Nurse reprimanded, put on probation following teenager’s death at Newport News Behavioral Health Center


NEWPORT NEWS, Va. (WAVY) — A 17-year-old woman died whereas being handled on the Newport Information Behavioral Well being Middle (NNBHC), and a state report concluded the facility failed to provide adequate care for her.

Three years later, a nurse who was disciplined by NNBHC management for her involvement within the teenager’s care is being held accountable by the Virginia Board of Nursing.

Raven Keffer was already sick when she was admitted to the NNBHC on June 22, 2018. She had been out and in of docs’ workplaces and emergency rooms 9 occasions within the 5 months main as much as her dying, together with two days earlier than she was admitted to the NNBHC, based on a lawsuit filed towards the ability by Raven’s sister, Haley Keffer.

Raven had a troubled childhood and commenced abusing medicine and alcohol at a younger age. She was looking for assist for her habit at Phoenix Home in Arlington earlier than she was transferred to the NNBHC. Her social employees didn’t imagine Phoenix Home may look after her medical points, which included an elevated coronary heart charge, issue respiratory, vomiting and dehydration, the lawsuit states.

Social employees believed the NNBHC can be a extra acceptable place for Raven. That facility gives psychological well being and habit remedy for kids and adolescents. The Division of Social Companies informed NNBHC workers about Raven’s medical points earlier than the middle accepted her as a affected person, the lawsuit alleges.

A nurse named Jamie Holmes assessed Raven’s well being on the day she arrived on the NNBHC. Holmes famous Raven’s low blood stress however did not notify her supervisor, a health care provider, or the ability’s nurse practitioner of {the teenager}’s signs. Holmes would later admit that Raven was the primary affected person she’d ever performed an admission evaluation on by herself, based on a VBN report.

Raven’s signs acquired worse over the eight days she was on the NNBHC. Raven informed Holmes she couldn’t maintain meals or liquids down and that she was vomiting bile on June 25, 2018. Though Holmes documented that Raven regarded pale, she once more failed to inform anybody in regards to the teenager’s signs, the VBN report states.

Raven’s well being continued to worsen. The day earlier than she died, she informed Holmes she couldn’t stroll, felt dizzy, and was seeing black spots. Holmes helped Raven to her room and informed her to go to mattress early, however once more did not notify anybody of {the teenager}’s deteriorating situation, based on the VBN report.

Regardless of a number of requests to go to the hospital, nobody within the facility took the initiative to get Raven medical consideration. A former NNBHC staffer, who spoke to 10 On Your Facet investigators below the situation of anonymity, mentioned that nurses instructed workers to disregard Raven’s pleas for assist as a result of they believed she was attempting to get ache remedy.

Raven collapsed and have become unresponsive on June 29, 2018, however NNBHC workers didn’t instantly name 911. A 15-year-old resident made an emergency name and informed the dispatcher she was anxious that heart workers weren’t doing all the pieces medically essential to deal with Raven.

“They’re telling her she’s doing this to herself, and she or he’s faking it,” the resident informed the dispatcher.

Ultimately NNBHC workers did name emergency companies, however by that point Raven was torpid, gasping for air, had dilated pupils, and was pale and chilly to the contact. She went into cardiac arrest on the best way to Mary Immaculate Hospital and died later that night time, the lawsuit states.

The Medical Examiner decided that Raven died of lymphocytic adrenalitis, an auto-immune illness. The lawsuit claims that the ME’s report famous that Raven’s sickness was treatable and that her dying was preventable.

A former NNBHC workers member, who witnessed nurses interacting with Raven, filed a proper criticism towards Holmes with the VBN, the company in control of regulating nurses. 10 On Your Facet tried to acquire remark from Holmes, however didn’t obtain a response from her earlier than publication.

The VBN investigated these claims and located that Holmes was disciplined by the NNBHC for failing to inform her supervisors of Raven’s situation and demonstrating “poor judgement and poor communication abilities.” Holmes informed the VBN that she “did the perfect she may with what she had” referring to Raven’s care.

The VBN additionally discovered different points with Holmes’ work on the NNBHC between February and October 2018. These further points weren’t associated to Raven’s care, however included:

  • The nurse did not doc a discontinued dosage of remedy and inform the pharmacy of a medicine change
  • The nurse made a transcription error that resulted in a resident being under-medicated for 4 days
  • The nurse did not transcribe a resident’s immunization orders into their information
  • The nurse made one other transcription error
  • The nurse was formally disciplined for failing to acquire an order and move down related medical info
  • The nurse did not administer psychiatric remedy, leading to a resident lacking a dose of it
  • The nurse was formally disciplined for failing to recheck and doc very important indicators on the route of a resident’s physician
  • The nurse was formally disciplined for failing to have a resident’s situation evaluated in a well timed method after receiving irregular lab outcomes
  • The nurse did not discontinue a medicine as ordered, inflicting the resident to obtain eight additional doses

The VBN formally reprimanded Holmes and put her on a year-long probation. For the primary six months of the probation, Holmes can solely observe nursing in a VBN-approved setting below an on-site nurse with an unrestricted license. Holmes should additionally submit quarterly stories together with her present handle, contact info, and employment standing. Her supervisor should additionally present stories to the VBN about her efficiency, documentation conserving and scientific judgement.


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