STATE OF WASHINGTON DEPARTMENT OF CORRECTIONS MONROE CORRECTIONAL COMPLEX P.O. Box 777 • Monroe, Washington 98272-0777 Q_6Q) 794-2600 • Fax: (360) 794-2569 PERSONAL & CONFIDENTIAL DELIVERY April 18, 2019 Julia Barnett Facility Medical Director Monroe Correctional Complex · Ms. Barnett: Notification of Disciplinary Action This is official notification that I am discharging you from your Facility Medical Director position (FMD) position #C688, with the Department of Corrections (DOC), at Monroe Correctional Complex (MCC), effective immediately. Additionally, you will be paid fifteen calendar days in lieu of notice. This disciplinary action is being taken in accordance with Washington Administrative Code (WAC) 357-40 of the Civil Service Rules. Misconduct This disciplinary action is for the following misconduct: During the period of January 16, 2018 through September 10, 2018, you failed to exercise sound clinical judgement; provide adequate medical care to patients; advocate for patients; make timely and necessary arrangements for adequate medical care to be provided to patients outside ofMCC; ensure that ,, providers whom you clinically supervised were providing timely, adequate medical care, evaluations or assessments; ensure that sufficient documentation and charting was occurring so that the patient's condition could be adequately monitored; and communicate significant changes in a patient's condition to other critical medical providers. Specifically: 1. Patient L.J. (See investigation attachment 12, 13 and 14) a. During the period June 8, 2018 through August 25, 2018 you failed to exercise sound clinical judgement and failed to provide adequate medical care, or ensure that others were providing adequate medical care, when this patient's pulmonary condition was deteriorating, yet you maintained the patient in the MCC Inpatient Unit (IPU) under the status of Housing only (requiring the patient to be seen as needed), and then to Observation in the MCC IPU (requiring the patient to be seen monthly) instead of assigning him to Skilled Care in the MCC IPU (requiring the patient to be seen daily). You also failed to ensure that you or the providers you clinically supervised were providing timely, adequate medical care, evaluations and assessments. "Working Together for SAFE Communities" G recj'cled pnper BARNETT, JULIA 2019-775MD PAGE 2086 Page 2 of27 b. During the period July 24, 2018 through August 25, 2018, you failed to exercise sound clinical judgement, failed to advocate for this patient and failed to make necessary arrangements for adequate medical care to be provided outside MCC when you failed to timely send this patient to an outside medical provider for further medical evaluation and treatment. The lJatient's oxygen/pulmonary function was declining, with oxygen levels ranging from 92% down to 54%, and the patient at times refusing the nebulizer and nasal cannula (NC). The patient was afraid to use a face1nask, frequently had a clry cough, fever, chills, labored or course breathing and complaints of being unable to breathe. The patient's oxygen level diminished to 44% on August 25, 2018, he had signs of blue lips and blue fingernail beds, and the patient stated, "I don't want to die here." 2. Patie11t C.P. (See investigation attachments 8 and 9) During the period August 31, 2018 through September 4, 2018, you failed to exercise sound clinical judgement, failed to provide adequate medical care, and failed to advocate for this patient to make necessary arrangements for timely and adequate.medical care to be provided outside ofMCC. On August 31, 2018, you directed this patient to be housed in the MCC Close Observation Area (COA), even though it was suspected that he lmd inserted a six inch woodless pencil up his urethra. RN Jana Robison was concerned that the pencil was in the patient's bladder. The patient had bloody mine, lower abdominal cramping, and a history of inserting foreign objects, yet you continued to house the patient in the COA until Septembet 4, 2018, when an xray was performed, which confirmed the foreign object. You then agreed to transfer him to an outside medical facility for furt11er evaluation and treatment, where his bladder was determined to be perforated and the pencil was surgically removed. 3. Patient J.K. (See investigation attachments 15, 16 and 17) a. During the period June 18, 2018 through August 22, 2018, you failed to provide or ensure that providers whom you clinically supervised were providing timely, adequate medical care, evaluations and assessments regarding this patient, and to ensure that adequate documentation and cha11i11g was occurring so that the patient's condition could be adequately monitored. This patient had an open abdominal wound, complained of increased abdominal pain, and experienced changes in his symptoms to include difficulty breathing, pain in his left flank and ribs, shaky hands, appetite changes, vomiting and dianhea. b. . OnAugust 6, 2018, you failed to exercise sound clinical judgement and failed to advocate for this patient to make necessary arrangements "Working Togethel'/Ol' SAFE Commimlties" BARNETT, JULIA 2019-775MD PAGE 2087 Page 3 of27 for timely, adequate medical care to be provided outside MCC when you denied a request to send this patient to an outside medical provider, for further medical evaluation and treatment. Nursing staff expressed concerns that the patient's wound was tunneling, that they were unable to suction back any tlltid when the wound was inigated, and that the fluid may be going into his peritoneal cavity. The patient's condition continued to decline through August 22, 2018, when you fina lly agreed to send him to the hospital. 4. Patient B.A. (See investigation attaclunents l 0 and 11) During the period of September 9, 20 18 through September 12, 2018, you failed to exercise smmd clinical judgement, failed to provide or ensme that providers whom you clinically supervised were providing timely, adequate medical care, evaluations and assessments and failed to adequately communicate significant changes in this patient's condition to other critical medical providers. This patient had bad complications following two prior wisdom teeth extractions, and returned from an area hospital on September 9, 2018. You maintained the patient in the MCC IPU until September 10, 2018, w1der Observation instead of Skilled Care, desp ite his complications. You failed to ensure that you, or the providers whom you clinically supervised, evaluated tbe patient prior to releasing him from the MCC IPU later on September 10, 2018, or to consult with one of the facility dentists. You discharged the patient from the MCC IPU on September I 0, 20 18 with patient symptoms of swelling on/in the right side of his throat/jaw, unable to eat, and pain described as 10/10. You issued only pain medication, Magic Mouthwash and ice packs. The patient returned to the MCC IPU on September 11 , 2018, with a fever of 102.3, increased facial swelling, unable to swallow, breathing with his mouth open, i1mer mouth swelling to the back of his epiglottis, and feeling like he was drowning. On September 12, 2018, the patient was then sent ottt again for outside medical intervention, where he was maintained in an Intensive Care Unit. 5. Patient C.S. (See investigation attachments 18, 19 and 20) a. During the period Janumy 16, 2018 tlu·ough August 22, 20 18, you failed to exercise sound clinical judgement when you agreed to perfom1 bilateral plantar wart excisions on the bottom of both feet of this patient. This patient also had Diabetes, which complicated the patient's medical condition and healing. b. Dw-ing the period March 30, 2018 through August 3, 2018, you failed to provide or ensw-e that providers whom you clinically supervised were providing timely, adequate and standard medical care, evaluations and assessments when this patient received "bi-weekly" Cryotherapy treatments to both feet, over an extended period oftime which would not allow the sldn time to heal prior to the next treatment. "Working Together for SAFE Communities,, BARNETT, JULIA 2019-775MD PAGE 2088 Page 4 of27 6. Patient P.H.(See investigation attachments 20 and 21) a. During the period February 6, 2018 through March 17, 2018, you failed to exercise sound clinical judgement, foiled to advocate for this patient to make necessary arrangements for timely, adequate medical care to be provided outside MCC, and failed to adequately cmruntuii.cate significant changes in the patient's condition to other critical medical providers. This patient bad been discharged from Evergreen Hospital on February 5, 20 l 8. Upon his discharge, Evergreen recommended that he be seen by Endocrinology, but you failed to ensure that this medical consult occurred. On or about February 14, 2018, you failed to appropriately document and/or to ensure that providers whom you clinically supervised were appropriately documenting the patient's medical record when the diagnosis of Diabetes Insipidus (Dl) was added to his medical conditions without sufficient records of why the diagnosis was added. b. During the period January 23, 2018 through March 17, 20 18, you failed to provide or ensure that providers whom you clinically supervised were providing, timely, adequate medical care, evaluations and assessments and failed to ensure that adequate documentation was occtuTing so that the patient's condition could be adequately monitored. There is an inadequate number of encounters recorded in the Offender Management Network Information system (OMNI) between January 23, 2018 through March 17, 2018 and an inadequate number of examinations and assessments recorded in the patient's medical record between the period of February 26, 2018 through March 17, 2018. c. During the period February 6, 2018 through March 17, 2018, you fai led to exercise sound clinical judgement and failed to provide or ensw-e that others were providing adequate medical care when th.is patient was placed on Desmopressin (DDAVP), which can cause Hyponatremia, and allowed the patient to continue on DDA VP until March 17, 2018. cl. During the period Febrnaiy 6, 2018 th.rough March 17, 2018, you failed to exercise sound clinical judgement and fai led to advocate for this patient to make necessary arrangements for timely, adequate medical care to be provided outside MCC, when this patient was allowed to remain in the MCC IPU instead of being sent to an outside medical provider for fi.11ther evaluation and treatment for his deteriorating conditions. The patient was not sent out for outside medical intervention until March 17, 2018 when he was unable to eat, drink or take medication, was lethargic and barely arouseable, and had a sodium level of 115. He died the same day with cause of death cited on his Death Ce1tificate as Electrolyte Disorder. Also noted on the Death Ce1tificate were other conditions contributing to death, to "Working Together for SAFE Communities" BARNETT, JULIA 2019-775MD PAGE 2089 Page 5 of27 include: Diabetes Mellit11s> recent Viral Meningitis, and probable Arteriosclerotic Cardiovascular Disease. Investigation Investigator 3, Cassandra Chalmers, completed a fair and thorough investigation into this 111atter with the assistance of Dr. Patricia David and Dr. Sara Kariko. During the investigation the following information was provided: 1. Patie11t L.J. (See investigation attachments 12, 13 and 14) This patient was initially transferred from the Washington State Penitentiary, with oxygen (02) saturation of 95-99% on June 8, 2018. 01\ a}Jproximately July 28, 2018, his 02 levels began ta drop to 89%. You were asked by Dr. David why there was no diagnostic workup given this patient's sudden oxygen level drop, or consultation with the Pulmonologist, who had evaluated him for lung transplantation, prior to his trru1sfer to MCC. After reviewing the medical record, you said it appeated that the patient's change in pulmonary status occurred gradually _ over the course of approximately two months. Y01.1 said that you had several conversations with the Physician Assistant (P A-C) about the need to consult a Pulmonologist for recommendations, and particularly before adding medications to the patient's regimen. You said the patient's June 2018 typed notes from the Pulmonologist were not in his DOC record, but you recalled reviewing and printing them. You also said that there was also at least one report to you that the Pulmonologist had been called, hut had not rehm1ed the call. Yo:u fmther stated that it appeared the patieut did not always wear his oxygen and sometimes the results were recorded on room air instead. Dr. Kariko asked whether the patient's status ever changed to Skilled Care when his condition began to deteriorate. After reviewing the medical chmt, you said the Infirmary Face Sheet had both Observation and Housing checked on June 8, 2018, and there was no date d_ocumented as to when the patient was placed on Long Term Care. You did not mention any Skilled Care placement. You also added that you 1·ecalled having a great deal of disctission regarding the patient's desatmations. You said, initially, it would occur when he wasn't using his oxygen, and then when he began using his oxygen all the time, it would occur only at night. You said you were first notified (offurther oxygen desaturation) on August 7, 2018, and your assessment at that time was that he was a mouth breather and he needed to use prongs in his mouth. However, you said that August 7, 2018, was also the begitming-ofthe unhealthy air quality warnings for the Seattle, Washington area, which continued for .the next two weeks. Around this ti.me, you said you received an email that one of the night nurses complained to "admin," skipping you entirely, that this patient was desaturating and nothing was being done. You said this prompted you to raise the issue in the nurses meeting, that you expected to be informed if such an event happened again. "Working Togetlierfor SAFE Comtmmities" BARNETT, JULIA 2019-775MD PAGE 2090 Page 6 of27 Dr. Kariko asked what your rationale was on August 19> 2018 for placing the patient under Observation instead of sending him to the Emergency Room (ER) when the patient's 02 saturation ranged from 56 to 70%. You said the nurse called you when the patient's 02 increased to 70% and you asked the nurse at that time to check the patient's 02 level again and call you back. However, yoi1 never received another call. You stated ~hat you were not called again about this patient until 0645 hours on August 25, 2018, and you sent him out to an outside hospital at that time. Dr. David asked you why the patient was not evaluated by a J)ractitioner during the period August 20 tlu·ough August 23, 2018, why there were no encounters noted in OMNI or notes entered in the patient's medical record by a practitioner. During this period, the patient was described by nurses as having "air himger" and respiratol'y distress with an 02 saturation drop as low as 60%. You said there were fairly extensive daily discussions with nursing regarding his care. 2. Patient C.P. (See investigation attaclunents 8 and 9) During your investigatory interview, Dr. Kariko asked you why, on August 31, 2018. this patient was transferred to the COA instead of the IPU or other options, when it was suspected that he had inserted a pencil into his i1rethra. You stated that the patient did not appear unstable medically, and that the COA had a nurse on duty at all times. You were asked about a response you made that was noted by nursing 011 August 31, 2018, at 1230 hours. When the nurse asked you what the plan was for this patient, you responded, "We don't do anything as long as he can w-inate" and "it is unlikely he pushed it all the way in." In response to this question, you stated, "X-ray was unavailable at the time of the il~ury, for teasons that aren't clear in the chart.", You further stated that the usual process for m-etlu·al insertions was not to send the patient to the ER unless there was c1ctually a foreign body present that required surgical removal, or if the patient wa$ w1able to mh1ate. You said this patient's entire medical plan hinged on the x-ray results, and as long as he continued to void and remained hemodynamically stable, the x-ray was not an emergency. Dr. David stated during her investigatory interview that the patient had blood in his urine, that the pencil was assumed to have been in his bladder, and he was not sent out to the ER until September 4, 2018. The patient was then hospitalized for a perforated bladder. When the investigator, Ms. Chahners, asked if the pencil should have been removed and the patient then re-evaluated and put into the COA to be monitored, Dr. David said, "Right, yes." . 3. PatientJ.K. (See investigative attachments 15, 16 and 17) "Working Togetherfor SAFE Com1mmities" BARNETT, JULIA 2019-775MD PAGE 2091 Page 7 of 27 You were asked by Dr. David s medical record by a practitioner. Your response when asked about this was that there were foirly extensive daily discussions with nursing regarding his care. I find this to be inadequate. You stated in your investigatory interview as well as during the pre-disciQlinary meeting, that you had daily discussions with PA-Cs and nurses, regarding patients in the IPU, and that you had many discussions regarding this patient, yet you contradict this by stating during the pre-disciplinary meeting that you were not made aware of this patient's epfaodes of poor oxygenation until much later than was appropriate. You also stated during the i11vestigatory interview that you did not receive a call regarding this patient until August 25, 2018, when you then sent him. to the hospital. You were however made aware of the patient's deteriorating condition based on the practitioners and nursing notes dated August 7, 8, 9, 10, 13, 19 and 23, 2018. You also i11dicated dul'ingyour investigatory interview that a nurse complained on August 7, 2018 1 that the patient • was desaturating and that nothing was being done. Despite this complaint, the patient was not sent to the ER, nor was he sent to the ER on August 19, 2018, when his 02 saturation ranged from 56 to 70%. Instead, he was placed tU1der Observation instead of Skilled Care. When a nurse called to inform you the same day that the patient's 02 level had increased to 70%, you asked her to check it again and call you back. However, you did not receive a return call, nor did you follow up with the nurse. There were no fmther notes from practitioners or you, August 20 to 24, 2018, no evaluations by a practitioner, no encounters noted in OMNI or the patient's medical record during the period August 20 to 23, 2018, when the patient was described by nurses as having "air hunger/' was anxious, and exhibiting respiratory distress, with an 02 saturation dr~p as Jow as 60%. On August 24, 2018, at 1129 hours, the Infinnary/Extended Observation Unit Progress Recol'd signed by Registered Nurse 2 (RN), John Sordetto states, the offender called stating, "I ... can't ... breathe" with 02 saturation of 54% aitd resting rate of 60%. It required two nebulizer treatments to raise the patient's O2 level up to 80%. RN Sordetto's notes further state, "Called provider. J. Ross came to see inmate ... nmsing requested that the patient be sent out 911 but requests to send the patient to the ER were ref·used. '' On August 24, 2018, at 1230 hours, you, along with PA-C Jennifer Ross, saw the patient and advised him to use his mask or the NC in his mouth, and avoid any activity other than lying in bed. PA-C Ross and you determined at that thne the patient would remain on the current plan. At 2100 hours the same day, the nurse repmted this patie11t was "Worklng Together for SAFE Communities" BARNETT, JULIA 2019-775MD PAGE 2097 Page 13 of27 in respiratory distress with an 02 level of 50 to 60% when not using his mask. Despite nursing concerns and information provided to you reJ)eatedly, requests to send the patient to the ER were not approved and at HQ time was a Pulmonologist consulted about the patient's deteriorating 02 saturation, nor was there a diagnostic workup performed by you, or the practitioners under your clinical supervision. There was one medical note from PA-C Stanhury on August 7, 2018, that states, "Scheduled £1u with Pulmonologist" arid you stated during your investigatory interview that, "There was at least one report to me that the Pulmonologist had been called, but had not returned the call." Yet there was no ftirther follow up clone by you or the providers that you supervised. b. I find that during the period July 24, 2018 through August 25, 2018, you failed to exercise sound clinical j uclgement, failed to advocate for this patient and failed to make necessary arrangements for adequate medical care to be provided outside MCC. On August 25, 2018 the patient's 02 levels contim1ed to decrease to the 50 to 60% level, and at 0645 hours the patient was noted as gasping for air with an O2 level of 44%, with labored breathing, shaking, and blue lips and fingemail beds. The patient stated, "I don't want to die here/' at which time you finally gave the order for staff to call 911. You had clearly been informed of this patient's deteriorating condition since August 7, 2018, yet you failed to exercise sound clinical judgement and advocate for this patient to receive appropriate consultation with a Pulmonologist, or to send him out for consultation with a Pulmonologist,·or other outside medical care in a timely maimer. Furthel'more, you continued to rationalize your decisions during the predisciplinary meeting, stating that you did not believe that the patient would have been admitted to the hospital had you attempted to admit him prior to when you did, and you were remiss of fhe fact that the patient had not been seen by a Pulmonologist or any other specialist, since an'iving at MCC in June 2018. 2. Patien~ C.P. (See investigation attachments 8 and 9) I find that you failed to exercise sound clinical judgement, to advocate for and to make necessary arrangements for timely and adequate medical care to be provided outside of MCC, when you allowed this patient to remain in the COA for four days, instead of sending him to the ER. It was believed that he inserted a pencil up his uretlu·a on August 31, 2018. Adeleide Horne, PA-C, documented in the medical record on August 31, 2018, at 0030 hours, that the patient inserted a pencil into his uretlu·a, believed to be six inches long, and that the patient could feel it coming out slightly when he tried to void. PA-C Horne fin1her noted that the patient had blood at voiding, .and pain and cramping desctibecl as 10/10. A medical note from PA-C Horne at 0655 how-s stated that the patient felt like he was retaining mine. PA-C Horne stated that she discussed the "Working Together.fol' SAPE Communities" BARNETT, JULIA 2019-775MD PAGE 2098 Page 14 of27 case with you, and you instrncted her to transfer him to the COA rather than the IPU. The patient continued to have blood in his urine during this time and was not sent out t6 a hospital until September 4, 2018, at 1900 hours, when he WflS finally transported to Providence Hospital in Everett, Washington. The patient had the pencil surgically removed and m1.cle1went bladder repair surgery, and returned to the MCC IPU on September 7, 2018. Although you stated during your pre-disciplinary meeting that a reasonable physician might choose differently, and that did not make your choice wrong, I find that you unnecessarily delayed critical treatment, which placed the patient at further risk. Furthermore, your poor clinical judgment put this patient in undue pain and discomfort, and resulted in this patient's prolonged recovery. 3. Patient J.K. (See investigative attaclunents 15, 16 and 17) a. I find that you farted to provide or ensure that providers whom you clinically supervised were providing timely, adequate medical care, evaluations and assessments. I also find that you failed to ensure adequate documentation and charting was occurring so the patient's condition could be adequately monitored. This patient had an open wound over an extended period of time. Although there were various orders requested by providers during August 2018, there were no examination~ noted during the period August 2 to August 2-1, 2018. You . stated during the investigatory interview that the medical records show that exams were performed on August 14, 15, 17, and 20, 2018. However, on the 14th PA~C Ross ordered an x-ray, on the 15th she ordered an IV, on the 17th she performed wound site treatment and on the 20th she ordered another CXR to compare to the prior. At no time was there a note or encounters done by the providers, regarding the com1JJetion of a thorough exam, despite the patient continuing to deteriorate. • The medical n;cords indicate that during the period June 18 through July 13, 2018, a wound vac was applied, the wound was dressed and the wound vac was assessed at several visits. The patient began to complain of abdominal pain on July 14, 2018 and until July 18, 2018, he was given various pain medication, yet.his complaints of abdominal pain continued. On July 18, 2018, he complained of nausea and on July 23, 2018, he complained that the pain at the wound site was causing difficulty for him to sleep. On July 25, 2018, MRSA was found in the wound and isolated. During the period July 26, 2018, until August 6, 2018, blood tests were ordered, dressing w_as changed, and he was continued on medications for symptoms of pain and nm.1sea. On August 6, 2018, nurses voiced their concerns that when the surgical wound was irrigated, there was no retum and the wound was tunneling. They were concemed that the Iluid was going (or had been going) into the peritoneal cavity. They felt the patient should be sent to an outside hospital for evaluation, which you denied. He continued being treated with medication. During the period August 8 through l0 1 2018, wound "Workhtg Togetlte1·for SAFE.Conmumitie-s-" BARNETT, JULIA 2019-775MD PAGE 2099 Page 15 of27 vac dressing treatments were applied daily. On August 11, 2018, the patient began to complain of pain in the left flank/rib and that it hurt to breath and nurses stated there was barely any discharge from the wound vac. ·on August 12, 2018, his pain was described as 10/10 and his hands were noted as shaking. On August 13, 2018, the patient continued to complain ofleft flank pain and crampi11g, the nurse was unable to touch his left side due to pain, and you ordered a collagen wound dressing. On August 14, 2018, an x-ray was ordered by PA-C Ross. On August 15, 2018, PA-C Ross consulted with you. The notes indicated that the x-ray showed left lower lobe "most likely representing pneumonia" and an order was placed for a CXR, Intravenous (IV) Cefepin1.e/Doxy (antibiotics) and Robaxin (for pain). No abdominal exam was docmnented. On August 16, 2018, you were informed that the patient was asking for pain meds, but 110 order was provided. PA-C Ross ordered nutritional packets at the request of Brent Carney, the nutritionist. During the period August 17 to 21, 2018, the patient's appetite decreased, he had liquid stools, abdominal pain, nausea and vomiting. PA-C Ross notified the nurses on August 20, 2018 to notify the provider if there was sudden abdominal pain, if the patierit stopped producing stools or had nausea and vomiting, though many of these symptoms had already been ongoing. On Tuesday, August 21, 2018, the patient's pain elevated to 12/101 radiating from the center of his chest to his spine, and he had shortness of breath with a tender abdomen and hypoactive bowel sounds, yet there was no practitioner exam. The fiatient was finally sent out to a hospital 011 August 22, 2018, stating he was dehydrated, and was described to be cold and clammy with respirations of30-34. It is clear to me that this patient should have been sent to an outside hospital based on his deteriorating condition that was repeatedly noted by the nurses August 6, 11 and 12, 2018, yet you refosed until August 22, 2018 to make time] y arrangements for outside medical care and treatment to occur. b. I find that you also failed to use sound clinical judgement when, despite concerns from nursing on August 6, 2018, related to changes in the irrigation and appearance of his wound, you maintained this patient in the !PU and refused to send him to an outside hospital. Even during the period August 7 through 22, 2018, You continued to fail to advocate for this patient in the following weeks, despite the patient's deteriorating condition, his contfoued struggles with pain, new pain symptoms, difficulty breathing and sleeping, and shaky hands. You also failed to arrange for timely adequate medical care to be provided outside of MCC. Per a Primary Encounter Repo1t dated August 20, 2018, the patient's medical conditions were Renal Cell Cancer, Malignant Neoplasm Liver, Neoplasm Not Otherwise Specified (NOS), Anemia NEC, Constipation, Edema and Abdominal Pain Generalized. When you finally agreed to send the patient to an outside hospital on August ''Wo,~king Together for SAFE Comm,mities" BARNETT, JULIA 2019-775MD PAGE 2100 Page 16 of27 22, 20 LS, he died August 27, 20 18 due to pancreatitis, sepsis and a perforated duodenum. 4. Patient B .A. (See investigative attachments IO and LI) I find that during the period September 9 tlu·ough September 12, 2018, you failed to exercise sound clinical judgement and to ensure that you or providers whom you clinically supervised were providing timely, adequate medical care, evaluations and assessments when you discharged this patient from the IPU on September I 0, 2018 at 1122 hours, without sufficient monitoring or an examination by yoLU"self or a practitioner. You also failed to exercise sound clinical judgement when you maintained this patient at the [PU, despite his complaints and multiple visits to sick call, clue to a worsening of his condition until 0700 hours on September IL , 201 8. This patient had oral SLU"gery at an outside medical provider on September 6, 20 18. He retrn11ecl to the IPU on September 7, 20 I 9, was sent to the ER clue to complications on September 8, 2018, and returned to the IPU on September 9, 201 8 at 1930 hours. On September 10, 20 18, at I 030 hours, progress notes from lPU wiitten by RN Mary Avera indicated that tlie patient had slight swelling of his right jaw area, with level tlu·ee difficulty eating and drinking. Despite his recent complications and hospitalization, you ordered Clindamycin, Prednisone, Ibuprofen and Senna (a laxative), and discharged the patient from the TPU back to MSU, at 1122 hours, less than twenty-four hours after he arrived, and without a physical evaluation from a practitioner. I find that you failed to adequately co1mnL11ucate significant chan ges in the patient's condition to other c1itical medical providers, speci fically the dentist. While at MSU on September l 0, 20 18 at 20 l 0 hours, the patient went to sick call. Licensed Practical Nurse, Theresa Ledbetter noted tl1at the patient was unable to swallow, and had swelling on the side of his neck, ear and jaw p~, and swelling inside his mouth. You ordered M agic Moutliwash, pain medicine and instructions for him to attend sick call in the morning. At 2320 hours on September 10, 2018, the patient went to sick call again. RN Paul Ma1tin noted that the patient had swelling, was unable to open his mouth over 10 nun, described pain as 10/10 and was unable to eat. You kept the patient at MSU and ordered additional suppo1tive therapy of an ice pack and medication. The patient went to sick call again on September l l, 2018 at 0000 hours with complaints and was told again he would need to go to sick call in the morning. At 0700 hours, the patient returned to sick call and RN Susan Williamson noted swelling on the right side of the patient's face from cheek to eye, breatlung with his mouth open, unable to drink fluids, unable to swallow, and a statement by the patient that it felt like he was drowning. He was bot to the touch and there was swelling in his moutli "Working Together for SAFE Communities"' BARNETT, JULIA 2019-775MD PAGE 2101 Page 17 of27 on the right side, upper and lower jaw and cheek. The swelling appeared to extend back to his epiglottis and he was unable/unwilling to extend his tongue beyoi1d his teeth stating it hurt. Y011 then ordered that he be transfol1'ed to the IPU. The Admission Orders signed by PA-C Robin Smith ordered pain medication, IV antibiotics and a soft diet, and he was placed under the status of Observation. She also ordered blood cultures and requested dental consultation however, there is no evidence that you or any of the providers attempted to contact a dentist to consult on this case. On September 11, 2018 you ordered the discontinuance of prednisone and added an order of Cefepime. During the period 1300 hours to 2300 homs; the patient continued to have issues with pain, swallowing ancl swelling, and his temperature increased to 102.3. On September 12 1 2018 at 0800, RN Avera noted that the patient was having trouble breathing. He was evaluated by PA-C Smith and finally sent to the ER where he was admitted to the Intensive Care Unit at Evergreen Hospital in Kirk.land, WA. He did not return to the MCC IPU until September 16, 2018. It also concerning that during your investigatory interview, you admitted that the patient went to sick call at MSU several times after being discharged from the IPU during the period September 10 through 11, 2018, yet you described his complaints about not being able to swallow as "subjective,» remiss of the fact he had not been evaluated by a practitioner prior to his discharge from the IPU or after. The patient's medical records also show little aii:empt to contact a dental provider and no follow up was noted. He should have been placed under Skilled Care for monitoring when he returned. from the hospital on September 9, 2018. Instead, he was placed under Observation and discharged to MSU, despite retuming froth the hospital due to complications. It is apparent to me that this patient endured unnecessary discomfort and a difficult and lengthy recovery, clue to poor clinical judgement by you and lack of adequate and appropriate practitioner involvement. 5. Pati~nt C.S. (See investigation attachments 18, 19 and 20) a. I find that you failed to exercise sound clinical judgement when you 1Jerformecl bilateral plantar wart excisions 011 the bottom of both feet of this patient on March 30, 2018. Regardless of whether the patient preferred to do both feet at the same time, it was your decision whether or not to perform the procedure, in consideration of the patient's medical conditions of diabetic neuropathy and poorly controlled diabetes. You also foiled to exercise sound clinical judgement when you failed to send this patient to an outside medical provider for further evaluation and assessment orto a Podiatrist until August 23, 2018. Your efforts to treat his condition were not working, and his ability to ambulate independently was deteriorating. "Working Togethel'fOI' SAFE Communities" BARNETT, JULIA 2019-775MD PAGE 2102 Page 18 of27 b. I find that during the period March 30 through August 3, 2018, you failed to provide or ensure that providers whom you supervised were providing timely adequate and standard medical care, evaluations and assessments when this patient received non-standard, bi-·weekly (twice weekly) Cryothe rapy treatments to both feet over au extended period of time. It is Lmderstandable that the words bi-weekly may have been misunderstood to mean twice weekly instead of every other week. However, the n onstandard treatment continued for an unacceptable amount oftime during the period April 25, 2018 through August 3, 2018, until the patient was finally sent to a Podiatrist on August 23, 2018. Additionally, you provided no direct follow up with the patient after performing the surgery March 3 0, 20 18, or adequate oversight during the period above. He continued to have complications, which included the need for special shoes April 25, 2018, a wheelchair June 1, 2018, complaints of leg spasms June 20, 20 18, having to ambulate with a cane, bi-lateral electrical leg pain June 23, 20 18, and joint pain July 9, 20 18. Regardless of continuous complaints of pain and discomfort, this patient was not sent out to see a Podiatrist until August 23, 2018. 6. Patient P.H. (See investigation attachments 20 and 2 1) a. I find that you failed to exerc ise sound clinical judgement and to advocate for this patient to make necessary a rrangement for timely, adequate medical care to be provided outside MCC, wh en the patient was m aintained io the lPU during the period Februa1y 5 through March 17, 2018. The patient was having ongoing and increased complaints of dizziness, headach e, double vision, inability to transfer or change clothes independently, decreased vision in his right eye, and chest pain. I also find that you failed to adequately communicate significant changes in the patient's condition to other c1itical medical providers. You failed to ensure that a consult occur with an Endocrinologist per the prior hospitalist's recommendation . It is of additional concern that you gave multiple reasons during your investigatory interview why a consultation with Endocrinology did not occw-. You said that you were sure it had been ordered but the placeholder wasn't in the chait. You also indicated the hospitalist's test results were questionable, and that you did not agree with them. In regard to failing to approp1iately document, and ensure that providers whom you clinically supervised were appropriately documenting, the patient's medical record when the diagnosis of DI was added to this patient's medical conditions, you admitted that it was not clear who made the diagnosis of DI on or about February I 5, 2018. You recalled having extensive conversations with the PA regarding diagnostic testing, and that when water deprivation studies were performed, the results came back consistent with DI. There was clearly a failme to apprnpriately document and to ensure that providers whom you clinically supervised were appropriately documenting the patient's medical record. "Working Together for SAFE Communities" BARNETT, JULIA 2019-775MD PAGE 2103 Page 19 of27 b. In regard to foiling to provide or ensure that providers whom you clinically supervise were providing timely adequate medical care, evaluations and assessments during the period January 23 through March 17, 2018, you stated that it was not your expectation for PA-Cs to enter Inpatient Encounters in OMNI as it was not part of the medical record. In respo1ise as to why (here were inadequate examinations and assessments recorded in the patient's medical record between the period Febmary 26 to March 17, 2018, you said you did not know why there were no practitioner examinations documented during this period. You could only state that there was a changeover oflPU providers during this time, and you specifically recalled providing both written and verbal instructions regarding documentation requirements. It was your responsibility to ensure that timely adequate medical care, evaluations and assessments occurl'ed, yet the medical records reflect that that did not occur. c. You failed to exercise sound clinical judgement and failed to provide or ensure that others were providing adequate medical care when it was determined to place this patient on DDAVP, which c~n cause Hyponatremia (a condition that occurs when the concentration of sodium, an electrolyte in the blood, is abnonnally low). You said that you and the PA determined that a trial of DOAVP was warranted. You also stated that the patient was being watched carefully. However, the DDAVP treatinent began February 15, 2018, and continued through March 16, 2018, with no documented practitioner examinations after February 26, 2018. The patient was in the IPU and should have been seen frequently, which required if not ovel'sight by you, a personal review of the case. You should have been aware the patient had severely low sodium and that he either should not have not have been getting DDAVP or he should have been sent to the hospital. There are no records that you ever evaluated the patient personally, despite the seriousness of his condition and ongoing complications. d. You failed to exercise sound clinical judgement and failed to advocate for this patient to make necessary arrangements for timely, adequate medical care to be provided outside MCC during the period February 6 through March 17, 2018. You allowed this patient to remain in the MCC IPU, despite his deteriorating condition, until March 17, 2018. At that point, he was unable to eat, drink or take medication, was lethargic, barely arousable, and had a sodium level of 115. He died the same day. The cause of death was Electrolyte Disorder. You stated during the pre-disciplinary meeting that you.felt this patient died of Osmotic Demyelination Syndrome, resulting from an inappropriate increase in his DDAVP, which was ordered without consulting you and administered before you could intervene. You have an obligation to ensure appropriate oversight of the PAs under your supervision .. I find that you failed to provide aclequate ;oversight to the providers you supervised or to provide sufficient direct patient care in order to ensure that "Working Together fot SAFE Commllnities" BARNETT, JULIA 2019-775MD PAGE 2104 Page 20 of27 reconunenclations for strategies and optimal coordination of multidisciplinary health care needs for seriously ill patients was adequate, appropriate and timely. Despite having daily discussions with the providers under your supervision and concerns expressed by others on multiple occasions, you fai led to advocate for these patients and delayed emergency medical care, which was essential to life and caused significant deteriorations in patients' medical conditions. You failed to ensure that specialty medical consults occmred, and fai led to document why the consults were not executed. You also failed to ensure evaluation and assessment medical documentation was adequate and that significant changes in a patients' condition were conummicated to other c ritical medical providers. 1n relation to consults, the DOC H ealth Plan (Attachment B) states that DOC is not obligated to execute recommendations. However, these recommendations are subject to the same criteria as any other DOC provided care and when primary care practitione rs do not execute consultant recommendations, they are expected to explain their reasons to the patient and document the reasons in the health record . 1n the case of patient L.J., you stated you informed the PA of the need to consult with the Pulmonologist many times, but that the Pulmonologist did not retum the call. However, the referral occurred prior to June 8, 2018 and no fo llow up or consultation occurred prior lo the offender being sent to the ER August 25, 2018. In the case of patient P .H ., who was referred to Endocrinology by an outside hospital on or about February 5, 201 8, you recalled that the consult had been ordered but the placeholder wasn't in the chart. You also added that the hospitalist's test results were questionable and you did not agree with lbem. Again, no follow up or documentation was completed to ensure the consult occurred or to docmuent the reason it was not executed during the period February 5, 2018 to March 17, 201 8. Other critical medical documentation was also insufficient as there were often lapses in documentation to support that adequate practitioner m edical care, evaluations and assessments had occurred. When asked about these issues, you often said the patient was being monitored closely, and that you had extensive daily discussions with the PA's about the patient. Th.is is insufficient and does not support the critical decisions made for the patients ultimately under your responsibility. Patients who were seriously ill were oft.en placed w1der Observation or LongTerm Care, which resulted in insufficient monitoring, instead of Skilled care, which would have required that they be seen daily. This left patients under the care and monitoring of nw·ses for long periods with inadequate practitioner involvement. When nurses voiced concerns and requested that patients be sent out to a hospital, their requests were often denied for too long. Thorough evaluations and assessments by practitioners were also non-existent or insufficient as shown by the patients' records. When treating these seriously ill patients, your lack of sound clinical judgement often delayed medical intervention that could and should have been provided to reduce or prevent the significant deterioration of patient symptoms. These delays may have made future care more dangerous, complicated and less likely to succeed. You should have been aware that your behavior was in violation of: "Working Toget/,e,-Jor SAFE Communities" BARNETT, JULIA 2019-775MD PAGE 2105 Page 21 of27 0 • e • • & The Washington DOC Health Jllan (Attachment B); DOC Policy #600.000 Health Service Management (Attachment C); DOC Policy #610.600 Infirmary/Special Needs Unit Care (Attaclm1ent D); The DOC Policy and General lnfo1111ation training you received on March 7, 2017 (Attachment E); Your Performance and Development Plan (PDP) Expectations for Supervisors m1d Managers (PDP) (Attachment F); and Your Position Descdption (PD) (Attachment G). (Your PDP states that your Position Description was reviewed with you.) The DOC Henlth Plan (Attachment B} states in pa1·t: F. Emergency Care Medically necessary emergency assessment, treatment and related services will be available at all times ... An offendet may be transfen·ed to a community clinic or emergency room for care, if the level of service required cannot be adequately provided in the facility's health care unit. If medically necessary; an offender may be transported by anibulance, includtng air anibulance, to expedite transfer to the 111:ost appropriate care setting. IV. Definitions: Medical Necessity [WAC 137-91-010): Medically necessa1y care meets one or more of the following criteria for a given patient at a given time: o e o o IP It is essential to life or preservation of limb Reduces Intractable pain Prevents significant deterioration of AOL's Is ofproven value to significantly reduce the risk of one of the three outcomes ·above Immediate intervention is not medically necessary, but delay of care would make future care more dangerous, complicated, or significantly less likely to succeed XIII. Special Circumstances or Exceptions C. Role of Consultants and their Recommendations During the colu·se of health care, patients are sometimes refe11·ed to consultants including specialists, ER providers and hospital providers. Such referrals often generate recommendations including instructions and orders. DOC is not obligated to execute these recommendations, which are subject to the same criteria as any other DOC provided care. nworki11g Togethel'fo1· SAFE Communities" BARNETT, JULIA 2019-775MD PAGE 2106 Page 22 of27 ... When primaiy care practitioners do not execute consultant recommendations, they are expected to explain their reasons to the patient and document the reasons in the health record. You violated the DOC Health Plan by failing to ensure medically necessary care was being provided consistent with the criteria above to these patients, by you, or the advance care practitioners you supervised. DOC Policy #600.000 Health Service Management (Attachment C) states in part: IL Health Services Employee/Contract Staff Requirements D. Licensed providers wi ll report tluough their chain of command to the Health Authority. The FMD will oversee clinical care in collaboration with the Chief Medical Officer and Clinical Directors. l . All providers who provide clinical care to offenders will participate in formal clinical oversight according to the facility and Health Services clinical overnight structure. F. FMDs will ensure that the clinical care delivered in their facilities is appropriate, and will: l. Have final clinical judgment at the facility level, unless superseded by the Chief Medical Officer. 2. Ensure that clinical care provided by the facility practitioners meets standards established by the Chief Medical Officer and is in accordance with the Offender Health Plan. 3. Collaborate with the Health Authority in administrative functions and operations that support appropriate clinical care. 4. Collaborate with facility clinical discipline leaders to ensure quality and appropriateness of care. You violated Policy 600.000 Health Services Management by fai ling lo provide adequate and appropriate clinical oversight of the advanced care practitioners you supervised. You also failed to ensure the clinical care provided by the advanced care practitioners met standards established by the CMO and in accordance with the Offender Health Plan. DOC Policy #610.600 Infirmary/Special Needs Unit Care (Attachment D) states in part: Directive: l. General Requirements "Working Toget/zerj'or SAFE Communities " BARNETT, JULIA 2019-775MD PAGE 2107 Page 23 of2'7 A. An infirmary is a specific area of a healthcare facility, separate from other housing areas, where offenders are housed and provided health services. 4. Health services provided while in the infirmary will be documented in the inpatient section of the patient's health record. B. A Special Needs Unit is an area of a fa,cility designated to house offenders who require Skilled Nursing Care, Extended/Assisted Living Care, or Sheltered Care, and who meet certain classification requirements. 1. Offenders assigned to the Special Needs Unit are considered outpatients. C. An Extended Observation Unit (EOU) is intended for short stay medical ob~ervation'of up to, but no to exceed, 96 hours. 1. EOU's will be operated per the Extended Observation Unit Protocol and all records associated with a patient's stay will be filed in the inpatient section of the patient's health record. IV. Infirmary Levels of Care A. Levels of cate are applicable to meclica1, dental, and mental health patients and will be dete1111ined by the admitting practitioner at the time of admission to the infirmary. B. The levels of care are defined as follows: 1. The Skilled Care level is for patients who require continuous services (eg., focused nursing/complex wound care, intravenous antibiotic treatment) and may include detoxification services when necessaiy. b. The initial visit by a practitioner will be documented 011 DOC 13-013 lnfinnary/Extended Observation Unit Progress Record and will include diagnosis, history of current problem, physical examination, assessment, and treatment plan. I) All subsequent documentation, dictation, and progress notes will be maintained in the infimrnry section of the patient's health record. c. A practitioner will make and document patient care rounds at least once every business day. "Working Together.fm• SAFE Com,mmities" BARNETT, JULIA 2019-775MD PAGE 2108 Page 24 of27 2. The Infirmary Observation Admission level is for patients who are only in the infirmary for a planned medical trip, 24 hour urine collection, pre-postoperative care including dental procedures, or as determined by the practitioner. 3. The Long-Term Care level is for patients who require assistance with one or 111ore activities of daily living and can no longer be managed in general population or housed in a Special Needs Unit. e. A practitioner will make and document patient care rounds at least monthly. VI. Transfer to Another Health Care Facility A. Patients requiring a higher level of care may be transferred to another Department facility or a community health care facility .... You violated Policy 610.600 Infirmary/Special Needs Unit Care by failing to ensure that patients admitted to the IPU were done so under appropriate admission statuses for thefr conditions or changes to those conditio11s. The DOC Policy and General Information training you received on March 7, 2017, (Attachment E) explains that you are expected to understand and abide by Department Policies and Expectations. Itihrther states that it is your responsibility to review policies on IDOC for the most up to date information throughout your employment. YOtff PDP Expectations for Supervisors and Managers (Attachment F), signed by you on July 11, 2017, states: Key Results Expected 2. Review and decide the care level of practitioner consults in a timely manner 3. Adherence to Off:ender Health Plan, formulary guidelines, DOC protocols and accepted medical evidence in providing and authorizing care 4. Demonstrate clinical skills and judgement suitable fol' supervising other practitioners in a primary care outpatient or infirmary setting 10. Adhere to medical record documentation standards per DOC policy You violated your PDP Expectations by failing to ensure medical care was following the OHP, established pl'otocols and guidelines. FUl'ther, you did not demonstrate appropriate judgement or clinical sk.ilis for those you supervise, and failed in ensuring proper documentation in the patient record so continuity of care could be maintained. AND "Workilig Together/01· SAFE Communities 1' BARNETT, JULIA 2019-775MD PAGE 2109 Page 25 of27 The CORE Competencies for AH Employees as written in yotll" PDP Expectations which states in part: Judgment and Problem Solving: Makes timely decisions based on the best i.nfonn ation at hand. Can describe the factors that were considered in making a decision and their relative .importance. Identifies and considers alternatives before making a decision. Seeks advice from others. Considers the impact of decisions on co-workers, clientele, and other program areas. Solves problems effectively. You violated the CORE Competency for .Judgment and Problem Solving by failing to make timely decisions based on the best information at hand. Had you reviewed the health records of these patients, you would have noticed the absence of appropriate and adequate clinical medical evaluations, assessments and documentation. Your Position Description states: This position analyzes, directs, and coordinates medical care provided to the patients at Monroe Conectional Complex .... The Facility Medical Director has oversight of all medical decisions and care at the facility and can countermand another clinician at the facility level. Primary Responsibilities (Duties aod Tasks): o Provide administrative and clinical direction and oversight to all medical providers at the facility o Review clinical compliance with the Department policies, Health Services Standard OperaLions and Procedure Manual including Health Services Offender Health Plan and DOC-DOH Health Environmental and Safety Standards o Plan the delive1y of hea lth care services at the MCC facilities. Take after hours call as necessary. o Design, approve, and monitor clinical delive1y processes at the facility levels. o Ensure implementation of and adherence to DOC Offender Health Plan, Policies, and Protocols o Provides direct patient care to meet facility requirements; care provided may be consultative in assisting other primary providers or as needed may be direct prima1y care as required to m eet the facility obligations. Accountability "Working Togetlierfor SAFE Communities" BARNETT, JULIA 2019-775MD PAGE 2110 Page26 of27 ~ Has direct responsibility for the quality of medical care and shared responsibility for the .overall quality of clinical services at the facility/facilities directed. Decision Making and Policy Impact o This position is the final authority at the facility level on questions of appropriateness and quality of medical care, including systematic issues of care delivery and medical management of individual cases. Thls position is also responsible for reconunending strategies for optimal coordination of multidisciplhmry health care at the facility level... You failed to meet the expectations in your position description when you failed to provide appropriate or adequate clinical oversight of the advanced care practitioners, ensure care being delivered to patients met DOC standards of care, and to adequately monitor clinical delivery prncesses. Dete1·mination of Sanction In determining the appropriate level of disciplinei I reviewed your previous work history, length of service, training provided, a11d your history of employment withDOC. " You were hired as a Physician 3 with MCC 011 March 6, 2017 and prnmoted to Facility Medical Director on May 1, 2017. o Your training records (Attachment G) reflect that you completed DOC Policy and General Information training. Your actions and inactions have proved you'r inability to perform your duties as a FMD. You had an obligation to ensure appropriate oversight of the PA-Cs under your supervi.sion and I believe that your lack of direct involvement and monitoring violated DOC policies regarding patient care and the health services · that are provided to patients m1der DQC's custody. As the FMD, y011 have the final authority and direct responsibility for the quality of medical care, and appropriateness of medical care, provided to patients. Despite having daily discussions with the providers under your supervision, and hearing concerns expressed by others on multiple occasions, you failed to advocate for these patients and delayed emergency medical care that was essential to life and that which caused significant deteriorations in patients' medical conditions. Your actions and inactions potentially created risk to the patients' health and safety and risk to the Depmtment. I cannot tolerate risk to patient health and safety, or risk to the Depa1tment. I no longer trust your clinical judgement and ability to be responsible for the health and welfare of the patients at MCC. i'Working Together for SAFE Communities" BARNETT, JULIA 2019-775MD PAGE 2111 Page 27 of27 Accordingly, I have determined. that dischai·ge is the appropriate level of discipline. Any lesser sanction would not express the seriousness with which I view your misconduct, deter others, or maintain the mission, integrity and reputation of the agency. Appeal Rights Under the provisions of the Washington Administrative Code (WAC) 35752-010 and 357-52-015, you may appeal this action by filing an appeal to the Washington State Personnel Resources Board (PRB), Appeals Program, 128 10th Avenue SW, Olympia, Washington 98504-0911. Your appeal must be in writing, and received by the PRB within thirty (30) calendar days after the effective elate of the action specified in the first paragraph of this letter. EH:eg Attachments: Julia Barnett's - Pre-Disci,plina1y Response (A) Washington DOC Health Plan (B) DOC Policy 600.000 7 Health Services Management (C) DOC Policy 610.600> Infinnary/Special Needs Unit Care (D) Julia Bamett - Training Transcript (E) Julia Barnett's - Performance and Development Plan Expectations (F) Julia Barnett's - Position Description Fann (G) cc: Personnel File (including pre-clisciplinaty letter and investigation) Payroll File (first paragraph only) "Working Together for SAFE Commtmitie,'f" BARNETT, JULIA 2019-775MD PAGE 2112