To: j****.*****@vnsny;k****.******@vnsny
Subject: A nurse who is a risk management issue
You should meet Arthur “I have 25 years’ experience” XXXXXXXXX who works in the borough of XXXXXX for VNSNY.
He does not know where his NYS nursing license ends.
He does not know what is not a stage 3 pressure ulcer despite “25 years’ experience”
He is a long-term family friend of the patient. Your call.
Arthur called me yesterday while he was at the bedside. The first thing I asked was “do you have my orders?” I asked because often field nurses do not have the orders which is confusing to all and because in this instance there were two waves of referral. I sent one referral which was subsequently revised when the condition of the ulcer changed before the first nursing visit. He did have my current orders and read them to me. After a discussion of his findings including revealing that he does not know the definition of a stage 3 pressure ulcer, he asked what the care orders were. I can’t make this up. He had just read them to me. I asked him to read them again. He again asked if I really really wanted the ulcer care daily. Mind you, my order in no way asks that VNSNY do the wound care daily because I know better than that. It actually says that family and caregiver have been trained and as always for my ulcers, I examine them weekly. I really really want the ulcer care daily because: 1) that is the standard of care for chemical debridement; 2) that is the manufacture’s recommendations for the product being used; 3) we want the ulcer debrided as quickly as possible and it’s bad to prolong debridement which would be an intentional delay in healing and therefore risk not meeting the goals on your care plan; 4) I never in my career have seen this product used less than daily nor would it be pharmacologically sensical to do so; and finally 5) what the absolute fuck? the ulcer is under my care and license.
By way of analogy, does Arthur feel he should “suggest” different antibiotics for her pneumonia because he has “25 years’ experience?” A different frequency for their administration? A longer or shorter course of treatment? Ask him why he feels that his license has any connection to treatment besides carrying out my orders. Its real simple nurses evaluate, communicate and carry out. Arthur has not taught pressure ulcer care at the bedside of a hospital for 9 years. Arthur has not given medical ground rounds on pressure ulcers at numerous hospitals. If Arthur thinks I am not fully invested in wound healing he hasn’t read my CV.
How “other physicians” who do not do wound care might be susceptible to suggestion from field nurse who does not know what he is talking about or from your “wound care” nurses is irrelevant. He was shocked to find that I was not oh so grateful for his “suggestion.”
Arthur is not self-aware that he does not know how to stage a pressure ulcer which is a limiting factor for his skills to communicate as a nurse. And this fact certainly did not affect his arrogance of continuing to try to get me, the licensed provider who writes the orders to accept his nonsensical mouthing off about treatment. He didn’t drop the matter after reading the orders to me for the third time, he went on about his qualifications. This ulcer as of yesterday was a category called unstageable L89.350. Arthur does not know what tissue layer is, by definition, visible at the base of a stage 3 pressure ulcer. Arthur does not know the difference between fascia and fibrinous exudate. Arthur makes shit up.
Furthermore, an important aspect of wound care is that it’s not static. An ulcer heals because of continuity of exam and adjusting treatment over time by the physician. Arthur saw this ulcer for the first time on 1/2/20. I have been examining it since. 12/11. “I have 22 days experience” with this particular ulcer in this particular patient and her unique care team.
Here is the state law emphasis added
§6901. Definitions. As used in section sixty-nine hundred two:
"Diagnosing" in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis.
"Treating" means selection and performance of those therapeutic measures essential to the effective execution and management of the nursing regimen, and execution of any prescribed medical regimen.
"Human Responses" means those signs, symptoms and processes which denote the individual's interaction with an actual or potential health problem.
Subject change but still Arthur
“Would she benefit from a palliative care ‘program?’” I asked about this so called “program” because the patient’s care plan is palliative already and he went off on hospice. I said hospice is hospice, what is a palliative care “program” outside of hospice? He went back to hospice. I asked what he thought her hospice diagnosis was and he said “failure to thrive.” Arthur’s is back to diagnosing again. For your information failure to thrive is a diagnosis of exclusion which in this case means she can’t have it because she has a diagnosis of pneumonia. In addition we think she has other pathology which would also exclude the diagnosis of exclusion. Now, you and I both know that VNSNY hospice will be happy to accept a patient wearing a name tag of “failure to thrive” even if that patient doesn’t have it. Who is going to challenge this misappropriation between now and the next whistle blower law suit for fudging criteria so you all can bill the tax payers? Fifty-seven million earlier this year. https://homehealthcarenews.com/2020/06/vnsny-agrees-to-57m-settlement-in-whistleblower-suit-related-to-physician-care-plans/ Ouch.
I used to have 25 patients for long periods of time with different branches of VNSNY. I was termed the physician with the most patients under simultaneous care with you. I used to care about your quality. I used to actually want VNSNY to improve each of your nurses attitude, knowledge and skills. I have done lectures for your hospice, yes on pressure ulcers. I no longer care as long as you don’t harm my patients. If you want to improve Arthur in a clinical sense, knock yourself out. I request that you do tell him where his license ends. I don’t care if he can’t tell a stage 3 pressure ulcer from an unstageable, but you might think that is important. I don’t care if he throws around a diagnosis of failure to thrive without knowing the diagnostic criteria, but you might.
I know you are wondering why I made a referral to VNSNY. Me too. Ask yourself why VNSNY accepted my referral since you all do not like to hear the truth. Did I slip through the black list? Maybe this email will reach the hands of a future whistleblower. One can only hope.