Nursing Facility Hit with Highest Fine Possible after Patient's...

Full story: News10 Sacramento

Written by Elizabeth Bishop , Senior Internet News Producer A nursing facility in Sacramento County has received the most severe citation under state law after a patient died of a massive morphine overdose in ...
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1 - 12 of 12 Comments Last updated May 22, 2013
The Witness

Elmira, CA

#1 Jun 29, 2007
I am a registered nurse, most of the time
I have worked the night shift. I have worked in acute care settings. Even in acute care,
medication and other errors are made that are not reported. I personally have made an effort to fill out Notification Reports, but, I know that my co-workers have often not.
There is a stigma to reporting errors that shouldn't be. We should all learn from errors and be the wiser. Not all hospital administrations react favorably to the help that they have who acknowledge errors. I worked at Methodist Hospital of south sacramento, who opereate Bruceville Terrace. This article is about a horrible medication error at Bruceville Terrace. With the amount of foreign help that Methodist hires (people who are often culturally afaid of their
superiors and fear for their job security because they have overseas families depending on them for money) it is no wonder that errors at both campuses get covered up or under reported. Methodist Hospital does not have good Labor Relations and an atmosphere of
blame creates this kind of secrecy. The overdose should have been reported immediately in this instance. So have I seen other lesser things happen that didn't get reported because the hospital liked it that way. Less paper work, less accountability, and see no evil make no changes.
I told you so

Elmira, CA

#2 Jul 2, 2007
I contacted the Department of Health
Services, Division of Licensing and Certification (years 2001-2003) about staffing and care issues at Methodist Hospital, parent to Bruceville Terrace (where this error took place.) I also wrote the DHS in concern that Methodist Hospital was poorly tracking their Patient Controlled Anesthesia, or PCA.
I noticed that entire shifts would not document the amount of PCA medication that
a patient got. In addition, there would be no charting on the amount of medication credited to the next shift. I provided Methodist Hospital with a analysis of one patient's chart who was using PCA at long term.
I suggested that there be a better flow sheet for PCA documentation. At that time, the Medication Record was the only spot to document PCA. A tiny space. Not condusive to evaluating the effectiveness of the medication or capturing how much monitoring the PCA got that shift. About 2 weeks after reporting this concern to the state, Methodist Hospital quickly drafted a flowsheet for the PCA.
PCA is usually a narcotic and the use and monitoring of it should be taken seriously, always at least double checked. It shouldn't have taken my letter to the state to wake these people up. Narcotic injection has risks and the risks can be reduced with proper handling, proper monitoring and patient education. I was told by former Catholic Healthcare West co-workers
that this medication error was very avoidable,
and that in fact, the nurse actually thought that she was hanging an IV antibiotic and not a narcotic.(She was a fairly new hire and English was her second language.) This error not only reflects poorly on Bruceville Terrace but it reflects badly on Methodist Hospital, as
Methodist Hospital relocates nursing supervisors from Bruceville Terrace to their acute care setting. Perhaps also this nursing home was beyond their scope in this instance, and with this patient.(I don't know.)
All I can say is that I could see this coming. Thank you.
I was warned

Vallejo, CA

#3 Sep 22, 2007
The previous writter wrote "Methodist Hospital relocates nursing supervisors from Bruceville Terrace to their acute care setting. Perhaps also this nursing home was beyond their scope in this instance, and with this patient.(I don't know.)"
Employees from Bruceville Terrace are moving from BVT to Methodist in hopes of staying within the local community and CHW system and to get away from Linda Turner the incompetent director that badgers and yells at her empoyees instead of fixing the issues and giving solid direction to good nurses that a so job scared they won't stay for long. She fires or runs off well seasoned staff that knows more than she does in order to hide her incompetence! CHW should fire her!
Nobody

AOL

#4 Sep 23, 2007
I have been a Paramedic in Sacramento for the last 13 years and an EMT-II before that.

Myself and other Paramedics used to complain all the time about SNF's.

NO ONE CARED.

Far to often I see the end results of medical mishapes. While mistakes get made accross all diciplines, mistakes seem to be higher in SNF's. Simple mistakes. Ones that are easy to correct, yet have catastrophic consequences if they are not fixed.

As a mandated reporter, I fill out the stupid APS form as required, go through the motions and follow proper protocal, knowing full well, NOTHING WILL EVER CHANGE.

I make a difference where I can, do my part in the system, and keep my side of the street clean.

I walk in, thank the SNF staff for an amazing job done, head to the room, work the code, tube my patient, start lines, push drugs and get the hell out.
Southwest Seminars Nurse

Katy, TX

#5 Oct 7, 2007
Come attend our Nursing Law Seminars offered by Southwest Seminars. We discuss,'chain-of-command', floating, delegation, supervision of other staff, staffing and other "hot" issues in nursing practice. Come learn how to better protect yourself and your empolyer from potential litiation. Our live, one-day interactive seminars provide quality up to date information and review "real" cases against "real" nurses. visit us at www.southwestseminars.com
Interested_Party

Huntington Beach, CA

#7 Sep 30, 2009
Someone should have listed to this intelligent person and this person is very right to say I Told You So to Methodist Hosptial and Bruceville Terrace. What a tough thing to have to carry around with you as a soul !!
Judy r n

Antioch, CA

#8 Nov 22, 2010
My daughter is recovering from severe burns 64 percent of her body and is now in rehab at bruceville. I am very pleased with her care and all the personal there do a great job. She has been hospitalized since 12-09 in several hospitals in Sacramento area and I am grateful to the caring staff at bruceville.
HumanSpirit

High Springs, FL

#9 Nov 22, 2010
Execute the CEO and torture the doctors and nurses in this case would seem appropriate.
A Former Employee

Sacramento, CA

#10 Dec 28, 2012
I was employed as a temp in the front office at Bruceville Terrace for a few months earlier this year. At first, Ms. Turner (or "Turner" as she is known by many at BVT) seemed genuinely interested in me and what I could contribute to her facility, however things degenerated rather quickly.

When I was fairly sure that my temp assignment was coming to an end, I endeavored to learn what day that would be so I could notify the staffing agency that I would be needing a new assignment. I checked in with the agency several times during what ended up being my last month at BVT, but they had no knowledge of the assignment ending.

On what became my last day at BVT, Heather ("Clinical Services Coordinator" or something like that) became violently upset and said I had asked when my last day would be too many times (I kept asking because nobody ever gave me a definite answer!). Heather stormed out of the main office and returned maybe half an hour later and told me to get out. This obviously came as a shock; I have temped off and on for 16 years and have NEVER had an assignment end in this way. I decided to double-check with Turner, just to make sure that Heather wasn't bluffing. Turner was in her office but wouldn't let me say anything, just told me that I would be paid for the entire day and to leave. I gathered up my belongings, said goodbye to a couple of the more friendly employees and left.

I would also like to mention that the office manager (Pam) was a handful. She is loud, rude, short-tempered, and has NO customer service skills.

If you have a choice, please work ANYWHERE other than Bruceville Terrace in Sacramento, California.
angela demartini

Sacramento, CA

#12 Feb 16, 2013
i was a patient at Bruceville Terrace for 3 weeks...the staff is very nice, but i was surprised at how they ignored my constant complaint everyday asking to be moved to another room because of the defective windo my bed was next to. the windows are old and leak so much cold air at night that i would just watch the wind blowing the curtains and of course here in Sacramento its around 30 or 35 degrees at night . they kept offering me a blanket or sleeping pills so that i could forget about the freezing air, what a poor solution. i would stay up everynight in the chair next to the bed with blankets wrapped around me and complain every morning...they really seemed to ignore me completely. i never want to go back to that place again...your discomfort means nothing to them...and they only solution they offered was sleeping pills...angela
Not Surprised

Sacramento, CA

#13 Feb 17, 2013
How that facility manages to pass inspection is beyond me. Angela, I'm so sorry that you had a lousy experience there. I wouldn't have put up with that for 2 nights, let alone 3 weeks. Hope you'll find someone higher up the food chain to inform of this situation; I do believe they would like to know about the potential abuse of medication going on at BVT, as well as the building's structural deficiencies!

Since: Apr 13

Location hidden

#14 May 22, 2013
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