Medical licenses in jeopardy after inmate’s death

Five medical professionals who treated an inmate at a Vermont prison in the days leading up to her death are facing allegations of professional misconduct.

The Office of Professional Regulation, a branch of the secretary of state’s office that enforces professional licensing, is seeking disciplinary action against four nurses and a physician.

Annette Douglas entered Chittenden Regional Correctional Facility on Dec. 29, 2014, to serve a 17-day sentence for twice missing work crew orientation.

Eleven days later, the 43-year-old was dead.

Douglas was diagnosed with diabetes and was an active heroin user, according to the Office of Professional Regulation. She was known to staff at the prison because she had been incarcerated before, the documents state.

Previous reviews of Douglas’ death indicated that during her brief stay in prison she refused treatment several times.

Her death was investigated by multiple agencies. Her demise was “caused by her failure and refusal to avail herself” of care that was available, the defender general’s office concluded in a report in August 2015.

“She expressed a desire to die, and she accomplished that by refusing treatment for her various medical conditions,” according to the defender general’s report.

That review was followed by an investigation by the Office of Professional Regulation. The OPR probe looked at medical professionals working for Correct Care Solutions — the private contractor that provided medical services in Vermont prisons at the time — who treated Douglas in the days before she died. The Office of Professional Regulation alleges that five medical professionals failed to follow protocols in providing care to Douglas.

According to Ben Watts, director of health services for the Department of Corrections, current department policy requires a patient’s refusal of care to be documented in an electronic health record. Patients refusing treatment must be told what that decision might mean for their health. If they continually refuse essential medications, they generally are referred to a provider for a follow-up visit. He said he could not speak to policies at the time of Douglas’ death because he was not with the department at the time.

Four nurses and nurse practitioners are facing allegations: Jed Lowy, Tara Schildhauer, Amy Kelly and Quincy Campbell. They have an opportunity to respond to the professional charges before the State Board of Nursing hears the case and determines whether any sanctions are warranted.

Dr. Peter Waldman, a licensed osteopathic physician, will also have an opportunity to respond before his case goes before the State Board of Osteopathic Physicians and Surgeons.

VTDigger made multiple attempts to contact all five professionals by phone, email and social media, but was only able to reach an attorney for Waldman, who would not speak about the case.

The five can contest the charges, which were filed in mid-December. However, the responses are not public documents, according to OPR Director Colin Benjamin.

Benjamin said hearings in licensing cases are often scheduled about four months after the charges are filed, but the timeline varies depending on the complexity of the case. The cases could also be resolved through a settlement.

If the boards in the respective cases determine any violation occurred, the person could face a range of disciplinary action, including a warning or license suspension or revocation, Benjamin said. At that point, the resolution of the case is made public.

According to a chronology presented in the OPR’s specification of charges, Douglas was initially held in a cell with a roommate when she was incarcerated Dec. 29, 2014, but was transferred to a segregation unit Jan. 1 after she threatened to punch her roommate.

Two days later, Douglas appeared to have increasing difficulty getting up and walking.

She showed signs of “extreme thirst” and “was frequently urine soaked to the extent that urine pooled on her plastic mattress and extended up her clothing into her hair,” the document states.

The state alleges Lowy failed to call an off-site doctor about Douglas’ high blood sugar levels after a nurse asked him to.

On Jan. 6, Lowy treated Douglas when she came to the infirmary. He noted she was complying with diabetes treatment, and the notes from the visit focused on neck pain she reported. According to the complaint, Lowy allegedly said at the end of the visit that she was “playing possum.”

After the appointment at the infirmary, Douglas was returned to her cell slumped in a wheelchair.

Video shows that correctional officers lifted her out and placed her on the cell floor. Fifteen minutes later, a nurse was called to the cell because Douglas remained motionless. The nurse, Kelly, was in the cell for less than a minute and failed to collect assessment data, document the call or notify a supervisor of any change in Douglas’ status, according to the report by the Office of Professional Regulation.

Five hours later, Douglas had not moved from the floor. At that point, she was moved to a mattress on the floor.

When another nurse, Schildhauer, came on shift that evening, she was told Douglas’ blood sugar levels needed to be rechecked in two hours. However, the Office of Professional Regulation alleges, Schildhauer did not check Douglas’ blood sugar during her shift.

The document reports that Schildhauer did go into Douglas’ cell twice early in the morning of Jan. 7 and recorded both times that Douglas refused medication. After the second visit, at 5:48 a.m., the nurse reported that Douglas refused treatment for diabetes by stating “NO” and that Douglas threw her fist in the air.

According to the OPR, video shows the nurse standing in the doorway of Douglas’ cell “while Correctional Officers attempt to get A.D.’s attention by snapping their fingers, kicking her mattress, and shaking her foot.”

According to the OPR complaint, Douglas never appeared to wave her fist in the air in the video.

Less than three hours later, Douglas was found unresponsive and was taken to UVM Medical Center. She died two days later.

According to the document specifying charges against Waldman, the osteopath responded to an emergency call for Douglas on Jan. 5 and did not assess the patient.

Campbell allegedly administered medication to Douglas through a food port in the cell door, while Douglas complained she was thirsty and was unable to walk to get water. The nurse allegedly did not take Douglas’ vital signs and glucose reading at that time, according to the document.

Three of the professionals facing charges now work for Centurion, the contractor that provides health care services in Vermont prisons, according to the Department of Corrections facilities director, Mike Touchette.

Multiple requests for comment to Lori Poirier, regional manager of Centurion of Vermont, were not returned.

Touchette said Douglas’ death was “an unfortunate occurrence.” The department reviewed the circumstances internally and sought review from external partners, he said. As a result, Corrections has instituted “improved practices” in an effort to prevent a similar occurrence, he said.

New protocols say that if an employee believes an inmate is experiencing a medical or mental health issue, the worker should immediately notify security and health staff. If an inmate is unable or unwilling to move or speak, staff are expected to put that person on a mattress, covered with a blanket.

The department also is encouraging greater communication between security and health staff, including holding daily meetings at each facility to discuss individuals’ cases, he said.

“This process has improved the exchange of information between security and health services staff that results in a more comprehensive and better-informed process to make decisions about safety, security and health care services delivered to inmates,” Touchette said.

Also, the department is in the process of formally removing from policy a disciplinary infraction for malingering, according to Touchette. He said the department has stopped sanctioning prisoners who are believed to be feigning illness. Instead, health services and correctional officers consult to address any care needs or to develop a behavior plan.

However, lawyer A.J. Ruben, of Disability Rights Vermont, said his advocacy group continues to see evidence of maltreatment in prison.

“I have no reason to believe that medical staff or correctional officers are being more attentive and following the rules any better than they did when Ms. Douglas died,” Ruben said.

Disability Rights Vermont also completed a report on her death, which determined she did not receive sufficient medical treatment.

“It’s pretty clear to me that Ms. Douglas wouldn’t have died nor have been treated the way she was if everyone was doing their job right,” Ruben said.

Ruben called for greater oversight of the independent contractors that provide care in Vermont’s prisons.

“There’s no evidence that anyone is making sure that these mistakes don’t happen,” Ruben said.

The post Medical licenses in jeopardy after inmate’s death appeared first on VTDigger.