Series: Nurse on Trial, Part 1
On January 22 and 23, 2008, Nurse Mark Neely, RN, a competent, capable, and hardworking critical care nurse in Missouri went on trial for his nursing license. In the next few blog posts I am going to tell you his story, and how the Missouri Board of Nursing engaged in one of the greatest miscarriages of justice in the Board's long history.
The story is long, and will be told in installments. At the end of the tale you will likely understand how few safeguards Boards of Nursing employ in how they discipline licensees, and how innocent people often get caught up in the machinery of government.
The night shift beginning at 7 pm on March 12, 2004, was like any other for Mark Neely. He had two patients in the Cardio-Thoracic Unit or CTU. They did not experience any problems, and he spent his time caring for them and helping other nurses with their assignments. "There was nothing unique about that night from my memory," he said.
The next evening, March 13, 2004, when he came in a few minutes early for his 7pm shift, he was met by the manager of the unit and the Vice President of Nursing. They showed him a Pyxis record that indicated he had gotten out two bottles of Diprivan. He did not recall doing so, but told them it must have been to have helped out a colleague. They then told him "no, we checked with everyone, and none of them asked for your help." Diprivan was not a controlled substance, and it was not even inventoried. He told them honestly that he didn't know what had happened to the Diprivan. They asked him if he had given it to his patients.
"Neither one of my patients was on a ventilator, so they knew the answer to that was no. That's what I told them," Neely said. At that point the manager told Neely that the two patients he had been caring for had been found obtunded after his shift, and one had been so badly obtunded that it was necessary for that patient to remain in the CTU rather than be transferred to a floor bed. They told him they believed he had given the two bottles of Diprivan to his patients.
"I felt like I was in a Twilight Zone episode," he said. But it kept getting worse.
"We found a used bottle of Diprivan," the unit manager told him, "in both of your sharps containers in your room. There were syringes with what looked like Diprivan in them."
Neely protested his innocence, explained he didn't put them there, and wanted to know what was really going on. The hospital, he was told, was suspending him pending a review with an eye to termination. They sent him home, and fired him a day or so later.
"I was stunned," he said. "I had been a loyal employee. Both the manager and the Vice President of Nursing had written me letters of recommendation for CRNA school only weeks earlier. I could absolutely not figure out what had happened."
Neely filed for unemployment and was turned down. His wife was pregnant with their second child. She was not working, and now he was not working. He filed an appeal of the unemployment determination and fought it as hard as he could. He had seen the Pyxis records, but he'd never seen the medical records or medication administration reports. The only thing he could figure was that he had checked out Diprivan for one of the other nurses, and that the nurse had simply forgotten about it. In his appeal he stated "while it is true I checked out the Diprivan for another nurse..." It was a statement that would come to haunt him later. Worse, it didn't help him before the coldhearted judge at the Unemployment Commission who ruled that no matter what his defense, he was discharged for cause and was not eligible for unemployment.
He finally found a job at another facility, and later moved to a large metropolitan hospital so that he could continue critical care nursing. As his financial condition began to improve with a new job in a new town, the second body blow came: the hospital had reported him to the State Board of Nursing.
In my next blog post, we'll detail the results of the Board's investigation.