First Healthcare Compliance CONNECT November 2022

sedative that is given on a regular basis. What
happened, unfortunately, was that the drug left the
patient brain dead. Later that day, two neurologists
from the medical center report the death to the
Davidson County Medical Examiner. However,
they did not mention the medication error, or the
vecuronium. The death was attributed to bleeding in
her brain and deemed to be natural, as bleeding in
the brain was what she initially came in for. Based
on information provided by the medical center,
the medical examiner did not do an independent
investigation into the death. That’s not uncommon,
either unless there’s a reason, especially when it’s
a renowned medical center, to dispute the findings
or to probe further or if the family has a request that
an autopsy be done. Normally, it is taken as natural.
In January of 2018, in light of the death, the Medical
Center took some significant actions first, they
did not report to state or federal officials which is
required by law that this had occurred. Secondly,
defendant Vaught was fired by Vanderbilt University.
And then subsequently, Vanderbilt negotiated a
settlement with the descendant’s family. That
primarily did three things: first, it gave them a
monetary settlement; secondly, the settlement was
not made publicly known, and lastly, there was a
provision that required them not to speak publicly
about the death or the medication error. Now having
a confidential agreement under a situation where
a patient either dies or has an adverse patient
outcome, that constitutes at a minimum negligence
is not unusual. But for their not reporting and not
being completely truthful with the family about what
happened, there was nothing ill or untoward about
the settlement. So that happens in early 2018.
By October of 2018, an anonymous person
alerts state and federal health authorities to the
unreported medication error that was responsible
for the patient’s death. From there, we have
different licensing boards begin to take interest and
begin investigating. For example, the Tennessee
Department of Health, investigated and decided
not to pursue any disciplinary action against Nurse
Vaught. In a letter to Vanderbilt the agency’s
investigations director said Vaught’s case did
not constitute a violation of the statutes or rules
governing her profession, which is the nursing
profession. And on the same day, the defendant
Vaught was sent a letter saying this matter did not
merit further action.
CMS had a different response. And in fact, they
came in to the Medical Center unannounced to do
a surprise inspection. And the inspection did in fact
confirm that the patient died from an accidental
dose of vecuronium and that the Medical Center did
not report the medication error to the government
or to the medical examiner, according to an
inspection report, and in late November 2018, the
circumstances of the fatal medication error became
public for the first time when CMS released their
report. However, they did not identify the nurse or
patient by name. And in fact, the Medical Center’s
reimbursement for Medicare was threatened unless
it could prove it took steps to prevent a similar error
and to provide a correction plan, which it did. So
that appeased the federal agency and its Medicare
reimbursements were secured.
In early 2019, the nurse was identified publicly for
the first time when she was arrested on a criminal
indictment for her alleged role in the death. Initially,
she was charged with reckless homicide and
impaired adult abuse. But Vanderbilt was not named
as a codefendant, and Vanderbilt did not take
any disciplinary action, nor did the board did not
take any disciplinary action. That’s the Tennessee
Board of Licensing, despite Vanderbilt purchasing
the automatic dispensing cabinet that was utilized,
despite it being responsible for the internal,
technical, physical, and administrative safeguards
being in place. And in light of, some of the issues
that nurses dealt with on a regular basis.
This is a large case. It seems like there were
so many different players in it that could
have been sued or prosecuted and I am
surprised they were not.
Right. So, at the beginning, I mentioned different
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