.

  3. Arizona Nurse Has License Threatened By Doctor After Providing Patient Education | The Nerdy Nurse Says:

    […] What Threatens One Arizona RN Threatens Us All Tweet Filed Under: Education, Family, Healthcare Systems, Medicine, Nurse, Nursing Issues, Review, Soapbox Worthy Tagged With: Amanda Trujillo, arizona, Arizona Nurses Association, arizona state board of nursing, bsn, doctor, Echo Heron, god-complex, going before the board of nursing, going before the state board, Health care, healthcare organization, hospice, hospital, invasive procedure, legal, medicine, nursing, nursing license, patient, patient advocate, patient education, physician, profession, registered nurse, rn, state board, state board of nursing, surgeon, surgery, tantrum, twitter, Vernon Dutton […]

  4. The Nerdy Nurse Says:

    Thank you for spreading the message for Amanda and nurses everywhere!

    I have add this post to the list I am aggregating of nurses who are blogging about Amanda.

  5. Rene W. Neville Says:

    This case is BEYOND outrageous. What is described is a perfect and extreme example of Why nurses have no desire to report unsafe practices and/or violations of Patients’ Rights. This RN appeared before the Arizona State Board of Nursing TODAY to ‘explain herself’ for doing what we ALL have a responsibility to do-Advocate for our Patients!
    As of today, Jan.24,2012, her license on the Arizona State Board of Nursings’ Verification website is stated as: ACTIVE: UNDER INVESTIGATION.
    Why should any nurse want to work in Arizona after THIS?

  6. Vernon Dutton Says:

    Amanda now has a Facebook page to help support her. All nurses should follow this story, you could be next. (The Future of Nursing is Here)
    Nurse Up for Amanda Trujillo – https://www.facebook.com/pages/Nurse-Up-for-Amanda-Trujillo/291370237585717

  7. Vernon Dutton Says:

    A Facebook page has been created so you can provide support and follow the case. ALL nurses should follow, you could be next.

    Nurse Up for Amanda Trujillo https://www.facebook.com/pages/Nurse-Up-for-Amanda-Trujillo/291370237585717

  8. amanda trujillo Says:

    this is the first ive learned of this. im absolutely humiliated. no one told me this was going to be changed, i wasnt warned or even updated. im devastated, im feeling hopeless now, i feel so ashamed. how can this happen? I cant stop crying. people all over the country and arizona can see this. ill never work again

  9. How to Support Amanda Tujillo (Arizona Nurse Fired for Patient Advocacy) | The Nerdy Nurse Says:

    […] RNcentral – What Threatens One Arizona RN Threatens Us All […]

  10. Gail Gabel Says:

    What happened to this nurse can happen at anytime to any of us. I am appalled at the surgeon, the hospital that fired her and Arizona State Board for suspending her license “pending investigation” AND they send her for a psych eval.

    Since when are nurses “crazy” for educating their patients? Are we all nuts? To strip her of everything she has worked for the sake of a surgeon’s ego?

    This is tragic and should not be happening, this is the 21st Century afterall.

  11. Kerri RN Says:

    She did the right thing to advocate for her patient. The whole issue is that she made a hospice consult without notifying the physician. If i had a patient who decided to hold off on surgery to get more information, I would have called the physician and informed him first and then suggested a case management consult. If the physician refused, then administration and the ethics committee would have been notified to protect the patient. The bottom line here is that we be advocates and protect our patients just as Amanda Trujillo did. The error lies in the order of actions that she took. We all know that nurses act with autonomy in certain situations and then let the physician know. However, when it happens with the wrong physician, it can be disastrous for the nurse’s career. I’ve seen similar situations occur where nurses were fired over it. In the case of this physician, I would bet that he wasn’t notified immediately because he’s likely one of those physicians who verbally abuses nurses when they call for orders.
    This is one of those moments where it’s become obvious that there is a serious discrepancy between what is expected of nurses and what they can actually do. It’s time for physicians and hospitals to be clear on what the nursing scope of practice is because Amanda Trujillo acted within hers.

  12. Penelope Rock Says:

    Indeed, the case against Amanda Trujillo is not just a case against her but a case against the nursing community. The threat against her is a threat against our licenses too if we in any case will practice patient advocacy. And above all her case is against our patients who deeply need knowledge, eh.

    Thanks for sharing,
    Peny@Nurse Up for Nurse Amanda!

  13. David Hammond Says:

    Banner is a horrible company, and the surgeon…well, he’s just a your typical (deleted) doctor. There should be a mass protest at this hospital…I don’t even know how the nurses that continue to work there put up with this.

  14. tlh Says:

    This nurse did nothing wrong by ordering a case management consult. Case management should have been ordered immediately upon arrival to the facility on a potential transplant patient. Nurses routinely order case management, nutrition, and social work consults. Telling the physian in the middle of the night was unnecessary and by no means required. It is clear the physician has been out of line from the beginning. Banner should be ashamed…….

  15. Tenzing Says:

    We were discussing this case in class today. It is bad enough that Amanda has to go through such a trying experience but it is a call for nurses everywhere to stand their ground. I don’t understand how one physician who had a fit could make a whole institution dance to his tune. Whatever happened to the notion of healthcare team and I really don’t understand how her colleagues and nursing administration dropped her like a hot potato instead of supporting her, especially when she did nothing wrong. Maybe she popped the ego of one physician but I doubt that calls for such harsh action.

  16. Richard Willner Says:

    Nurses,

    If one thinks one is in trouble with a Hospital or with a State Board, get some sound advice.

    I invite anyone to give us a call. Maybe we can point one in a good direction

    Richard Willner, CEO, Founder
    The Center for Peer Review Justice
    >>> NoNurseLeftBehind<<<

    http://www.PeerReview.org
    info@PeerReview.org

    Celebrating our 12th year!!!

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