,

...

--.

C~'bCG

.','

•

~ ~pitol

""-

~

VOl·

Blvd.

PO Boll 40911 '

O·ympUi. WA 98504-0911

STATE OF WASHINGTON

PERSONNEL APPEALS BOARD
HOME PAGE www.wa..gov/pab

RECEIVED

DEC 201999
Oep~entofCorrections

OAS Human Resources

December 17, 1999

Mark Anderson
Teamsters Local 313
In House Counsel
220 S. 2""" Street
Tacoma, WA 98402-2701

RE:

Gloria Wagner v. Deparnnent of Corrections. Reduction in Salary Appeal,
Case No. RED-99-0057

Dear Mr. Anderson:
Enclosed is a copy of me order of the Personnel Appeals Board in the above-referenced matter.
The order was entered by the Board on December 17, 1999.
Sincerely,

Don Bennett
Executive Secretary
DB:kw
Enclosure
cc:

1 1

fAX (360) 75
9
E-MAIL inf.o.pabepab.state.wa.us

Gloria Wagner, Appellant
Elizabeth Delay Bro~ AAG
Jennie Adkins. DOC

.
\

'

1

RECt:j~L:D
D~':'''.. : ! 1999

2

4

3

...

p•....

BEFORE THE PERSONNEL APPEALS BoAItfik JotRr:.
STATE OF WASHINGTON

4
5

6

GLORIA WAGNER.

)

7

8

Appellant,

. v.

CASE NO. RED 99-0057

)
)

DEPARDlENr OF CORRECllONS.
10

12

)
)

9

11

)

)

MOTION AND ORDER
OF DISMISSAL

)

Respondent.

)
)

----------------)

13

The appellant hereby notifies the Personnel Appeals Board that Respondent. the
14

IS

16
17
18

Depanment of Corrections. has rescinded the disciplinary action previously imposed.
converting the reduction in pay to a letter of reprimand.
Because the Personnel Appeals Board has no jurisdiction over corrective actions.
appellant now brings this motion to withdraw the above~ntitled appeal.

19

20

I

Signed at Tacoma. Washington. this ~ day of /kcanktr 1999.

21

~t!/~~~

22

Mark A. Anderson. WSBA =# 26352
Attorney for Appellant

23
24

2S

26

MOTION .-\.'ID ORDER OF OlSL\oIISSAL

Teamsters Local No. 313
220 South 27th Street
Tacoma. WA 98402-2701
(253) 627-0103

•
1
2

3

This matter came on regularly before the Personnel Appeals Board on the
consideration of the request of the Appellant to withdraw hislher appeal. The Board
having reviewed the files and records herein. being fully advised in the premises, and it

4

s

appearing to the Board that the Appellant bas requested to withdraw bisJber appeal, now
enters the following:

6

7

ORDER

8
9

10

NOW. THEREFORE. IT IS HEREBY ORDERED that the Appellant's request to
withdraw hislher appeal is granted and the appeal is dismissed.

11

12
13

DATED this

l~ day OiC:de .bs& 1999.
cM6

wASHINGTON STATE PERSONNEL APPEi·\LS BOARD

14

IS
16
17

18
19
20
21

22
23
24

2S

26

MonON AL'iD ORDER OF DISl'-OSSAL

Teamstel'3 Local No. 313
220 South 27th Street
Tacoma, WA 98402-2701
(253) 627-0103

, 11'9

~e:CEIVED

AUG 2
BEFORE THE PERSONNEL APPEALS BOARD D~a"mant

iJt

1999
':'0'0

'':'ons

AS Human Aesuu,c.:t:ls

STATE OF WASHINGTON

2
3
4

Appellant,

S
6

) Case No. RED-99-Q057

GLORIA WAGNER

vs.
DEPARTMENT OF CORRECTIONS,

7

8

)
)
)
)
)
)
)
)

NOTICE OF RESCHEDULING
APPE~ANT'S MOTION FOR SUM1v1AR.Y
JUDGMENT
(ORAL ARGUMENT REQUESTED)

Respondent.
II---...,-...,.....-:-~-:-....-o:'----::~~-:-~--=--)
Notice is hereby given of rescheduling the hearing on Appellant's Motion for Summary

9

Judgment. The hearing will be held in the Personnel Appeals Board Hearing Room., 2828 Capitol
10

Boulevard., Olympia. Washington. Monday, October 18, 1999, beginning at 1:30 p.m.
'"

11

Pursuant to WAC 358-30-060(4) any affidavits to be filed in support of a motion shall be

12

served with the motion at least twenty-one days prior to the date scheduled for consideration of the

13

motion. Responses to the motion and any opposing affidavits shall be filed and served at least ten

14

days prior to the date scheduled. Any reply and any counter affidavits by the moving party shall be

IS

filed and served at least three days prior to the date scheduled.
If the services of an interpreter are needed., notify Personnel Appeals Board staff. The

16

hearing site is barrier free and accessible to the disabled.
17

18

DATED this 28d1 day of July, 1999.

19

WASHINGTON STATE PERSONNEL APPEALS BOARD

20
21

Teresa Parsons. Hearings Coordinator
(360) 664-0479
23

cc:
24

2S
26

Gloria Wagner, Appellant
Mark Anderson, Attorney
Rob Kosin, AAG
Elizabeth Delay Brown. AAG
Jennie Adkins, DOC

112

Personnel AppC:l1s Board
2828 C;1pitol Boulevard
Olympia. W3$hingron 98S~

RECE. ,/ED

JUL 16 1999

O~~~~:;'~f~(i: THE PERSONNEL APPEALS BOARD

2

STATEOFWASHINGTON .

3
4

s

)
) NOTICE OF SCHEDULING

Appellant,

6
7

) Case No. RED-99-00S7

GLORIA WAGNER,

vs.
DEPARTMENT OF CORRECTIONS,

8

Respendent.

)
) APPELLAi"lTS MOTION FOR
) CONSOLIDATION (FOR PURPOSE· OF
) S~lARY JUDGEMENT ONL Y)
) (ORAL ARGUMENT REQUESTED)
)

9 11----------------),
10

11

Notice is hereby given of setting Appellant's ~otion for Consolidation (For Purpose Of
Summary Judgement Only). The Board will hear oral argument on Monday, August 16, 1999,

12

beginning at 1:30 p.m~ in the Personnel Appeals Board Hearing Room, 2828 Capitol

13

Boulevard, Olympia, Washington.

14

Pursuant to WAC 358-30-042(1) ... written motions and any supporting affidavits shall be

IS
16

filed and served not less than five

day~

before the date on which the motion has been noted for

consideration by the board ...; responses to the motion and any opposing affidavits shall be filed
17

and served not less than one day before the date on which the motion has been noted ...

18
19

DATED this 15!l1 day of July, 1999.
WASHINGTON STATE PERSONNEL APPEALS BOARD

20
21
22

23

cc:
24

Gloria Wagner, Appellant
Mark Anderson. Attorney
Elizabeth Delay Brown, AAG
Jennie Adkins. DOC

26
Personnel Appe:l1s Board
2S2S Capitol Boulevard..
Olympia, W3Shington 98504 .

1121·

c~~

~

2828 ypilol Blvd.

VOICE (360)

PO 80. 40911
Ol,mpia. WA 98So-a-G911

FAX (360) 753-0139 .

E-MAIL info-pahGpab.saale.wa.us

STATE OF WASHI~GTON

RECEIVEO

PERSONNEL APPEALS BOARD
HOME PAGE

RE:

JUN -11999

www.wa.gov/pab
.

May 27, 1999

;

S~ l

D~s~ent 01 Corrections
uman Resources

1 . til .

Gloria Wagner v. Department ofCo~tions, Reduction in Salary Appeal,
Case No. RED-99·00S7

Dear Ms. Wagner:
This letter is to acknowledge receipt of your appeal by the Personnel Appeals Board on May 12, 1999.
The Board will conduct a hearing of your appeal on a date to be detennined. The time it takes to
schedule a hearing date is affected by the availability of the parties and the number of appeals pending
before the Board.

of

You may attempt to resolve this appeal with the assistance of one the Board's contracted mediators. If
mediation is jointly requested by the parties before June 28, 1999, a mediator will be assigned to meet
with the parties in a good faith effort to negotiate a resolution of the appeal.
[fyou are represented by a union representative or an attorney, please encourage him or her to coordinate
a request for mediation with the appointing authority of the employing agency, or the assistant attorney
general who represents the agency. You may initiate this contact directly if you are not represented.
Appeals assigned to mediators will be returned after sixty (60) days if the parties are unable to agree
upon a date for mediation, and then scheduled for he:uing on the Personnel Appeals Board calendar.
Please note that pursuant to WAC 358~30-190. all future correspondence or filings to the Personnel
Appeals Board need to also be served on the opposing side.
Sincerely,

Don Bennett
Executive Secretary
DB:kw
cc:
Mark Anderson, Local 3 13
Linda Dalton, SAAG
Jennie Adkins, DOC

z:k'\v\ncw:lppl\wagncr.doc

1122 .

APPEAL FORM
WASHINGTON STATE PERSONNEL APPEALS BOARD
2828 Capitol Blvd.
P.O. Box 40911
Olympia, WA 98S04-{)9 I I

PH:

SCAN 321-1481
(360) 586-1481

FAX:

RECerv:.: :',~
- ...

(360) 153.013g\fAY

12 I£S9

AP~E.qSONi'fS.

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t~ a 9 ne r,

NAME:

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PRINT OR TYPE - SIGN ON PAGE 2
APPELLANT IDENTlFICATlON

PART I.

"

Glor i a

(Last name,

n"t nllD111. middle: iniJlal)

HOME ADDRESS:
eN.

PHONE NUMBERS:

WORK:

{3 6 O} 794. - 220,0

(lnclude area cadll)

HOME:

EMPLOYING AGENCY OR

INSTITUTION:_---lO::..:e"-'!J"-a:::..:..r..:::.t~m~e~n~t:.......:o~f_.:=.C.l:!o..:.r..:.r..::e:..::c:.,;t::...

AGENCY OR INSTITUTION THAT TOOK ACTION YOU ARE APPEALING:

l.!.."~;.(.,.,J,:.:.n""'-5

_

So e cia 1 0 f fen d e r 5 IJ nit

REPRESENTATIVE'S NAME, ADDRESS AND TELEPHONE NUMBER:

PART II.

Mark A. Anderson

220 South 27th Street

In-House Counsel

Tacoma, WA 984QZ
L2531. 627-0.1Q3

111

::;:(;::

~"t1'·l~l.I,J1':.li.\l" ~'-"'>~ i.lIlliJ,J;~:_I;\It:1~lililil~HL'?'_t!J$'i~ml:T ~ . "~ ,,' "rt,,?";1:J-l~\!~H1:t\i1 ,;.1,~. '" ~ ~?J,.~ ~'If\,~
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"·l~.·)-.l·),\l.\;l·l,!

TYPE OF APPEAL

PART III.

I

CHECK ONE OF THE FOLLOWING TO IN DICATE THE TYPE OF APPEAL YOU ARE FILING:

XXX a.

Disciplinary: (check applicable action(s).
_ _ Dismissal,
Suspension,

_ _Demotion,

xXXReduction in Salarv'.'
--

b. Disability Separation;
c.

Rule or Law Violation (complete Part IV. oftbis form);

d.

Reduction in Force/Layoff (complete Part IV. oflhis form);

e.

Allocation (position classification) (complete Part V. of this fonn)~

f.

Declaratory Ruling (see WAC 358-20-050);

_ _ g.

t

(CiiiW, " .. :;i ...).@iiiii

1123

Exemption of Position.

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RULE: VIOLATION OR REDUCfION-IN-FORCE APPEALS ONLY

PART IV.

What Rule(s) or law(s) do you believe were violated?

Explain the particular cm:umstances of the alleged violation:

How were you adversely affected by the alleged violation?

What remedy are you requesting in this c3Se1

ALLOCATION APPEALS ONLY

PARTV.

t

Ycs_ _

Has there been a review of your a1location7

I

No_ _

lfso, by whom7

_

What is your present classification7

_

To which class do you think your position should be allocated7

_

May 10, 1999
DATE SIGNED

1124
. .... x

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;

".'i.,h.Q.Q.

.WPS&Z.. . .Gh ...

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-

lffi ~ rc ~ no/J ~ [

CONFIDENTIAL -

APR 2 11999

DEPARTMENT OF CORRECTIONS

DISCIPLINARY ACTION AUTHORIZATION OFFICE OF THE ATTORNEY GENEF
LABOR &PERSONNa OM51m
Glaria

Wagner

~oyee's Name

!

I

RECOMMENCED ACTION:

214199
Date Received at Headquarters

I
I

RIP 5% x 6 months I S

RedtJdion in Pay:

(Percemagellengtl'l)

_

(Taral $ Amount)

RN2
Demotion 10:

Employee's Job Classlflcallon

·1

-------:-:-:-:=:---::---:--:---(Joe Classdication)

i

1.
,

soc

Suspen~jon: _ _---::"_:::-:(Length)

Employee' 5 JOD l.l2C:1t1on

Dismissal:

Chris Gr.!nam
Assigned Personnel OffiC2l'tPhone #

/::S---:'-=-:-~(Total S Lass)

----=---,--------

Date completed (onn faxed to PO

The attad1ed disciplinary action has been reviewed as noted below. "This information is provided underthe
attorney/cient relationsnip and invokes that j)nvllege. It should be considered CONFiDENTIAL in nature:

Initia'sfTitie

HR Administrator

Date

Approve

¥~~===~
Appropriate Deputy
Secretary

Comments

V

L..{-20

:----W~
AAG

Disapprove

J./ J"2) ~c. \ /
}'J_ _
V

_

V

<f(1/1{f7 .

Please hand deliver 10 all reviewers and return to Leslie Carrigg, HR • 8th Accr. upon completion.

J

11-25

•

DRAFT
PERSONAL AND CONJ'IDBHTIAL DELIVERY

,
Ms. Wagner:

This is official notification that you wUl be reduced in salary wi thin your
present classification as a Registered Nurse 2 with the Department of
Corrections at the Special Offender Unit of Monroe Correctional Complex,
Range 45N, Step P, $3801 per month, to Step N. $3617 per month. effective
_ _ to _
inclusive. (NOTE: 5% FOR SIX MONTHS)
This disciplinary action is takC:l pursua..~t to the Civil Service Law of
Washington State, Chapter 41.06 Revised Code of Washington, and the Merit
System Rules, Tide 356 Washington Administrative Code (WAC) Section 35634-010 (1) (a) Neglect at' duty, (hI Gros:! misconduct, (i) Willful violation of the
publl~ed employing agency or departnlent of personnel rules or regulations
and 356-34-020, Reduc=tioa 1D Salary - Demotion· Proced.ure••

Specifically, you neglected your duty, committed an act of gross misconduct
and will!ully violated published agency rules, when, an 7/2'2/98, you failed
to provide a physical a:5sessment of Inmate
and you also failed
to document his medical complaint in the infumary log, as well as, Inmate
IImedical file.
.
The evidence indicates that you received a call in the infirmary at
approximat':!l6: 10 PM on 7/22/98 from Karen McLellan, Correctional
Officer 2 on.unit. that Inmate.was complaining that he was having
trouble gettini air. You in turn asked C/O McLeUan if Inmate.was having
a problem speaking, to which C/O McLellan responded, "no". You then
stated to C/O McLellan that you were starting medication lines, that this
was a usual complaint from Inmatelll that his cell was probably hat and

ze-d

Wagner· Page 2
stuffy, and told C/O McLellan to have Inmateltake a cool shower to help
him feel better. You also told C/O McLellan. if he continues to complain,
call me back. 1t You continued with medication lines and heard no more from
the unit. As you finished medication lines, you inIonned RN 2 Mike Kalina
of C/O McLellan', call regarding Inmate" Without physically assessing
Inmatell complaint and as you had heard. nothing more from the unit staff
regarding Inmatellcomplaint, you and RN 2 Kalina· decided it was not an
emergent situation and RN 2 Kali.'1a agreed to check on Inmate.at
lockd.own medication line. which was at approximately 8:30 PM. When RN2
Kalina checked on Inmate. he was observed to be asleep and snoring.
There was no indication that RN2 Kalina communicated with Inmate~
check his p~9ical status or with. unit staff' regarding any further complain ts
that InIIlS:te.may have made.
.

At approximately 10:34 PM on 1/22/98, which was after your shift and you
were no longer in t.'1e institution, C/O 2 James Smith contacted the
infirmary and asked R.l\f 2 ~ann Cave to check on Inmate. C/O Smith
further reported to &~ 2 Cave that Inmateaad not changed positions in
approximately ninety minutes and that his feet appeared pale. R..~ 2 Cavl:
indicated that she was unaware oi any complaint from Inmate.as there
had been no documentation of any complaint from him in the infIrmary log
nor in Inmatellmedical record. rt should be noted that Inmate_died in
his cell that evening.
During the Admir.istrative Comments investigation of this incident, you
indicated to Ella Ray Sigmund. CMHPM and Acting Associate
Superintendent. that Inmatel had made similar complaints in the past and
that they were not always documented.
An Employee Conduct Report initiated on 8/3/98 describing this incident in
greater detail is attached (Attachment It 1) hereto and incorporated herein.
Inmate" complaint of having difficulty getting air was significant to his
documented physical problem of which all medical staff, including yourself.
were aware. The knowledge of this medical significance is information you
should have responded to.
The Department of Corrections Employee Handbook states, in part. under
J)epartment Objective., on pages 1 and 2:
The dc?artment's main objectives are to:

• ElUur••• tety tor... oa'eDdera, (emphasis added)

1127 .
2S"d

•
Wagner .. Page 3

• Treat all ofl'eDclen••• faid, ael equitably; (emphasis added)

·Ih.t the aatloa.alstudarda appropriate to the State af
WubiDstoll (emphasis added)
and also states, in part, under Code 01 Ethics on page 2:

-

B1p lIlonLl and ethical.taDdarda amonl correctioDal
employ••• an euential tor the 11lCceaa of the department'.
programa. The Department of C4rreetiou .ubscribe. to a
code ot uDfaiJJ"1 hollelty, respect tor dlpity anel
blcll?!duaUty ot humaD belDp. mel a colDmitment to
: profe!!iop,al gel comp.uianato ••rrice. (emphasis added) .
and further states. in part, unde!' Department ExpectatioDa, on page 2:
A5 a representative of the OC;lartment of Corrections, you will be
expected to:
•

Serve each offendar with appropriate COD.cem tor their

w.1tant•.• (emphasi~ added)
On 11/24/93, you acknowledged receipt of the June 1993 Employee
Handbook. further agreeing to become familiar with and have a thorough
knowledge and understanding of its contents. Copies of pages 1 and 2 of the
1993 Employee Handbook (Attachment ~2), and your acknowledgment of its
receipt (Attachment ~3) are attached he:eto and incorporated herein.
The classification questionnaire (CQ) for your RN 2 position, HE36. which
outlines its duties states. in part, under -Employee's Statement of Dutiesn :

Provide anloml nuninl treatment anel em.fleacy
treatment u llee~l.ary. (emphasis added)
Maintain. profe••tow nurslc& care .1nte&rity aa it appUes
to••• delivery of leme•• (emphasis added)
A copy of the CQ for your position, HB36, is attached (Attachment '4) hereto
and incorporated herein.
As an employee and Registered Nurse 2 with the Department of Corrections
at the Special Offender Unit of Monroe Correctional Complex, you have a

1128

•

Wagner - Page 4
duty and obligation to:
1. Adhere to its policies and procedures, which are designed to
ensure the efficient and effective management oC the Department's
progI'aII1!Ii

2. Ensure the safety for offenders; to treat all offenders fairly and
equitably; and to meet the national standards appropriate to the
State of Washington;
3. Ensure the high moral and ethical standards the department
expects oC lts employees to ensure the success of its programs;
4. Perform your duties in a professional, competent and
compassionate manner;
5. Meet the e..'"Cpectations of the agency as a whole; and
6. Serve each offender with appropriate concern for their welfare.
Inmate. complaint oi havi.~g dii'ficulty getting air i3 significant to his
documented overall medical condition, which all medical staff, including
yourself, were aware or should have been aware. Given his overall medical
condition, there was, according to Dr. Jonas, WSRU Contract Physician, who
I had review this incident, medical signiticanc: to his complaint, which you·
$hould have responded to. Even though you indicated during the course of
the investigation of this incide::t that Inmate.d made numerous medical
complai.~ts of a similar nature, it was noted in a review of his medical chart
that those "similar'" complaint~ had not been charted.

Additionally. while you retied on the observation of a correctional office:- that
he was able to speak, it should be noted that correctional officen are not
medical staff and are not qualified nor are they expected to conduct medical
assessments oC inmates. Also, while you did not hear back from unit
correctional staIf of any furthe:- complaints from Inmate.you took no
affirmative action after completing medication lines to ascertain his physical
status in person or by calling ur.it staff to check on him. Instead, you waited
until approximately 8:30 PM to have Inmat~checked on by RN2 Kalina.
Finally, even though you had rec:ived an indication from correctional staff of
Inmate.physical complaint. you failed to appropriately document that
complaint in either the infumatj" log or his medical chart.

11~
soe'd

Wqner· Page 5
By your behavior in this incident, you have clearly demonstrated:

1. A neglect o{your duty and obligation to meet the reasonable
the Department that you would adhere to its
OliciesJmd procedures; that you would ensure (or the safety of its
inmates and treat all offenders fairly and equitably; to meet the
national standards appropriate to the State of Washington; and
that you would perform your duties in a profcs~ional, competent
and compassionate manner, serving each offender with appropriate
concern for theu- welfare. These charges are based on your
behavior of failing to appropriately provide a physical assessment of
Inmate~r receiving a call at 6:10 PM on 7/22/98 from a .
~rrectional officer who said Inmate.was complaining that he was
having trouble getting air; your failure to take anyaffir:native
action, after completing medication lines, to ascertain his physical
status or calling unit st.afT to check on him until approximately 8:30
PM; and your failure to doc.mlent his medical complaint in the
infmnaI'Y log and Inmate_ medical file. This lack of
documentation failed to provide the next shUt nurse with necessary
information ne~ded to prope:-!y assess Inma:iclllater that evening.
During the Administrative Comments meeting with Ms. Sigmund,
you also indicated that you did not document in his medical me
any oC the nurn.erOU8 similar c:Jmplaints that he had made about
his difficulty getting air a."'ld that his complaints were many and
delusional in nature and t.'lac you did not document them as well.

~ectations of

2. A neglect of your duty to mc:e~ the reasonable expectations outlined
in your Registered Nurse 2 position's Classification Questionnaire,
H836, to provide ongoing nursing treatment and emergency
treatment as nec=:ssary; and to maintain professional nursing care
integrity as it applies to delivery of service. These charges are
based on your behaviors of faili'nto appropriately prOVide a
°tef receiving a caJl at 6: 10 PM on
physical assessment of Inmate
7/22/98 from a correctional 0 lcer who said [nmatellwas
complaining mat he was having trouble getting air; and your failure
to take any aifirmative action, after completing medication lines, to
ascertain his physical status or calling unit staff to check on him
until approximately 8:30 PMj and your failure to document his
medical complaint in me infirmary log and Inmate. medical me.
This lack of documentation failed to prOVide the next shift nurse
with necessary information r.eeded to properly assess Inmate.
later that evening.

1130
geod

Wqner· Page 6
3. A willful violation of the Department of Corrections Employee
Handbook by your failure to: assist the department in meeting its
objective of ensuring the efficient and effective management of its
programsi to ensure the safety of its offenders and to treat all
offenders fairly and equitably; meet the national standards
appropriate to the State of Washington; meet the moral and ethical
standards of the department that you would perform your
Registered Nurse 2 duties in a professional and competent manner;
and to serve each offendcr with appropriate concern for their
welfare. These charges are based on your behaviors of failing to
appropriately provide a physical assessment of Inmate lafter
receiving a call at 6:10 PM on 1/22/98 from a correctional officer
who said Inmate.was complaining that he was having trouble
getting air; your failure to take any afflrnlative action l after
completing medication lines, to ascertain his physical status or
calling unit staff to c:.."leck on him until approximately 8:30 PM; and
your failure to document his medical complaint in the infirmary log
and Inmatcllmedical chart. This lack oi documentation failed to
provide the next shift nune wit.;' necessary information needed to
properly assess rnmate.later that evening.
4. Gross misconduct by yOUI' blatant and" flagrant disregard for the
stated objectives and ethics of the Department of Correction~ to
ensurc the safety of offenders; to treat all offenders fairly and
equitably; to meet the national standards appropriate to the State
of Washington; and to subscribe to a code of unfailing honesty,
rescect for dignity and individuality of human beings, and a
co~itlnent to professional and compassionate se~icel all of which
adversely impacts the Depw.ment's abilitY to carry out its mission
and functions. These charges are based on your behaviors of
failing to appropriately provide a physical assessmen t of Inmate.
after receiving a call at 6: 10 PM on 7/22/98 from a correctional
officer who said Inmate_was complaining that he was having
trouble getting air; your failure to take any afflI'mative action, after
completing medication lir.e3 1 to ascertain his physical status or
calling unit staff to check on him until approximately 8:30 PM; and
your failure to document his medical complaint in the infirmary log
and Inmatell medical chart. This lack of documentation railed to
provide the next· shift nune with necessary information needed to
property assess Inmate.later that evening.

1131
Le"d

•

Wagner - Page 7
In reviewing your personnel file I find:

1. A Memo of Counseling dated 9/24/98, from your supervisor, RN 3
Bollinger. which addre~ha.viorof 8/31/98, dispensing
medication to I n m a t e _ and failing to immediately chart that
information, as required by law and as further directed by Ella Ray
Sigmund, CMHPM in a memo to RN's dated 8/13/98. By your failure to
do so, you were directly responsible Cor an overdose of medication
received by Inmate"
A copy o( the foregoing document from your personnel
(Attachm~nt IS) hereto and incorporated herein.

me is attached

In conclusion and full consideration of the foregoing, I have determined to
reduce your salary as a Registered Nurse 2 as indicated in paragraph one of
this letter.
Under the provisions of Washington Codes 358-20-010 and 040, you have
the right to appeal this action to the Personnel Appeals Board, 2828 Capitol
Boulevard, Olympia, WashingtOn, 98504, within thirty (30) days from the
effective date stated in paragraph one of this let~er.
The Merit Syste:n rules (WACS), Departlnent of Corrections' policies, Monroe
Concctional Complex-Special Offende:" Center Field lnstructions and the
Collective Bargaining Agreement are available for your review upon request.

Kenneth DuCharme
Superintendent
KD:cg

Attachments
CC:

Dave Savage, Deputy Sec:etaIy, OCO
Eldon Vail, Assistant Deputy Secretary, OCO
Phil Stanley, NW Regional Administrator
Jennie Adkins. Human Resources Administrator. OAS
Linda Dalton, Senior Assistant Attorney General
Cheryl Landen, NW Region Human Resource Manager
Bob Riordan. MCC Human Resource Manager
Personnel File

1132
ee-d

EMPLOYEE PROFILE

DEPARTMENT OF CORRECT10NS

PIIQe One at Twa

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Above sadion continued on Page Two

B. EMPLOYEE PERFORMANCE EVAlUAllONS

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DATES (MoIYr)
From
To

9/.}J/~ i

Ratings •

Far Exceeds

Ratlngs •
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II
11
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• Indlcars 1)tIM of E.,.lUstlon:

A • Accomplishment of Job Requirements
B • Job Knowledge and Competence
C • Job Reliability
o • Personal Relations
E • Communications Skills
F - Porformance as Supervisor

P • Prabationart
A • Annual
T • Trial
S • Special

1133

DePARTMENT OF CORREcnONS

EMP~JYEE

CONDUCT REPORT

THIS FORM TO BE USED IN COMPLIANCE WITH POLICY DIRECTIVE NO. 857.005
INSTRUCTIONS AND TIME LIMITS:
1. The person making the report shall provide a clear description of the incident under "Description of Incident"
and, with any witness(es) or person(s) having knowledge, shall sign in the space provided and submit to the
supervisor of the involved employee within fourteen (14) calendar days after the date of discovery of an
. employee's alleged misconduct.
2. The form shall be submitted to the employee involved who shall complete the "Employee's Statement" and
return the report to his/her supervisor within seven (7) calendar days following the date of receipt.
3. The appropriate supervisor shall review the facts of the incident. complete the "Supervisor's Report" and
submit the report to the Office Head within seven (7) calendar days following the date of receipt.
4. The Office Head or designated representative shall review and within thirty (30) calendar days following the
date of receipt determine whether misconduct has occurred. This shall be reported under "Administrative
Comments" and shared with the employee. When the supervisor and Office Head are the same person, the
supervisor's supervisor shall complete the Administrative Comments.
.
•

Gloria Wagner

O~G.>"'ZA TlCHAl.

;JNlT

,MCC - Special Offender Center
mole OF IHCOENT

RN2

7/22/98

6:10 PM

DAM OPM

DESCRIPTION OF INCIDENT:

ON 7/22/98 AT APPROXIMATELY 6:10 PM, YOU WERE NOTIFIED BY CO

~~~~~r:~~~~i ~~~""'.~"'AS""'Y""O-U-------INSTRUcrED CO MCLELLAN TO HAVE INMATE_TAKE A COLD
SHOWER

IN A MEMO YOU PREPARED 'fO Rri3 TERESA EOLL~I<fGER, YOU fNDICXl'ED
THAT "INMATE _
HAD COMPLAINED SEVERAL TIMES IN THE PAST
ABOUT HOw HE COULDN'T BREATHE IN HIS CELL" AND THAT AS YOU
"ASSUMED IT WAS THE HEAT Al\fD STUFFINESS IN HIS CELL" YOU TOLD CO
MCLELLAN"A COOL SHOWER MIGHT BE HELPFUL." AS YOU WERE DOING

INFORMING RN2 MIKE KALINA OF INMATE

COMPLAINT AND FOR

filM TO CHECK ON HIM WHEN HE OlD UflflT LOCKDOWi<l' MEDS.
ON ;,/18/19/20 1998, YOU WERE PRESENT WHEN RN3 BOLLINGER GAVE A
VERBAL DIREcrIVE TO ALL RN2'S PRESENT THAI THEY WERE TO
PHYSICALLY ASSESS Al'fY IN1-IATE WHO COMPLAINED OF Al'fY PHYSICAL
Aa~rORMi\LITY.

I

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·29.·

posmON nT\.e

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I· 1134

' SIGNA flJIlE

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POsmCN nT\.E

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SIGHAr1J~E

I

I
~ttachment

/

DATE

'.

August 10, 1998
On 7/22198 at
6: 10 PM, C/O Karen McLellen called the infirmary
and informed me IIM
was complaining that he was "having trouble
getting~. I asked "Is he having problems-speaking?" she said "No". I told her I was
just starting med lines, that this was a usual complaint from him, that his cell was
probably hot and stuffy. I told C/O McKeUen that a cool shower would probably help
him feel better. I also said "If he continues to complain call me back". I then did med
lines and heard no more from the unit.
As soon as we finished med-lines. I informed Mike Kalina. RN II of C/O
McKellan's call. We decided it was not emergent and M. Kalina. RN II agreed to check
on him at lockdown med-line since he was doing that side anyway. At 8pm as we were
eavin to do jockdown medications. I reminded M. Kalina. R..'l II to check on IIM
.

il

. He said he would. After checking with staff on the unit and listening to IIM
usual snoring, he noticed nothing amiss and returned to the infirmary_

IIM~d no history of respiratory or ca:diac problems. He was very
somatic and often times delusional. He would frequently say, '1 can't breathe in this cell,
could you talk to someone and see if! can go outside and get some fresh air." He was
never in any acute respiratory distress, his speech nonna! and clear, so [ would give him
reassurance and apologize for having no control over his lock down status.

The incident was not ignored. Because ofms history of many somatic
complaints, we did not feel it was emergent and since we received no call back from the
unit, we thought that the situation had resolved. It is common practice to assess Iflvl's,
especially those on lockdown status on the unit at lockdown med lines.

\

q)t1tL1-

v\ lJCL<J\I"t.." £U

Gloria M. Wagner, Rl'l II
cc: rvfike Wilson
Teamster Business Associate
Local3l3

Employee Conduct Report: Gloria Wagner, RN 2
September 21, 1998
Administrative Comments:
On August 3, 1998, you were issued an Employee Conduct Report (ECR) by Teresa
Bollinger, RN 3. It is alleged misconduct occurred by you on the evening of ~ul~
~ailedto respond to provide a physical assessment on offen~
~ after receiving a call in the infirmary at 6: to PM from Karen Mclellan:
Correctional Officer on 8Unit. It was later that same evening_died in his cell
ani-Unit.

Fmdings of this Review:
According to RN 3 Teresa Bollinger. on the dates of May 18, 19, and 20, 1998, you ~re
present when she gave a directive to all ~"'f 2's that they were to physically assess any
inmate who complained of any physical abnormality. This directive was based on a
memo directive this writer sent to Mrs. Bollinger. Y011 report not being aware of this
directive on July 22. 1998.

_take

You assumed_was complaining about his difficulty getting air beaw.se it was
a hot night and instructed CO Mclellan to have
a cold shower and to call
back if his problems persisted Although by your own report and the report of others this
was a common complaint o f _ CO Mclellan di'd not call back.
You were in the middle of doing med lines when you received the call from CO
Mclellan.
You did not document this call in the infirmary log or_medical file. Nor had
you documented in his medical file any of the numer~omplaints that he had
about his difficulty getting air. You state_complaints were many and often
delusional in nature and that you do not document them always. You acknowledge
bowing that if nurses do not document offender's complaints in their medicnl files and if
offenders do not make the same complaints to their trenting physicians. then they will not
have this infonnation.
You verbally reporte~ complaint to ~'l 2 Mike Knlina who looked in o n .
_
at approximately 8:30 PM to find him snoring as he slept. There was no verbal
communicntion at this time between_and rvlr. Kalian.
CO Taylor observe~~floor naked about 9:30 PM. According to
Mr. Taylor's report, at that time_indicated he felt better after taking a shower.

~ a difficult offender to assess for medical problems because he
complained often about a number of medical problems, some of which could be verified

113"6 .-

as not real and he was delusional (bis beliefsystem was idiosyncratic and often could not .
be verified).
According to o.r. Jonas, MD.,_treating physician. the aforementioned
complaint of having difficulty getting air is significant to his documented physical
problem of which all medical staff. including yourself: were aware. The knowledge of
this medical significance should be information commonly known among nurses,
according to Dr. Jonas. You state knowing the problem becomes a medical concern at
the time slhe becomes neumoniatic.
Persons prescribed psychotropic medications are more susceptible to the effects of heat
than are the general population. You indicate not having knowledge of this on the date of
July 22, 1998.

.
You recently became certified as a psychiatric nurse and the above information was not
included in the material you read for the exam you took to become certified
You state you or any of the other nurses would never.deliberately harm an inmate.
Conclusion: This reviewer finds misconduct for failing to respond to an offender
complaining of having :l medical problem (who later died), for the following reasons:

1. A CO is not a medically trained person therefore slhe ~elies on the medical expertise
sthe cannot be relied on to provide a medical assessment of an offender •s physical
complaints. nor should slhe be placed in the position to assume legal liability for
having done so.
2. Although it was stated in Nls. Lareau's investigative report at the time RJ.'\l3 Bollinger
verbally gave the physical assessment directive, included was not a time frame for
meeting with the offender after receiving a complaint, ~as not physically
assessed at any time during the evening of July 22, 1998.
3. The fact that it was an unusually hot evening is all the more ~~&'\i 2
Wagner should have been more concerned for the welfare o f _ Her
assumption he was having a minor reaction to the heat should have been confirmed or
not by a physical assessment.
4. The fact tha~epeatedly made the same complaint about having difficulty
getting air should have raised a red flag to Nls. Wagner to (1.) do a physical
assessment and (2) document this complaint in his medical chart for the treating
physician to further assess. And to provide recorded information to nurses working
the following shifts. As this information was not documented in any location. the fact
_complained of having a physical problem did not get passed on to the next
shift of nurses. RN ~rts she did not know of this complaint when she was
called to look in o n _ a t 10:34 PM, by CO Smith.

•

s.

Although you were in the middle of do~ med ~ you could have requested that
correctioual officers .brinl!~ the in:firmaIy for assessment while holding .
offon having the next gro~enders sent to med line.

Additonal Comments:

In addition to this writer's findings ofmisconduct for fiillure to respond to an offender's
physical complaint, your fililure to docmnent ~ medical file what according
to Dr. Jonas, MD. is pertinent medical information is also reason for misconduct This
lack ofdocumentation tailed to provide RN 2 Cave with necessary information she
needed to properly assess _ l a t e r that evening.
Ella Ray Sigmund, Office Head

<&&t~~

.

Llc/u-f;'~a>p ~~,L/CIlUH/~
C;-/?-fr

P

1138.

..
CHASE RIVELAND
SecreIaIy

. STAn OF WASHINCTON

DEPARTMENT OF CORREalONS
SPECIAL OFFENDER CENTER
P.O. Box S r4 • Parle Place • Montee. Washington 98272-05'4

9/9/98
TO:

Gloria Wagner

\

FROM:

Ray Sigmund
'0//
Acting Associate SuPerintendent

SUBJECf:

ADMlNISTRAT1VE MEETING

;f ~

I am scheduling a meeting with you on 9/10/98 at 2:30 p.•n. in my office to discuss the Employee
Conduct Report initiated by your supervisor. Attached ple3Se find copies of the following
documents:
•

Employee Conduct Report

•

Employee Rights Pursuant to Article 8.2 of Institutions CBA

The pUlllose of this meeting is to give you an opportunity to explain your account of the incident
prior to 'my making a decision as to whether or not misconduct occurred.
You are entitled to have an employee representative present at this meeting. No copies have
been sent to your representative. If you choose to have an employee representative pres~t is'·
your responsibility to forward these documents to himlher yourself.

BB
Att: (2)

cc: Linda Gilstrap, Personnel

•

. L

I1j~ .

•

Chronologic:lI Description ofIncident
ClO McLellan was.unit Booth Officer on Shift III. July 22 1998. It was a very hot
ni t and the air conditioners were not working well. C/O McLellan said tha~
was acting normally during her shift and not yelling that night. At approximately
1810
activated the cell intercom by yelling that he was having trouble getting
air. C/O McLellan replied t o _ h a t she would notify the infinnary, and said that
she sent an officer to check on him (1 did not corroborate this.) C/O McLellan said that
_
had enough breath to activate the intercom, which took a fairly loud noise to
activate. C/O McLellan said that this was the only time that she knew of on this shift
which-'=omplained or activated the intercom. She said that~as
known to have many complaints, but could not recall exactly ifhe had complained of
trouble gettirlg his air, or ind~s specific complaints, in the past. C/O McLellan
said that there was nothing i~presentation which was unusual or which
alanned her. She also said that the nurses had always been very attentive t~
and had always evaluated his complaints in a timely ~hion. For her part, she said. she
always relayed the inmates' complaints to medical without delay.
That night, RJ."J'2 Wagner was conductin medication lines when she received the call from
_Unit Booth C/O McLellan, stating tha
was complaining of having
trouble getting air. R..'\S2 Wagner asked CIO ~(cLellan if
as having problems
speaking, and was told that he was not. Since it was such a at rnght. &.'i2 Wagner
thought perhaps the heat was botherin~ and suggested to C/O McLellan that a
cool shower might help. &"J'2 Wagner further asked C/O McLenan to call her back i_
_
had any more problems; C/O McLellan's memo did corroborate this. &.'i2 Wagner
said that she did not hear back from the unit. and 50 assumed~asfeeling
better.
&.'12 Wagner said that she completely trusted C/O McLellan and the rest of the unit staff
to follow through with~d let her know if he was having further problems.
She (and several other nurses- Atchison, Cooper-Schmidt. and Kalina) said t h a t .
_
complaint of having trouble getting enough air was a frequent complaint for him,
that he was never in any respiratory distress when evaluated for this complaint. and that he
frequently included the request to go outside and get some fresh air, saying that he could
not get enough air in his cell. Ri'\f2 Wagner said that she had no reason to believe - either
fro~_past medical history or the presentation of his complaint that night -. that
~ n any danger or that this was different in any way from previous similar
complaints.
At about 1830-1845. after finishing the dinner medication lines, R..'\f2 Wagner told lvfike
Kalina, &.\i2. about_complaint and her conversation with C/O Mclellan. The
Shift [II nurses spli~rsing duties. and that evening it was the responsibility of
~fike Kalina RN2 to respond to non-emergency complaints onltJnit. They decided that
since this was a frequent complaint and hitherto without objective findings for

li40

2

and since they had not heard back from the unit, RN2 Kalina would check on
at the 2000 medication rounds.
C/O McLeUan stated that one of the officers who saw~this time said that
he was puffing a little, but nothing out the ordinary for~id take a cool
shower, and the officers could hear him "whooping and hollering" in the shower (which
did not, as RN2 Kalina later pointed out, indicate respiratory distress.)
Mike~2, and an officer checked

on_

at about 2030. RL"J'2 Kalina said
that _ w a s asleep and snoring q~s was corroborated by C/O
McLeUan's 7/23 memo) as was his habit. _respirations at that time were even
and regular and he appeared, when seen through the cell window, to be merely asleep and
in no distress. Attempts made to awaken
y calling and knocking were of no
avail. RN2 Kalina said that since these medications were voluntary medications, an~
known to sleep through this medication pass (despite the noise of the calling
and knocking) nothing seemed out of the ordinary.

_was

<

At some time between 1300 and 2~ct time has not been determined) a religious
was "really out
volunteer ( Dan Dierdorff) visite~ He thought tha
of it" that night. He was unable to communicate with
or the first time in
"numerous visits." The volunteer said that he did not think
was in a life
threatening situation and so did not ask an officer to check on him. In retrospect,
however, he sai~'looked like a man with a high fever."
.C/O Benda checked~about 2130 and~as Iyin~ floor.
(Immediately after~th I asked several people who knew.-.wlflying
on the floor and/or being naked was unusual for him. No one thought it was very out of
the ordinary for him. This was before my investigation and I do not remember who or
when I asked, though.) C/O Benda aske~ifhe was feeling OK and according
to C/O Benda.,_replied "Yes, I'm a little hot, I took a shower, I'm OK."
I did not think it appropriate to interview, nor to include any information from a
"declaration" written by SOC Inmate Sean Morin #912839. This is the inmate who could
be heard yelling on the videotape of the entry a
ell the night he died. The
point of~lr. Morin's letter is to debunk and expose actions and inactions by the nursing
and custody staff. This memo is included in the packet of memos.

li41

•

3

Nursing Interviews

W
er chose not to go s e e .
RN3 Bollinger wrote the ECR She alleges thaMRN2
~ n the unit when C/O McLellan relayed
complaint. RN3 Bollinger
stated that on May 18, 19, and 20, 1998 she announce at e noontime nursing meeting
that all nurses were to physically assess any inmate who complained of any physical
abnonn~ conce~ is that ~2 Wa~er neglected her duty by failing to physically
assess_ _at the orne of his complamt.

In my interview with RN3 Bollinger on 8/24, she stated that she had infonned the nurses
that they must bring down to the clinic and physically assess all patient complaints of
potentially severe problems such as chest pain. shortness of breath, severe abdominal pain,
etc. RN3 Bollinger says that she did not state a timeframe within which these problems
were to be assessed, nor put her directive in writing, nor have the nurses sign that they had
received this directive. RN3 Bollinger estimated that the SOC nursing staff receives 10-20
notifications of physical problems each week. not all of them severe. Further, when asked
if she thought that the nurses should assess the 201b instance of a particular complaint by a
particular patient like the I st, she replied ·'yes."
[ asked &"I3 Bollinger what her thoughts were on the nurses perfonning "telephone
triage" of patient complaints. that is. trying to ascertain aver the telephone which
complaints were significant enough to warrant physical assessment. While stating that the
nurses have to use their clinical judgment to ascertain which problems are significant
enough to warrant the patient being brought down to the clinic and assessed, she also
stated that it was not the officers' job to judge what was an emergency or even to describe
how the inmate appeared to them. (I happen not to agree with this last thought. the
officers are trained observers and are well able to describe in layman's terms how someone
looks. This is not asking the officers to make a medical judgment or call.)
Every nurse interviewed expressed the deep frustration and concern that they did not have
enough time on their shifts to complete their tasks, and many thought the latter half of
Shift ill was the busiest and most difficult (although nights was, as well.) The general
opinion was that there was no "slack" time between about 1615 and 2200: any urgency or
emergency must be carefully evaluated for its significance because of the impact on the
shift duties. Some examples given were: giving the"dinner" medications too late could
impact the" bedtime" medications because many medications cannot be given too close
together. One nurse running late could adversely impact the" bedtime" medication line for
the whole institution. And many times there would be more than once special (timeconsuming) problem per shift, such as an inmate requiring an involuntary shot or other
medication as wen as an urgency or emergency.
When asked. R..'\l3 Bollinger stated that she had filed the ECR because &"l2 Wagner had
not followed the directive concerning physical assessment, and because she did not think:
that RN2 Wagner had used good medical judgment. &"l3 Bollinger, also when asked,

•

4

stated that the reason she filed the ECR was for "someone else to investigate (the
situation) and make a decision on whatever needed to be done."

In interviews with all of the seven full-time nurses at SOC, when specifically asked if they
remembered RN3 Bollinger "announcing the expectation that every time an inmate voiced
a physical complaint he would be visualized and assessed by a nurse," four - including
RN2 Wagner - replied no, one replied no but it was standard operating procedure to do
so, and two replied that they had heard her say this in the past but couldn't remember
where or when.

Included in the ECR packet were DOP Policy 620.020 and TRCC Field Instruction
620.020" Inmate Deaths." Neither of these seems applicable to this part of the situation.
Also included is TRee Field Instruction 610.020 "Inmate Health Emergencies" which
states "The following conditions constitute a medical necessity for emergency
transfer: ....Any clinical situation that presents as life threatening or requires physicianlevel intervention... i.e.... respiratory impainnent..... ~

Investigative Statement
1. Appropriate communication occurred between nursing staff and custody staff.

Nursing staffhad asked for a "call back" i f _ h a d any further problems and a
second call was neither made nor received.
2. Telephone triage is a necessary tool in this setting and must be used with accurate
observations and reporting by custody staff combined with the use of good nursing
judgment.
3. None of the nurses or officers who wrote memos or were interviewed about.
_omplaint of the evening of7/22 thought he was having resRiratory
impairment or that he was experiencing a life threatening problem..
~ed and hollered" in his cool shower that evening. RN2 Kalin~
- _sleeping (s~irationsas "~d regular" on his (RN2 Kalina's)
2030 follow-up o f _ complaint. _ _ told C/O Benda at 2130 that he
was OK. The one incongruity is in the religious volunteers' description of his visit with
_
- but the only potentially relevant observation which the volunteer made on
that was done in retrospect

-.r_

4. It is unclear whether RL'l3 Bollinger's verbal directive to visualize and assess every
inmate who complained of a severe physical abnormality reached aU the staff

.

,- .

.

."

.

..".:'~~~J: ~<~.~j.~~~\~~}
: :/. :.
_.

"

..

.'.. .

.

.

STATE OF WASHINGTON
DEPARTMENT OF CORRECTIONS

. MEMORANDUM

TO:

0:(1 ~d"14-

DATE:"

FROM:

ro~;;,?X//!~tJ#~.

SUBJECT:

7-d.3-f8.

~
/J(jC

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August 10, 1998

This memo is being written in response to the incident on 7/22198 involving IJM
my memo dated 7/24/98, I described the events on the swing shift that I
encountered before going off duty.
I was asked to check in on ~uringlockdown med line, which I did.
When I came to his cell, I noted that he was snoring loudly, which was not unusual for
him. His breathing pattern was even and regular. ~ad a usual snoring habit
that could be heard without the aid of the overhead sp~stem. ~so has
slept through the med lines at 8:00 PM, which because he was not on involuntary meds
was always listed as a refusal. When I checked ~ e attempted to awaken him
by t3.pQing keys on the window, opening the food sl~ng out to him, knocking on
the door but he continued to sleep as evidenced by his rhythmic snoring. I.did not notice
any change in his skin color, evidence of sweating or other abnormalities. C/O McLellan
stated that when ~ his cool shower he was whooping and hollering when he
turned the shower on. This was not indicative of someone in respiratory distress. C/O
Mclellan also stated the ~erbalizedthe uh~ felt better" following the shower.
After talking with the unit staff and listening to and visualizing ~ I had no
reason to believe that this was anything more than his usual somatic complaint.

I want to add also, that other staff has witnessed IIM""'izarre and somatic

behavior. ~as made the complaint of not being able to.zet air, that he's cur.ed
his disease through prayer, people were entering his cell and were raping him during the
night. He has also stated that.people wer.e ente~s cell at nigbI.and drinking his
blood, how he was Martin Luther King, Jr. re·incarnated. When IIM~as brought
to the infirmary for blood draws, he would request to have all his blood removed. He
also offered to perfonn sex acts for C/O's or Nurses to gain his freedom from his cell.
He was also known to repetitively request of anyone .that would listen, if they could buy
him a "rock", because he hadn't had any crack cocaine for a long time. I have had the
occasion to have ~mplain that he bas difficulty bre3.thin~"fhile taking
medications, drinking JUIce and smiling at me after finishing the juice.

Michael T. Kalina. RN II
cc: Mike Wilson
Teamster Business As.§ociate
Local 313

1.148

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To:'· ·WAGNER·GLORIA.':,: "'~ ..:..:
From.: MCLELLAN KAREN

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Date: Thursday' 23-JUi-9'S
8 :5.3pm.
Subject: INMATE_
.
4
ON 7-22-98" AT APPROXIMA1'ELY 6: 10 PM INMAXE
caI,LED THE'. 5
UNIT BOOTH AND ASI<ED ME TO~CALL THE INFImmRY AND TELL THEM: 'THAT HE WAS
6
HAVING TROUBLE GETTING AIR. I CALLED AND TALKED TO R.N. WAGNER WHO TOLD
7
ME TO 'HAvE INMME_TAKE A COLD SHOWER. S~ ASKED ME TO LET. 'HER
8
KNOW IF BE DID NOT GET BETTER• .AFTER: INMATE_TOOK ~S SHOWER I HAD
9
C/O TAYLOR CHECK ON lmf~ HE~,WAS LAYING DOWN AND APPEARED TO BE KEY.
10
ABOUT A HALF HOUR LATER. C/O BENDA CHEeRED AND fOUND THE SAME THING.
11
DURING 8: 30 MEDS ~ R:N. KALINA AND I WENT TO INMATE" CELL ANI? FOUND
12
HIM ASLEEP AND SNORING.
13
AT APPROXlliATELY 9: 30 P.M. C/O BENDA WENT TO INMATE'" CELL TO
14
CHECK ON HIM, HE WAS LYING ON THE FLOOR. C/O BENDA SAID ARE YOU OK?
15
INMATE _SAID. '''YES I'M JUST A LITTLE Har~ I TOOK A SHO~R AND "AM 16
FEELING BETTERft. HE THEN LEFT THE TIER.
17
C/O KAREN MCLELLAN
18
DOC-DP~G1-THA
cc:
BOLLINGER TERESA
19
*** End of Message ***

Function:
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09:15 AM
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To:

S"lSter Rene, SOC Monroe

cc:

Subject:

visit. 7/22198

I came in on Weds. eve. and beg!!:" my usual ~ts to all four tiers in •
unit.
.
When I was talking to other inmates on the tier (where"was toeated)~ I could hear him moan
and talk incoherendy. When I went to visit him I was su~ as he had no clothes on. He was
lying on his bed, and I said ~ are you OK?. .
He said something I could n~rstand, moved quicJdy to the floor of his cell,lay on the floor,
·and acted physically and mentally. upset. In retrospect, I would say he tooked like a man with a
er~ I don"t think he knew I was visiting him. This was the first time in numerous visits that
_ i
and I were unable to talk to each other.
I.asked_f .he wanted me to pray ~boUt anythi!'g. He did not a~.swer, so I p~at ~od
would give him peace. When I left that tier I casually said to a woman officer tha~was
really out of it tonite. and did not have a stitch of clothing on. I did not ask an officer to:check on
him, nor did I believe that he was in a life threatening situation.
Sister, I am available to talle to someone at SOC or to.speak to the family.

.'

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1.154·

TO:

DEHAVEN,BARRY
SPECIAL OFFNDR CTR
i673G'FERRY ROAD
M9NROE

FROM: DEHAVEN BARRY
SPECIAL OFFNDR CTR
1673G FERRY ROAD
MONROE

'::<, ::.~~~"'; ~·::~~:~~~~~fr=¥::~~~~,

DOC-OP-Ci -BD3 r

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''65.; 29$24 ?'.. . '/':'
...... ~ ..."."!'""'.......
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WA 9S272-eeeG
DOC-DP-Gf-BD3 23-JUL798 e5:f4:s4
WA 9S272-GGee

'SUBJECT: I/M

DOC-DP-Gi-B03/MA~

--------------------------------------------------------------------------ITO CONNE.R LAR1=~Y
IFROM DEHAVEN BA~RY
IDATE THURSDAY 23-J
ISUBJECT IIM .

DOC-DP~Gf-LC3 OK
OOC-DP-G1-B03 OK

UK
OK

AT APPRClX GG47 Hl,jURS·! RECE!VED A CALL FROM C/O JIM SMITH ASKIHG . l4HERE
THE SCT. WAS HE INF'ORME:D l'iE THAT INMATE _
HAD NOT APPEARi::D_ TO MOVE
SINCe: THEY CA~iE ON SHIFT.
I CONTACTED lHE ~Gl. AND HE WENT TO THE·UNIT. ALONG WITH RN 2 'LEA ANN
CAVE I THEN CONTACTED LT. CONNER OVER Ar TRce AND ADVISED HIM THAT WE
HAD A POSSIBLE SITUATION AT ~oc. HE ADVISED ME TO KEEP HIM POSTED.

TH£RE AFTER LT. CONNER RETURNED AND LT. CONNER SGT. MILAN. C/O'S
BROWN. NETHERTON. TAYLOR AND RN 2'S RICHARD TODD AND LEA ANN CAVE WENT
10 ENTER THE CELL TO CHECK ON INMATE~
SHOR~LY

C/O SMITH NOTIFIED ME Al G127 HOURS THAT THEY WERE ENTERING THE CELL. AT
APPRUX G130 r WAS NOTIFIED BY C/O SMITH THAT IT APPEARED AS IF THE
INMATE WAS DECEASED. AT 0134 LT. CONNER NOTIFIED ME THAT THE INMATE WAS
DECEAS£D. AT 0134 SNO PAC 911 .OPERATOR 193 WAS CONTACTED BY ME AND
ADVISED THAT WE HAD AN INMATE THAT WAS DECEASED AND WE NEEDED MONROE
POLICE AND THE SNO CO. MEDICAL EXAMINER.

Al 0150 POLICE OFF1C~k MARTINEZ ARRIVED ON SIlEo AT 0200
COUNT WAS CONDUCfED P~R POLICY. ALL INMAYES ACCOUNTED FOR

AN

'!NFOF:i'~AL

CLEAi=~ING

I-. .

·r

G209.

AT ili,lS
ASSISTED

THi:':: e/Q {oiETHt=:RTON F:E.L!E'oJED l'lE or: MAIN CONTROL DUT1ES AND r
LT. CONNER IN GATHERING INFORMAflON ON fHE !NMAT~
AND
COMi"iUi·dcATING YJIlH n~E Dur'.. Gr'F'J:CE.R AND OTHEi, 1~:Ela.:U1RED STAFF. I I:JI;S SeNT
TO THE UNIT WITH IHE MEDrCA~ EXAMINER AND STOUD BY AW~IrING ~URTH£R
INSH.:lJCTIQNS.

I

~SCORTED

UN!T.

THIS

lliE
E~DED

POLIC~

MY

TO lHE UNIT TO INT£RVIEW r~MATES AND OFF
THIS EMERG~NCY S(TUATION.

7H~

PARfICIPATION !N

c/o BARRY DEHAVEN

--------------------------------------------------------------------------* *

END 01: MESSAGE

~

~

PRINTED ON

23-JUL-98 AT 05:29:29 MA¢

1155~

:

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srATE OF WASBINGTON

DEPARTMENT OF CORREcnONS
SPECIAL OFFENDER. CENTER.
P.O. BOXS14 ·PARK PLACE· MONROE. WASHINGTON 98272 - 0514

TO:

U. Conner, Larry

DATE:

07/'Z3/98

SUBJEcr:~

FROM: Sgt.Milan, Tony

_ _U ~

At Or" about OOSShr:s I received a aU from C/O Smith that the nurse W:lS coming up to tlie Unit tQ see
~o.to _having aot moved at aU on our" shift and he w:as being unresponsive.
At O~ arri~the Unit and RN Todd stated tha"'seemed to be bre:tthing. but-was
unresponsive. RN Todd, ao Brown and CIa Taylor" wer"~ to get~o response Co them
ailing to him and they also tried throwing socks aad water at him. Still he W:lS unresponsive. [ asked
if he was asleep and bre:1thing, RN Todd sUted that he· ~ appe:tr"ed to be bre:1thing and
asleep. ( recommended that we let him sleep, but would call the Lt. to get the ok:Jy to open the Cell.
Lt. Conner stated that he was on his way back to SOC and to wait for bim to arrive. When the Lt.
did arrive the Video Camera and M::1.t w ebrou
ille
bt up to the Unit and A Entry Debriefing was done.
At 0 1~ Conner attempted to get ! / M t o response to SbCf, No Response was received
from'" So (gave the order to open
Brown and
lor with myself entered the
celL The m:J.t was placed o . t Whl
lm~did not mov
W:lS ordered by CIa
Taylor to place his arms be In IS ack, No resp~~· C/O aylor t o o k _ y the right
ann and tried to place it beh~ back, but the :um w~~ move that eas~'1
~onner had
RN Todd come in and ch~out.At which time RN Todd suted that
as Dcce::tSed
and that at this time CPR and an.'nd
o f First Aid would not help. At 0133hrs
0 d stated that
was Dece:1sed. At 0145hrs
cell was closed as a Crime scene by Lt. Conner.
_ h r s the Monroe Police Dept. fficer C. Martinez on grounds and at 0222hrs he was on AUnit to view the crime scene.
At 032Shrs Snohomish County Coroner D. Selove MD arrived and W:lS t:1ken to the crime scene.
At 0403hrs ~was removed from his cell by the Snohomish County Coroner and :It 0407hrs
the cell was closed for investigation.
.
At 0422hrs
as·removed from the Unit.
OAt OS03hrs
waS removed from SOC grounds by the Snohomish
County Coroner.

0

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SuIT Involved:
'. Lt. Conner, L.
Shift Lt.
. Sgt. Milan, T.
Shift Sgt.
C/O Dehaven, B. Maia Control
C/O Brown, C.
Mat I RM
C/O Taylor, M.
M::It I Unit Suff
C/O Smith, J.
Unit Staff
C/O Netherton, S. Camera Oper3tor
RN Todd, R.
Medic:11 $(:1((
RN Cave, L
Medic:11 Su(f
End of Report:

1156

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MEMORANDUM

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EMPLOYEE HANDBOOK

The Employee Handbook is designed to acquaint you widl dle
Department of Coacctions and state employment. Guidelines and
job-rc1atcd infomwioo are given to assist you in the performance of
your assigned duties. It is intended as a supplement to departmental
directives. state laws. Merit System Rules and facility or office
procedures. [f you need further information or clarification. you
should contact your supervisor or personnel representative. They can
provide you with 4lI1SWers or refer you to the location of the specific
roles or source documents.

DEPARTML.'Ifr OBJECTIVES
[0 May of 1981. the Washington State Legislamre established the

,.

Department of Corrections. separating it from tbe Department of
Socill1 3I1d He:J1th Services.

.'

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1

The depanment's mission is to promote public safety by providing
f:u:ilities :uld services to c:valuate. control. 3I1d redirect the behavior
of adult felony offenders committed to our jurisdiction by the courts.
In carrying out our mission. the department cooperates with other
state criminal justice systems and endeavors to assure that offenders
charged to our care are prepared for release and reintegration into the
community.

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~.

The department's main objectives are to:

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• Ensure safety for the public, staff:uld offenders;

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• Punish the offender for violating the law, generally through the
denial of libeny;

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• T(Cat 3.11 offenders :uld staff fairly and l:quitably;
• Reflect io the system the values of the community by avoiding
idleness. adopting the work ethic. providing opponunities for selfimprovement. providing tlJ1gible rewards for accomplishments.
and sharing the oblig:ltion of the community;

•

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• Effectively:uld efficiently manage resources;

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• Provide for n:stiOJuon;
• Be accountable to the citizens of the state;
• Meet the national standards appropriate to the State of Wasbington.

CODE OF ETHICS
High moral 3lld ethical standards among correctional employees are
csscntial for the success of the deparanent's programs, The Department nf CQ!lJ&tions subscribes to a code of unfailing honcsty. .
~ for dignity andiiKhvidualitY of hwnan beings. and a commitment to professional 3lld compassionate service.
...-

-

DEPARTItlENT E.'"{PECTAnONS

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'

As :l new employee of the department. you will have many things to
t~. no~t!!~~~ of which:~ill be_~e ex~=-~~ti..C?.~,o.GOUfsiipefVE
sor. your co-workers. and the :lgency as:l whole. To assiSt you with
this responsibility, following is a list of some dep311mental expecutions for your study. Familiarize yourself with the list so that you
may underst3lld and fulfill the duties of your position.
As :l represenutive of the Department of Corrections, vou will be
emected to:

,

;-;-".'1.

• Positively represent Washington State government to everyone you
meet. You:lre our best public relations agent:
• Dress appropriately for your job classification and duties. aodling
may not have monos, logos, or advertisements that may be offensive or in conmct with the goals of the Deparunent;
,

"

Wez issued uniforms only as authorized:

.....: ...
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• Be a good citizen. obey laws while on and off-duty. Your conduct
off duty may reflect on your fitness for duty:
• Tre:l.l fellow st:1ff with dignity and respect;

.
,

Be imparti31. underst3llding and respectful to offende~;

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Serve c:l.ch offender with Jppropriate concern for their welfare and
with no purpose of personal gain;

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1161

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Employee Name (please Print)

ACKNOWLEDGEMENT OF RECEIPT OF
DOC EMPLOYEE HANDBOOK
.
.
I aclmowledge receipt of the June 1993 Washington State Department
of Corrections Employee Handbook and agree to become familiar
with and have a thorough knowledge ang. understanding of the
contents.

Original - Personnel File

~ttachment ...;;;;-;::=?~__
11~2

lIO...

STAT! 01' WASMlMGTON

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CLASSlFICAnON QU'
(POSITION aESCR

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10NNAIRE

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! I. AGI!JtCY HAIIfi
'Oepartment of Corrections

lIMCNl! NO.

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OA VIS, Tamara J.

794-2236

"'.'1. STOP
DOP/SOC/Infirmarv

NM-&4

AGSICV

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Re istered Nurse 2
RNC

S. POSITIaN Ac:noN NO

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794-2236 , Registered Nurse 3

Fran Bartlev
cuss

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21 EMPI.OVEe·s ST.TEMENT OF aunes

REAO INSTRucnONS l:.\REF\JLI.Y BEFORE COMPUTING nilS SEcnON.
UST TliOSE DDlles FIRST WHICH occupy MOST OF YOUR lIME. UNOEJI1JNE YOUR MOST RESPONSI8U
DUTY.

!

Under the sucer'/ision of the RN 3. the RN 2 Drovides comcrehensive i _. - . '" ....
: nursine: care services in the dinical settine: of the 5cecial Offender ·.:enter, l:~~~:
j a 109-bed adult correctional facilitv oravidin! intensive theraoeutic !. ..~--~:,~-<...~.::. .
. communitv ser·,ices ~o mentally ill offenders.
i-----.-.---..... ---.

I

l.l0% I Accurately set up, adminster, and record all medications, such as major 1
; tranquilizers, neurole;>tics, anti-parkinsonian meds, antibiotics, and anti-;
i convulsant medications, as we!! as others as ordered.
I

I

In·"·~~t up, distribute, and record aU decanoate meds, maintaining the tracking I
,i1ethod and document any side effects.

,
i

10% .~ssist ;)sychiatrist with med re'/lews on uni ts. Complete all orders and l
in case I.
relay ':0 pharmacy. Assist P•.~.s when needed. . Particioate
.
I,
management on all uni ts.

10% Enter computer data. for upcoming jJsychiatric appointments. Order batch
reports.
I

10%, Provide ongOing nursing treatment and emergency treatment as necessary.
5%

Clear inmates for food service and keep accurate documentation.

5%

Obtain scheduled and emergency EKGs.
minor surgery.

Assist P.A. wi th sick call and

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Provides for the safety, securi ty, and sani tation of supplies, equipment, and
the lnfirmary area.
"'aintains professional nursing care integrity as it applies to appearance,
behavior, demeanor, and delivery of services. Performs other work as
required.

.

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(allllen 8001110".' ..heelS ., ".cesuIV)

-ORIGINAl. COPY
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AGENCY

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Kegwft"OD 01 t1ea1lD l"rolesslOas-uIUlOrm UiSopljn'lry Act

(3) TI= license holder shall sign a waiver allowing the
progra~ to release infonnation to. the disciplining authority

If the hc:cnscc docs not comply with the rcquiremenas of this
section or is unable to practice with reasonable skill or
safety. The substance abuse program shalt report to the
disciplining authority any Iic:cnsc holder who faits to comply
with the requirements of this section or the program or who.
in the opinion of the program. is unable to practice with
reasonable skill or safety. License holders shalt report 10 the
disciplining authority if they fail 10 comply with this section
or do not complete the program's requirements. License
holders may. upon the agreement of the program and
disciplining authority, reenter the program if they have
previously failed 10 comply with this section.
(4) The treatment and pretreatment records of license
holders referred to or voluntarily panicipating in approved
programs shall be confidential, shall be exempt from RCW
42.17.250 through 42.17.450, and shall not be subject to
discovery by subpoena or admissible as evidence cxcepl for
monitoring records reponed to the disciplining authority for
cause as defined in subsection (3) of this section. Monitoring records relating to license holders referred to the pro. gram by the disciplining authority or relating to license
holders reponed to !he disciplining authority by the program
for cause, shall be released to the disciplining authority at
the request of the disciplining authority. Records held by the
disciplining authority under this section shall be exempt from
RCW 42.17.250 Ihrough 42.17.450 and shall not be subject
to discovery by subpoena except by the license holder.
(5) "Substance abuse:' as used in this section. means the
impairment, as determined by the disciplining authority. of
a license holder's professional services by an addiction to, a
dependency on. or the us.: of alcohol. legend drugs. or
controlled substances.
(6) This ·section does not affect :m employer's right or
ability 10 make employment-related decisions regarding a
license holder. This section does not restrict the authoritv of
the disciplining authority 10 take disciplinary action for -any
other unprofessional conducr.
(7) A person who. in good faith. reports information or
takes acrion in connection with this section is immune from
civil liability for reporting information or taking the acrion.
(a) The immunity from civil liability provided by this
section shall be liberally construed to accomplish the
purposes of this secrion and the persons entitled 10 immunity
shall include:
(i) An approved monitoring treatment program;
(ii) The professional association oper:lting the program;
(iii) Members. employees. or agents of the program or
association;
(iv) Persons reporting a license holder as being impaired
or providing information about the license holder's impairment; and
(v) Professionals supervising or monitoring the course
of the impaired license holder's tre:1tment or rehabilitation.
(b) The immunity provided in this section is in addition
to any other immunity provided by law. [1993 c 367 § 3;
1991 c 3 § 270; 1988 c 247 § ~.I
Legislative inlenl-l988 c :.&7: -~isting 1~", docs nOI provide (or
progr.un (or reh:abilil:llIOn of hc.1llh proicssion:lls whose compclCllC)' l1l:ly
be imp:lired <Iuc to the muse of .1lcohol :and othc:l' drugs.

:I

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II ~s ~ inlClll of lhc legislacun: ltw lite disciplining 3lIlhorilies seck
ways .10 ldemiiy and suppoft the n:l1ahiliwicn of hea1Ib professiaaals whose
pncuce or compctc:ney may be impait1:d due to chc abuse of dnags or
alcohol The I ~ inlCllds ltw web bc:IIIb pnlfcssioaaJs be IIcIIcd so
~ llIey C:IIl n:tum 10 or .~nriDuc 10 practice choir profession in a way
~hl~ .~cguank ~ publ\C- •The legisJal1Il'C spec:ific::l1ly inwIds ilia the
d~p~n~ IlId1onu~ csWJl~h an aJlCmalivc program 10 lhe aadilional
adminlSU:lt1ve proccechngs agauw such he31lh professionals.· (1988 c 247

§1.1

RCW 18.130.180 Unprofessional conduct. The
f?lIowing conduct, acts: or conditions constitute unprofessIonal conduct for any license holder or applicant under the
jurisdiction of this chapter:
(1 ~ The commission o~ any act involving moral turpitude. dishonesty, or corrupuon relating to the practice of the
person's profession, whether the act constitutes a crime or
noL If the act constitutes a crime. conviction in a criminal
pr~ceeding is not a condition precedent to disciplinary
action. Upon such a conviction, however. the judgment and
scn~ce is concl~ive eVid~nce at the ensuing disciplinary
heanng of the gullt of the license holder or applicant of the
crime described in the indictment or information. and of the
person's violation of the statute on which it is based. For
the purposes of this section. conviction includes all instances
in which a plea of guilty or nolo contendere is the basis for
the sonviction and all proceedings in which the sentence has
been deferred or suspended. Nothing in this section abrogates rights guaranleed under chapter 9.96A RCW;
(2) Misrepresentation or concealment of a material fact
in obtaining a license or in reinsCllement thereof;
(3) All advertising which is false. fraudulent. or misleading;
(4) Incompetence. negligence. or malpractice which
results in injury to a patient or which creates an unreasonable risk that a patient may be harmed. The use of a
non~ditional treatment by itself shall not constitute unprofesslOn~1 conduct. provided that it does not result in injury
to a patient or create an unreasonable risk that a patient mav
be harmed;
(5) Suspension. revocation. or restriction of the
individual's license to practice any health care profession bv
~ompetent ?uthority in any state. federal, or foreign jurisdidnon. a cemfied copy of Ihe order. stipulalion. or agreement
bein~ ~onclusive evidence of the revocation. suspension. or
resmCl1on:
(6) The possession. use, prescription for use, or distribution of controlled substances or legend drugs in any wav
other Ihan for legitimate or therapeutic purposes. diversio~
of controlled substances or legend drugs. the violation of any
drug law. or prescribing controlled substances for oneself'
(7) Violation of any state or federal statute or admini~­
trative rule regulating the. profession in question. including
an~ statute or rule defining or establishing standards of
pattent care or professional conduct or practice;
(8) Failure to cooperate with the disciplining authority
by:
(a) Not furnishing any papers or documents;
(b) Not furnishi ng in writing a full and complete
explanation covering the maller contained in the complaint
filed with the disciplining authority;

leb. 18.1JO-;J. 111

(1997)

Attachment _ _- - - - -

i.iS4
.
~

Practical and Registered Nursing
(ii) MediC3l and surgical nursing.
(iii) Parent/child nursing with only an assisting' role in
the are of clients during labor and delivery and those with
complications.
(tv) Geriatric nursing.
(v) Mental health nursing.
(vi) All nursing courses shall include components of
restorative. rehabilitative and supportive care.
(vii) Uboratory and clinic31 practice in the functions of
.. me practic:U nurse, including but not limited to, administration of medications, common medical surgical techniques
and telated client te:lChing.
(viii) Concepts of client care management.
FOR REGISTERED NURSE PROGRAMS:

(a) Instruction in me physical and biologic:ll sciences
and shall include content drawn from me arc:lS of anatomy
and physiology, physics. chemistry, microbiology. phannacology and nutrition. which may be integrated. combined., or
presented as separate courses.
(b) Insuuction in the soci31 and behavioral sciences and
shall include content drawn from the are:lS of communications, psychology, sociology and anthropology, which may
be integrated. combined, or presented as separate courses.
(c) Theory and clinical experiences in the areas of
medical nursing, surgic31 nursing, obstetric nursing, nursing
of children and psychiatric nursing, which may be integrated,
combined. or presented as separate courses. Baccalaureate
programs also sh3l1 include meory and clinical experiences
in community health nursing.
(d) History. trends. and legal and ethical issues pertaining to the nursing profession. which may be integrated.
combined. or presented as separate courses. Bacc3laureate
programs shall include study of research principles.
(e) Opportunities for the student to learn JSsessment of
needs, planning, implementation. and evaluation of nursing
care for diverse individuals and groups. Bacc:lIaure:ue
progr:uns shull include the study and practice of leadership.
(f) Clinical e:cperiencc:s in the care of persons at each
staoe of the human life cycle. These e:cperiences shall
inciude opportUnities for the student to learn and have diteCt
involvement in. responsibility and accountability for nursing
care in the areas of acute and chronic illnesses. promotion
and maintenance of wellness. The emphasis placed on these
arc:lS, the scope encompassed. and other allied experiences
offered shall be in keeping with the purpose. philosophy. and
obje1:tives of me program.
(g) Opportunities for the student to participate in multidisciplinary health c:lI'e.
(Stuulory AUlhorily: RCW 18.i9110. 95·21-012. § :!46·840·Si5. filed
10116195. effective IlIt6l95.)

WAC 2-Ui-840-iOO Standards of nursing conduct or
practice. The purpose of defining standards of nursing
conduct or practice through WAC 246-840-700 and 246-8-W710 is to identify responsibilities of the nurse in health care
settings and JS provided in me Nursing Pr:1ctice Act. chapter
18.79 RCW. Viol:ltion of these standards may be grounds
for disciplinary action pursuant to chapter 18.130 RCW.
Each individual, upon entering the practice of nursing.
assumes a measure of responsibility and public truSt and the
corresponding obligation to adhere to the standards of
(1113198)

246-840-575

nursing practice. The nurse shall be responsible and
accountable for the quality of nursing care given to clients.
This responsibility cannot be avoided by accepting the orders
or directions of anom.er person. The standards of nursing
conduct or practice include, but are not limited to the
following:
FOR REGISTERED NURSES:

(I) Nursing process:
(a) The registered nurse shall collect pertinent objective
and subjective data regarding the health status of the clienL .
(b) The registered nurse shall plan and implement
nursing care which will assist the client to maintain or return
to a state of health or will support a dignified death.
(c) The registered nurse shall communicate significant
changes in me client's statUS to appropriate members of the
health care team. This communication shall take place in a
time period consistent with the client's need for care.
(d) The registeted nurse shall document, on essential
client records, the nursing care given and the client's
response to that care.
(2) Delegation and supervision: The registered nurse
shall be accountable for the safety of clients receiving
nursing service by:
~(a) Delegating selected nursing functions to others in
accordance with their education, credentials. and demonstrated competence.
(b) Supervising others to whom he/she has delegated
nursing functions.
(3) Other responsibilities:
(a) The registered nurse shall have knowledge and
underst:l!lding of the laws und rules regulating nursing and
shall function within the legal scope of nursing practice.
(b) The registered nurse shall be responsible and
accountable for practice based on and limited co me scope of
her/his education. demonstrated competence. and nursing
experience.
(c) The registered nurse shall obtain instruction. supervision. and consultation JS necessary before implementing new
or unf:uniliar te1:hniques or practices.
(d) The registered nurse shall be responsible for maintaining current knowledge in hislher field of pr:lctice.
(e) The registered nurse shall conduct nursing practice
without discrimination.
(f) The registered nurse shall respect the client's right to
privacy by protecting confidential information.
(g) The registered nurse sh3l1 report unsafe nursing acts
and practices. and illegal acts ::IS derined in WAC 246-840-

730.
FOR PRAcnC.\L :-nJRSES:

(4) The licensed practic:l1 nurse. functioning under me
direction and supervision of other licensed health care
professionals as provided in RCW 18.79.060, shall be
responsible and accountable for his or her own nursing
judgments. actions and competence.
(5) The licensed practical nurse shall practice practic31
nursing in the state of Washington only with a current
Washington license.
(6) The licensed practical nurse shall nOl permit his or
her license to be used by another person for any purpose.

~ttachment __0__-

lebo

~

WAC-p. (7)

116~;.· .

246-840-700

.

actic:d and Registered Nursing

(7) The licensed practical nurse shall have knowledge of
the statutes and rules governing licensed prae:tic:al nurse
practice and shall function within the legal scope of licensed
practic:d nurse practice.
(8) The licensed practical nurse shall not aid, abet or
assist any other person in violating or circ:umventi~g the
laws or rules pertaining to the conduct and practIce of
Ucensed practical nursing.
(9) The licensed practical nurse shall not disclose the
contents of any licensing examination or solicit. accept or
compile information regarding the contents of any examination before. during or after its administr.1tion.
(10) The licensed practical nurse shaJl delegate activities
only to persons who are competent and qualified to undertake and perform the delegated activities. and shall not
delegate to unlicensed persons those functions that are to be
performed only by licensed nurses.
(11) The licensed practical nurse. in delegating functions. shaJl supervise the persons to whom the functions have
been delegated.
•
(12) The licensed practical nurse shall act to safeguard
clientS from unsafe practices or conditions. abusive acts. and
neglcct.
(13) The licensed practical nurse shall repon unsafe acts
and practices. unsafe practice conditions. and illegal ac~ to
the appropriate supervisory personnel or to the appropnate
state disciplinary board or commission.
(14) The licensed practical nurse shall respect the
Glient's privacy by protecting confidential information. unless
required by law to disclose such information.
(15) The licensed practical nurse shall make accurate.
intelligible enaies inco records required by law. empl?y~ent
or customary practice of nursing. and shall not talsl fy.
desuoy, alter or knowingly make incorrect or unintelligible
entries into client's records or employer or employee
records.
(16) The licensed practical nurse shall not sign any
record attesting to the wastage of controlled substances
unless the wastige was personally witnessed.
(17) The licensed practic:lI nurse shall observe and
record the conditions of a client. and report significant
changes to appropriate persons.
(18) The licensed practical nurse may withhold or
modify client care which has been authorized by an appropriatc hc:lIth care provider. only after. recei.ving directi~ns
from an appropriate person. unless In a hfe threatenlDg
situation.
(19) The licensed practical nurse shall leave a nursing
assignment only after properly reponing to. and notifying
appropriatc persons and shall not abandon chent~.
. (20) The licensed practic:11 nurse shall not misrepresent
his or her education and ability to perform nursing procedures safelv.
(21) The licensed practical nurse shall respect the
property of the client and employer and s~all not take
equipment. materials. property or drugs .for hiS or he: ?wn
use or benefit nor shall the licensed pracllc:lI nurse sohclt or
borrow money. materials or property from clientS.
.
(22) The licensed practical nurse shall not obtain.
possess. disaibute or administer legend drugs or cona-olled
substances to any person. including self. except as directed
by a person authorized by law to prescribe drugs.
{Ch. %46-840 WAC-p. UII

(23) The licensed practical nurse shall not practice
nursing whilc affected by alcohol or drugs. or by a mental.
physical or emotional condition to the extent that there is an
undue risk that he or she. as a licensed practical nurse.
would cause harm to him or herself or other ·persons.
(24) It is inconsistent for a licensed practical nurse to
perform functions below the minimum standards of compeEencyas expressed in WAC 246-840-715.
(Sla1UUlry Audlority: 0Iapcer 18.79 RCW. 97·13-100, § 246-&40-700. fiIcd
6118197. cffCClivc 7/19197.1

WAC 246-840-705 Functions of a licensed practic:d
nurse. A licensed practical nurse is one who has met the
requirements of the Washington State Nurse Practice Act.
chapter 18.79 RCW. The licensed practical nurse recognizes
and is able to meet the basic needs of the client. and gives
nursing care under the direction and supervision of the
registered nurse or licensed physician to clients in routine
nursing situations. In more complex situations the licensed
practical nurse functions as an assistant to the rogistered
nurse and carries out selected aspectS of the designated
nursing regimen.
A routine nursing situation is one that is relatively free
of scientific complexity. The clinical and behavior.1l state of
the client b relatively stable and requires abilities based
upon a compar:ltively fixed and limited body of knowledge.
In complex situations. the licensed practical nurse
facilitates client care by meeting specific nursing require.
mentS to assist the registered nurse in the performance of
nursing care.
The functions of the licensed practical nurse makes
practical nursing'a distinct occupation within the profession
of nursing.. The licensed practical nurse has specific roles in
nursing in direct relation to the length. scope and depth of
his or her formal educ:1tion and experience. In the basic
program of practical nursing education. the emphasis is on
direct client care.
With additional prepar:ltion. through continuing education and practice. the licensed practical nurse prepares to
assume progressively more complex nursing responsibilities.
[SWUlory Authority: Chapter 18.i9 RCW. 97·13·100. §
6118197. cffccnvc 7/19197.]

246·~-;OS.

filed

WAC 246-840-710 Violations of standards of
Dursing conduct or practice. The following will serve as
a guideline for the nurse as to the acts. practices. or omissions that are inconsistent with generally accepted standards
of nursing conduct or practice. Such conduct or practice
may be grounds for action with regard to the license to
practice nursing pursuant to chapter 18.79 RCW and the
Uniform Disciplinary Act. chapter 18.130 RCW. Such
conduct or practice includes. but is not limited to the
following:
.
(1) Failure to adhere to the standards enumerated In
WAC 246·840-700( 1) which may include:
(a) Failing to assess and evaluate a client's status or
failing to institute nursing intervention as required by the
client's condition.
(b) Willfully or repeatedly failing to repon or document
a client's symptoms. responses. progress. medication. or
other nursing care accurately andlor intelligibly.

A.ttachment __7~

~

(~IJl98l

116~.

Practical ad

R ~ Nursing

246-840-710

(c) Willfully or repeatedly failing to make entries.
(I) Standard I • The practical nurse assists in implealtering entries. destroying entries. making incorrect or
menting the nursing proc:css. The nursing process is defined
illegible entries and/or making false entries in records
as a systematic approach to n~ing care which has the goal
pertaining to the giving of medication. lrCatments. or other
of facilitating an optimal level of functioning for the client,
. nursing C:I.rC.
recognizing cultural and religious diversity.
(d) Willfully or repeatedly failing to administer medicaThe components of tJ:1e nursing process arc assessing,
tions and/or treatments in accordance with policy and
planning, implementing arid evaluating. Written and verbal
communication is essential to the nursing process.
procedure.
(e) Willfully or repeatedly failing to follow the policy
Competencies:
and procedure for the wastage of medications where the
(a) Assessment· Malces observations. gathers data and
nurse is employed or working.
assists in identification of needs and problems relevant to the
(f) Willfully causing or contributing to physical or
clienL
emotional abuse to the clienL
(i) Makes basil: observations of clients' safety and
(2) Failure to adhere to the standards enumerated in
comfort needs.
WAC 246-840-700(2) which may include:
(ii) Identifies physical discomfort and environmental
threats to client safety.
(a) Delegating nursing c3t'e function or responsibilities
to a person who the nurse knows or has reason to know
(iii) Identifies basic physiological, emotional. sociological. cultul'31. economic. and spiritual needs.
lacks the ability or knowledge to perfonn the function or
(iv) Collects specific dat:l as directed.
responsibility. or delegating to unlicensed persons those
(v) Identifies major deviation from nonnal.
functions or responsibilities the nurse knows or has reason
to know are to be performed only by licensed persons. This
(vi) Selects data from established sources relevant to
section should not be construed as prohibiting delegation to
client's needs or problems.
(vii) Collabol'3tes in organizing dat:l.
family members and other c3t'egivers exempted by RCW
18.79.1)40(3). 18.79.050. 18.79.060 or 18.79.240.
(viii) Assists in formulating the list of clients' nc-...ds or
problems.
.
(b) Failure to supervise those to whom nursing activities
have been delegated. Such supervision shall be adequate to
(iX) Identifies major short-term and long-term needs of
clients.
prevent an unreasonable risk of hann to clients.
(3) Failure to adhere to the standards enumerated in
(b) Planning - Contributes to the development of
approaches to meet the needs of clients and families.
WAC 246-840-700(3) which may include:
(i) Develops client care plans. utilizing a st:lndardized
(a) Performing or attempting to perform nursing
nursing care plan.
techniques and/or procedures for which the nurse lacks the
(ii) Assists in setting priorities for nursing care.
appropriate knowledge. experience. and education andlor
(iii) Participates in client care conferences.
failing to obtain instruction. supervision and/or consult:ltion
(c) Implement:ltion • Carries out planned approaches to
for client safety.
client care.
(b) Violating the confidentiality of information or
(j) Cwes out nursing actions developed in care plan to
knowledge concerning the client. except where required by
ensure safe and effective nursing care.
law or for the protection of the client.
(ij) Performs common therapeutic nursing techniques.
(c) Writing prescriptions for drugs unless authorized to
(iii) Administers medic:llions safely and accur:uely.
do so by the board.
within institutional policies and procedures. and with
(4) Other violations:
knowledge of the medication being administered.
(a) Appropriating for personal use medication. supplies.
(d) Evaluation· Utilizing a standard plan for nursing
equipment. or personal items of the client. agency, or
care. appraises the effecti veness of client care.
institution.
(i) Collaborates in data collection relevant to outcome
(b) Practicing nursing while impaired by any mental.
of care.
physical and/or emotional condition to the extent that the
(ii) Assists in comparing outcome of care to formulated
person may be unable to practice with reasonable skill and
objective.
safetv.
(iii) Assists with adjustments in care.
(c) Willfully abandoning clients by leaving a nursing
(iv) Reports outcome of care given.
assignment without tr.lIlSferring responsibilities to JPPropriate .
(2) Standard II. The practic:l1 nurse uses communicapersonnel or caregiver when continued nursing C:lre is
tion skills effectively in order to function as a member of the
required by the condition of the client(s).
nursing team. Communication is defined as a process by
(d) Pr:1cticing nursing while impaired by alcohol and/or
which information is exchanged between individuals through
drugs.
a common system of symbols. signs. or behaviors that serves
(e) Conviction of a crime involving physic:lI abuse or
as both a means of gathering information and of intluencing
sexual abuse relating to the practice of nursing.
the behavior and feelings of others.
(S~UIOt'Y .~UlhoriIY: Ch3ptc:r 18.79 RC'W. 97·13·100. § :46-8-10-710. filed
Competencies:
6118197. c:ffc:etivc: 7119197.1
Applies beginning skills in verbal. nonverbal and written
communication. recognizing and respecting cultural diversity
WAC 246·840.715 Standards/competencies.
and respecting the spiritual beliefs of individual clients.
Minimum $tandards of competency ex~ted of beginning
(a) Uses common medical terminology and abbrevialicensed pl'3ctical nurses include the following:
tions.
(11131981

ICh. 246-a.ro WAC--1!. 191

li67

PractiCll and Registered Nurnog

evaluatC the performance of the nursing assistant. including

subject io any employer .o::prisaJ or disciplinary action by the
Washington nursing C3l'C quality assurance commission for
refUsing to delegate tasks or refusing to provide the requin:d
training for delegation if the nurse determines delegation
may compromise patient safety.
(9) Nursing assistants shall not be subject to any
employer reprisal or disciplinary action for refusing to accept
delegation cjf a nursing task.

direct observation of me skHl and ability of me nursing
assistant to perform the deJegated nursing task. The nurse
must also reevaluate the patient'S condition. me care provided to the patient. the C3pabilicy of the nursing assistant. the
outcome of the task. and any problems. Frequency of
supervision is at the discretion of the registered nurse to
ensure safe and effective services are provided. Reevaluation and documentation must occur at least every sixty days.
(2) A registered nurse may assume delegating responsibilities from the delepting registered nurse for the delegadon process. provided the registered nurse assuming responsibility knows the patient through their assessment. the skills
of the nursing assistant. and the plan of care. This may
include a reevaluation of the patient by the nurse assuming
responsibility for delegation. The nurse assuming the
responsibility for delegation from another nurse is accountable and responsible for the delegated taSk. The nurse must
document the following in the patient's record:
(a) The reason and justification for another nurse
assuming responsibility fgr the delegation;
(b) The nurse assuming responsibility must agree, in
writing, to perform the supervision: and
(c) That the nursing assistant and patient have been
informed of this change.

(StalUmry Authority: OtapIet 18.79 RCW.
2119196, effective 3121196.1

lSl:I1UlOry Aul/toriIY: Clupter IS.79 RCW 96-05-060. § ~46-840-95o. filed
2119196. effective 3121196·1

WAC 246·840·960 Accountability, liability, and
coercion. (1) The registered nurse and nursing assistant are
accountable for their own individual actions in the delegation
process. The delegated task becomes the rcsponsibility of
the person to whom it is delegated but the registered nurse
retains overall accountability for the nursing care of the
patient. including nursing JsseSsmenl. evaluation. Jnd
assuring documenlation is completed.
(2) Nurses Jeong within the protocols of their delegation
authority shall be immune from liability for Jny action
perfonned in the course of their del~gation. duties.
.
(3) Nursing assistants follOWing wntten deleg:ulon
instructions trom registered nurses for delegated tasks shall.
be immune from liability.
(4) The nursing care qualil)' assurance commission shall
take no disciplinary action Jgainst nurses following delegation protocols Jppropri:ltely.
(5) Complaints regarding deleg:ltion of specific nursing
tasks may be reported to the aging :lnd adult services
administration of the dep3lU11ent of soci:li and he:1lth services
or via a toll-tree telephone number.
(6) All complaints specifically related to nurse-delegation shall be referred to the nursing C:lfe quality assurance
commission.
(7) No certified community residential program for the
development:llly disabled. licensed adult f:lmily home. or
licensed boarding home contraCting to provide assisted living
services mav discriminate or ret:lIiate in Jny manner Jgainst
a person beCause the person made a complaint or .:oopc:r:ued
in the invcsthz:nion of a complaint.
(8) No p';:rson may coerce a nurse into compromising
patient safety by requiring the nurse to delegate if the nurse
determines it is inappropriate to do so. Nurses shall not be
(7113198)

~.Q60.

§ 2~960.li1ed

. WAC 246-340·970 Rescinding delegation. (1) The
registered nurse may rescind delegation of the nursing task
based on the following circumstances which may include.
but are not limited to:
(a) When the nurse believes patient safety is being
compromised;
(b) When the patient's condition is no longer stable and
predictable;
(c) When the frequency of staff turnover makes delegation impractic:lI to continue in the setting;
(d) When there is a change in the nursing assistant's
willingness or competency to do the wk:
(e) When the task is not being performed correctly: or
(f) When the patient or authorized representative
requests' that the delegation be rescinded.
(2) [n the event delegation is rescinded. the delegating
registered nurse assumes responsibility for performing the
task or initiating and participating in developing an alternative plan to ensure the continuity for the provision of the
task.
(3) The delegating registered nurse must document the
reason for rescinding delegation of the task :lnd the plan for
ensuring continuity of the task.
lSl:I1Ulory Aul/tOrily: Ch:lpler 18.~9 RCW 96..15"J60. § :.:6·340·970. tiled
2119196. eifectivc: 3121/96.1

WAC 2~6·840·980 Evaluation of nurse delegation.
The nurse must participate in recordkeeping as required by
the secretary of health to facilitate evaluation.
lS~Ulory

Authomy: Cll:lpler
2119196. effeaivc: Y~1/96.1

IS.~9

RCW 96..)5.060. §

!~3-IG-980.

filed

WAC 2~6-840-990 Fees and renewal cycle. (1)
Licenses for pr:lctical nurse and registered nurse must be
renewed every ye:lf on the pr.1Clitioner's birthday as provided
in chapter 246-12 WAC. Part 2.
(2) Licenses for advanced registered nurse must be
renewed every two years on the practitioner's birthday as
provided in chapter 246·12 WAC. Pm 2.
(3) The following nonrefundable fees shall be charged
by the health professions quality assurance division of the
department of health. Persons who hold In R1"l and an LPN
license shall be charged separJte fees for each license.
Persons who are licensed as an advJnced registered nurse
practitioner in more than one specialty will be ch:lfged a fee
for each speci:lity:

~ttachment _...lX'.-:;..__

leh. ~ WAC-p.291

1168

}

STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
OFfiCE OF CORRECTIONAL OPERATrONS
TWIN RIVERS CORRECTIONAL CENTER I SPECIAL OFFENDER CENTER
PO BOX 514 • Monroe. Washington 98272·0514 • (360) 794-2200
FAX (3601 794-2314

September 24, 1998

TO:

Gloria WagI}er, Registered Nurse 2

FROM:

Teresa

~APaU~ CJ t-:3
Bo~r, R~s~ed Nurse 3

Regarding: Memo of Counseling
~

An incident occurred during ~ d line on 8/31/98 in which you
dispensed medication to I / M _ and then failed to immediately
chart this fact, as required by law and as further directed by Ella Ray Sigmund
in a memo to RN's dated 8/13/98. By your signature on Ms. Sigmund's memo,
you acknowledged that you were aware of the directive prior to the occurrence
of this 8/31/98 incident.
.

an

I sent you
e-mail on 9/12/98 to refresh your memory relative to the content
of Ms. Sigmund's 8/13/98 directive.
By your failure to adhere to lawfully mandated and management reinforced
prescribed procedure in the process of medication distribution, you were
directly responsible for the overdose of medication received by I / M _ o n
the evening of 8/31/98. Such neglect of duty at the least caused considerable
discomfort for I/M_and if you persist in such practice, could present a'
future situation of life-threatening proportion.
.....

I am now advising you that any future disregard of Ms. Sigmund's 8/13/98
directive regarding medication charting procedures will result in further
corrective/ disciplinary action up to and including dismissal from your
employment with the Department of Corrections.
cc: Personnel file
TB:ap

~ttachment __Cf
........;; ; ; _
~

P

•

r_ .....

!_.·.. . . . ,

·Warlom: T()(lp.'r.p.r fnr SAFE Cnmm'If1it;p<:"

1169

---

.~

..

---,

--

r-.V4

~ooa

...
1 was presQt 08 ~ 18, 19 1Ilc) JG, 1998; wIIeJllU'l3 Te!'eS4 BoUfupr

. stated she pve.1I verbal directive reprdiDcmmatc coD1pbiat3.
1 do Dot reaD hurla. the aUeted verbcl dlnedve stadJIlll1lr!1S will
phy3icaDy lUess !lIlY iamate campla!luD' of. physical abaoMll81ity.
/0-/,:3-'1' &'
])ace

0'Date
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Date

---'-------------=D:-at-e---N.ml
Name

Dace

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I WAS NOT PRESENT ON MAY 18, 19•.20, 1998. WHEN TERESA
BOLLINGER, !HEN ACTING TEMPORARY RN3. GAVE A VERBAL
DIR.ECTIVE REGARDING INMA1E COMPLAINTS. 100 NOT
RECALL HEARING nm ALLEGED VERBAL DIRECTTVE s'rATlNG
NURSES WILL PHYSICALLY ASSESS ANY INMATE COMPLAOO:NG
OF A PHYSICAL ABNORMALITY.

..'1

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36e 794 2S69

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•

*** CONFIDENTIAL ***

DEPARTMENT OF CORRECTIONS
DISCIPLINARY ACTION AUTHORIZATION
Gloria

Wagner

employee's Name

RECOMMENDED ACTION:

2/4199
Date Received at Headquarters

RIP 5% x 6 months IS

Reduction in Pay:

(Percentage/Length)

RN2

Demotion to:

Employee's JOD Classification

(Total S Amount)

----~~,---,,--.,..-----

(JOD Classification)

soc

Suspension: _ _---:,--

employee'S Job Location

Dismissal:
Chris Graham
Assigned Personnel Officer/Phone fI.

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(Tolal S Loss)

----"""':'::C::---:--------(Effective)

Date c:cmpleted fonn faxed to PO

The attached disciplinary action has been reviewed as noted below. "This infonnation is provided under the
attorney/client relationship and invokes that privilege. It should be considered CONFIDENTIAL in nature."

Approve

InitialslTiUe

Date

HR Administrator

Lf-lO

~

AAG

Appropriate Deputy
Secretary

DOC Secretary

4:20

Disapprove

Comments

V

V

....

~;)~

t<?~

Please hand deliver to all reviewers and return to Leslie Carrigg, HR , 8th Floor, upon completion.

1173

•

*** CONFIDENTIAL ***
DEPARTMENT OF CORRECTIONS
DISCIPLINARY ACTlON AUTHORIZATION
_ _ _ _ _ _...;;G;,;.;lona;,;.;·,;;;

:-w,,:,,:a~g.;..ne.;.;,r

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EmpIayeo'S Name

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Oats Received at Headquarte~

RN2

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En'lllloyee's JOD Classllicallon

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soc

RECOMMENCED ACTlON:
Redue:ton in Pay:
(Percantagel!.ength)

Demotion to:

IS
(Total SAmount)

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.

5uspen~ion:

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(Total S LosSI

Employee's JoD !.:leaDon

c.'1ns Gr.anam
Assigned Personnel Officer/Phone #

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Dismissal:

Susp (/by dismissal
(Effec::ve)

---=-4- -5 4'5,-=-_
Date completed

~rm

faxed

:0 PO

The attached disciplinary action has been reviewed as noted below. "This information is provided under the
attorney/dient relationship and inVokes :hat privilege. It should be considered CONFIDENTIAL in nature.~
I

~~.

I

I

InitiatslTiUe

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~:~~d'
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cjJfV'

Date:

0/2-/((1,

Disapprove

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Comments

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Appropriate Deputy
secretary

II

Doc:s~er
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,

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.

'15/::;(1
., I : !

/

."

Please hand deliver to all reviewers and return to Leslie Carrigg, HR . 8th Floor. upon complelion.

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P.filI2

DRAFT

Date

PERSONAL AND CONFIDENTIAL DELIVERY

Gl . W

Ms. Wagner:
This is official notification of your suspension without pay from your position
as a Registered Nurse 2 with the Department of Corrections at the Special
Offender Unit of Monroe Correctional Complex from _date_ to _datc_ to
be followed by your immediate dismissal at the end of your regularly
!c:teduled shift on _date.

This disciplinary action is taken pursuant to the Civil Service Law of
Washington State, Chapter 41.06 Revised Code of Washington, and the Merit
System Rules, Title 356 Washington Administrative Code (WAC) Section 35634-010 (1) (a) Neglect of duty, (h) Gross misconduct. (i) Willful violation of the
published employing agency or department of personnel rules or regulations
and 356-34-040, Diamia.at· N'Ot1ficatiOIl. and 356-34-050. au.pealoD •
J'ollowed by Diamiaaa1.
Specifically, you neglected your duty. committed an act of gross misconduct
and willfully violated published agency rules, when. on 1/22/98. you failed
to mcet the basic standards of nursing care in physically assessing a medical
compla.int by tnmate_andyou also failed to document his
medical complaint in ~ log, as well as, Inmate_medical tile.
The evidence indicates that you received a call in the infirmary at
approximately 6: 10 PM on 7/22/98 from Karen McLellan, Correctional

117~

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Wagner· Page 2
Office:r 2 onl unit, that Inmate.was complaining that he was having
trouble getting air. You in tum asked C/O McLellan if Inmat.was having
a problem speaking,. to which C/O McLellan responded, "no". You then
stated to C/O McLellan that you were starting medication lines, that this
was a usual complaint from lnmatea that his cell was probably hot and
stUffy, and told C/O McLellan to have Inmat.take a cool shower to help
him feel better. You also told C/O Mclellan, "if he continues to complain,
call me back." You continued with medication lines and heard no more from
the unit. As you finished medication lines you infonned RN 2 Mike Kalina
oC C/O McLellan's call regarding Inmat_ Without physically assessing
Inmat. complain t and as you had heard nothing more from the unit staff
regarding Inmate.complaint, you and RN 2 Kalina decided it was not ~
emergent situation and RN 2 Kalina agreed to check on Inmate.at
Iockdown medication line. which was at approximately 8:30 PM. When RN2
Kalina checked on Inmatellhe was ObSCIVCd to be asleep and snorir,i:.
There. was no indication that R.1\f2 Kalina communicatcd with Inmate_to
check his p~ical status or with u."1it staff regarding any further complaints
that (nmate~ay have made.
At approximately 10:34 PM on 7/'2'2/98, which was after your shift and you
were no longer in the institution, C/O 2 James Smith contacted the
lnfirmary and asked RN 2 ~ann Cave to check on Inmate. C/O Smith
further reported to RN 2 Cave that Inmatcllhad not changed positions in
approximately ninety minutes and that his feet appeared pale. RN 2 Cave
indicated that she was unaware of any complaint from Inmate_as there
had been no ~mentationof any complaint from him in the infirmary log
nor in Inmate_medical record. (,
_

During the Administrative Comment3 investigation of this incident, yo
indicated co Ella Ray Sigmund. CMHPM and Acting Associate:
Superintendent, that Inmatellhad made similar complaints in the past and
.'
"e not always documented. I[-should be rIOted -that
Inmatelliied in his cell that evening".:------_.
An Employee Condc.ct Re:port initiated on 8/3/98 describing this incident in
greater detail is attached (Attachment # 1) hereto and incorporated herein.

Inmate.ampt.lnt of havillC dimculty getting air is aipUlcut to his
documented phyalcal problom ot whi~h a1llDodl~a1 .taft", ln~l\1cliDg
youne1f, were aware. The knOWledge ot this medi~al atgn!f1cance is
lntormation you should. have re.poneled to.
The Department of Corrections Employee: Handbook state:s. in part, unde:,
Department Objectives, on pages 1 a."'1d 2:

-

.

___

" ..... - . . . - ~ ~

•.

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_ _ .... , _ _

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•
Wagner· Page 3

The department's main objectives are to:

• Buure aaf'ety (or•••oft'eZlden; (emphasis added)
• Treat all oft'eZlden...rauly and equitablYi (emphasis added)

.• Meet the ut1aaalltaDdarda appropriate to the State of
WuhiDltoll (emphasis added)
and also states, in part, under

~de

ot EWca on page 2:

._HJp DlorallUld ethieal atandar. amoll' eorreetional
em.ploy.e. are .11.atia! for the luccess of the department'.
proaram" Th. Oepartmel1t of Cornc:tloll' 8ub.crib•• to •
coele ot 1UI1'aUbaC boD.lty, :e.pect tor cUplty and
buUviduality of human beiDp, mel a commitment to
professional and compassionate lamea. (emphasis added)
and further states, in part. under ~partmellt Expeetatiolla, on page 2:
As a representative of the Department of Corrections, you will be
expected to:

• Serve eaeh offender with appropriate
welfare..• (emphasis added)

COliC ern

Cor their

On 11/24/93, you acknowledged :,cceipt of the June 1993 Employee
Handbook, further agre~ing to becoce familiar with and have a thorough
knowledge and understanding of its contents. Copies of pages 1 and 2 o( the
1993 Employee Handbook {Attachment i2}, and your acknowledgment orits
receipt (Attachment #f3) are attached hereto and incorporated herein.

The classification questionnaire (CQ) for your RN 2 position, HB36, which
. outlines its duties states, in part, ullder "Employee's Statement or Duties":
Provide ollioini nuninC treatment and emerlency
treatment aa lIee••lary. (emphasis added)
Maintains profe•• low nursing cue integrity as It IlppUes
ta... delivery of ••me•. (emphasis added)

1.17B

•

Wagner· Page 4
. A copy of the CQ for your position, HB36. is attached (Attachment #4) hereto
and incorporated herein.
RCW 18.130, Replatioll ot Health Prote••ioD•• l1nitorm Disciplinary
Act, states, in part, under RCW 18.130.180, Unprofesaional conduct,
sUbparagraph 4:
The following conduct, acts, or conditions constitute
unprofessional conduct for any license holder or applicant under
the jurisdiction of this chapter:
._(4) IDcompetenc8, nellic.nce, or malpractice which relulb
in 1zljury to a pationt or which create. an 111U'ealonable
riak that • patient may be harmed. (emphasis added)
A copy of RCW 18.130.180 (4) is at:aclled (Attachment N5}1 hereto and
incorporated herein.

WAC 246-840. Practical and Ralistared NursUaI, states, in part, under
WAC 246·840-700, Standard. of Duninc conduct or practice:
...Bach individual, upon enterlDi the practice or nutlful,
aaaumes a. meuu:e of reaponaibWty and public trust and the

correapondiDl oblilation to adhere to the standards of
Auninl practice. The nurse ahall be 1'1!IlIponaible and
accountable ror the quality ot nuniul care given to client••
The atandards of nuninl conduct or practice include, but
are Dot Umited to the (aUawin,:
FOR REGISTERED NURSES:
(1) Kuninl proce..:

(a) The re&1.tlred nune shall collect pertinent obj~ctive and
lubjectiv. data reprdlnc the health statu. 01 the cUent.
(e) The reliatered Dll.%'H shan communicate lipil1cant
chaD.e. in the client'. statu. to appropriate members of
the health car. team. Th!. communication shall take
place in a time period consistent with the cllel1t'. need

tor care.

,
117~

r

.
Wagner - Page 5

(el) The AIi.tared Duzae ahaD document. OD. ODelltial elleat
recorda, the Dtu.tne cue pen aDd the cUent'. reapOMe
to that care.

(a) The raptered

DUrie

,hall have bowJedle aDd

1Ulderatancllq of tho 1&... and rule. recuIatiDllluniDc and

.haD f\mCtioD within the lepllcope or D11DUlg pnctice.
(emphasis added)
A copy of WAC

246~a40-700

I

Standard. of Duralnl cODduct or practice:

rcR UGISTEUD NURSES, is attached (Attachment 1#6) hereto and
incorporateCi herein.

WAC 246~a40. Practical aJld Regiatered Nursing, states, in part, under
WAC 246~a40-710, ViolatioDs or standards or nurainc conduct or
practtc~:

The rouowtnl will lerve aa a pidellDe tor the nurae aa to the
acts, practic•• or omia.toa. that an incoDIi.tellt with
pnerally accepted standarda ot Durable conduct or
practice .••Such conduct or practice mcludes, but 11 not
Umited to the (ollowin&:

(1) '.llure to adhere to the ltaDdard. eDWIlerated in WAC
~46·840-7OC(1) which may mclude:

(a) 'a11lnl to asa... and evaluate a ellent'. status or
falling to In.titute l1ur.ing IDtetventio!l .a required by
the cUent', condition.

(b) WU11W1y or repeatedly ramnS to report or document a
client'. aymptom., reapoDles, prop••,
medication, or other nuniDI caro accurately azul/or
intelligibly.
(e) WUlfully or rep.atedly fai1inc to make entrie., altodul
entrie., cie.troyinc entries, maJdDl incorrect or
m.lible e!lUie. Ineilor maldDI £al.o .utri•• in Rcarcla
pertaining to the giving ot medication, treatments, or
other lIunlna care. (emphasis added)
A copy of WAC 246-840-710. Violation. at ,tandarda ot Duntssc or
practice, is attached (Attachment 1#7) here~ and incorporated herein.

... ~

p.e7

•
Wagner - Page 6

WAC 246-840, Pnctical aDel ReptereciRusiq, states, in Part. under
WAC 246-840-960, AccoWltabWty, UabBlty, ad coercloa, subparagraph
1:
(1) The recfatllrecl D1U'88 ud. Durable a88istaDt are
.ccoUDt.~J. for their 0W1l butlvtclual ac:t!oll8 iJl the
cle1epUoQ proc.... The cIe1eptaci talk 'ecom•• the
n.poDaibUlty or the penoll to whom. It is de1epted but
the l'eptared Dune retabu ovenll accoUDtabWty' tor the
Bunmc cue of the p.deD~ mc1ud1n l JlW'stne
....s8mant, ,valuatioll, and uaurizll documentatioD 1.
completed. (emphasis added)
A copy of WAC 246-840-960, AceountabWty, Uability, and coerciou, is
attached (Attachment #8) hereto and incorporated herein.
~

You were aware, or should have been aware of the foregoing provisions of
RCW 18.13.180 and WAC's 246-8a.0-100, 246-840-110, and 246-840-960,
as evidenced by the fact that you have been a licensed Registered Nurse
within the State of Washington since gaining employment with the
Department of Corrections on 9/21/87.
As an employee and Registered Nurse 2 with the Department of Corrections

at the Special Offender Unit of Monroe: Correctional Complex, you have a
duty and obligation to:
1. Adhere to its policies and procedures, which are designed to
ensure the efficient and c1Tective management of the Department's
programs;
2. Ensure the safety for offenders; to treat all offenders fairly and
equitably; and to meet the national standards appropriate to the:
State of Washington;
3. Ensure the high moral and ethical standards the department
expects of its employee$ to rnsure the success of its programs;
4. Perform your duties in a professional. competent and
compassionate manner,
5. Meet the expectations of the agency as a whole.
6. Serve each offender with appropriate concern for their welfare; and

118.1

369 794

p.ee

2::169

Wagner· Page 7

1. Meet the department's expectations that you would meet the laws
and regulations of the State of Washington regarding nuning care
and the standards of nursing conduct or practice, required for
licensure as a registered nurse, which includes: the accountability
for the quality of nursing care given to a client; and the gatheriJ1g
and documentation of pertinent data regarding the health status of
the client in essential medical records.
Inmate. complaint of having difficulty getting air is significant to his
documented overall medical condition, which all medical staff, including
yourself, "(ere aware or should have been aware. Given his overall mc:dic~
condition, there was, according to Dr. Jonas, WSRU Contract Physidan, who
I had review this incident, medical significance to his complaint, which you
should have responded to. Even though you indicated during the course of
the investigation of this incident that Inmate. had made numerous medical
complaints of a similar nature, it was noted in a review of his medical chart
that those "similar'" complaints had not been charted.
Additionally, while you relied on the observation of a correctional officer that
he was able to speak, it should be noted that correctional officers are not
medical staff and are not qualified nor are they expected to conduct medical
assessments of inmates. Also. while you did not hear
from unit
correctional staff of any further complaints from Inmate you took no
affirmative action after completL'"1g medication lines to ascertain his physical
status in person or by calling unit staff to check on him. Instead you waited
until approximately 8:30 PM to have Inmate .checked on by RN 2 Kalina.

blk

Finally. even though you hac received an indication from correctional staff of
Inma. physical complaint, you failed to appropriately document that
complaint in either the inrumarj log or his medical chart.
By your behavior ir. this incident, you have clearly demonstrated:

1. A neglect of your duty and obligation to meet the reasonable
e:cpectations of the Department that you would adhere to its
policies and procedures; that you would ensure for the safety of its
inmates and treat all offenders fairly and equitably; to meet the
national standards appropriate to the State of Washington; that you
would perform your duties in a professional, competent and
compassionate manner, se:ving each offender with appropriate:
concern for their welfare: and that you would meet the laws and
regulations of the Sta.te of Washington regarding nursing care and

118Z

p.eg

•
"{aguer • Page

'i

a

the standards of nursing conduct or practice required for your
licensure as a registered nurse. These charges are based on your
behavior oC t'ailing to appropriately provide a physical assessment of
Inmate.after receiving a call at 6:10 PM on 1/22/98 from a
correctional officer who said Inmate.as complaining that he was
having trouble getting air, and your failure to take any affirmative
action, after completing medication lines, to ascertain his physical
status or calling unit staif to check on him until approximately 8:30
PM.
2. A neglect of your duty to me:t the reasonable expectations of the
Department that you would obey a111aws while on duty, which.
included the laws and regulations of the State of Washington
regarding nursing care and the standards oC nursing conduct or
practice required for your licensure as a registered nurse, to
include: accountability for the qual~ty of nursing care given to a
client; and the collection and documentation of pertinent data
regarding the health statUs oi the client in essential medical
records. These charges are based on your failure to document his
m.edical complaint in the infir.nary log and Inmate"medical file.
This lack of dOC'..lmentation failed to provide the next shift nurse
wit."1 necessary information needed to properly assess Inmat~
later that evening. Dur.r.g the Administrative Comments meeting
with Ma. Sigmund, you also indicated that you did not document in
his medical file any of the numerous similar complaints that he had
made about his difficult'j getting air and that his complaints were
many and delusional in r.at"..ll"e and that you did not document
them as well.
.
3. A neglect of your duty to ~eet the reasonable expectations outlined
in your Registered Nur3e 2 position's Classification Questionnaire,
HB36. to provide ongoing !'!uning treatment and emergency
treatlnent as necesaary; ar.d to maintain proCesaional nursing care
integrity as it applies to deHvery of service. These charges are based
on your behavior of failing to appropriately provide a physical
assessment of Inmat.after receiving a call at 6: 10 PM on
7/22/98 from a correctional officer who said Inmat.was
complaining that he was having trouble getting air; your failure to
take any affinnative action. after completing medication lines. to
ascertain his physical stat'..:.s or calling unit staff to check on him
until approximately 8:30 PMj and your failure to document his
medical complaint in ±e ~nrmnary log and Inmate_medical
chart. This lack of docume:ltation failed to provide the n~t shift

lt8~ .. ··

"~R-al-99

e~:32

PM

WSR

PERSCHHE~

OFFICE

360 7'94 2S69

•

Wagner· Page 9
nurse with necessary information needed to properly assess Inmate
.later that evening.

4. A willful violation of the Department of Corrections Employee
Handbook by your failw-e to: assist the department in meeting its
objective of ensuring the efficient and effective management oC its
programs, the safety of its offenders, that all offenders would be
treated fairly and equitably, and that the national standards
appropriate to the State of Washington would be met; meet the
moral and ethical standards of the department that you would
perform your Registered Nur~e 2 duties in a professional and
competent manner, meet the expectations of the department tha~
YQu would obey alllaw3 while on dUty, which includes the laws and
regulations of the State of Washington regarding nursing care and
the standards of nursing conduct or practice required for your
licensure as registered nune; and tl') serve each offender with
appropriate concern for their welfare. These charges arc based on
your behavior of failinLto appropriately provide a physical
assessment of Inmate.after receiving a call at 6:10 PM on
7/22/98 from a correc:ional oificer who said Inmat.was
complaining that he was haVing trouble getting air, your failure to
take any affirmative action, after completing medication lines, to
ascertain his physical Status or calling unit staff to check on him
until approximately 8:30 PM; and your failure to document his
medical complaint in the infirmary log and Inmatell medical
chart. This lack of documentation failed to provide the next shift
nurse wit."l necessary infoI":I1ation needed to properly aSBess Inmate
" later that evening.
5. Gross misconduct by your blatant and l1agrant disregard for the
stated objectives and ethics of the Department of Corrections to
ensure the safety of offenders; to treat all offenders fairly and
equitably; to meet the national standards appropriate to the State
of Washington; and to subsc:ibe to a code of unfailing honesty,
respect for dignity and individuality of human beings, and a
commitment to professional and compassionate service, all of which
adversely impacts the Deparartment's ability to carry out its
mission and functions. These charges are based on your behavior
of failing to appropriately provide a physical assessment of [nmate
IIIUter receiving a call at 6: 10 PM on 7/22/98 from a correctional
officer who said lnmace.as complaining that he was having
trouble getting air: your failure to take any affirmative action, after
completing medication lL."es, to ascertain his physical status or
•

0'.

"AR-el-99 e4:33 PM

WSR

PERSONNE~

OFFICE

369 794

2~69

P.l1

Wagner· Page 10
calling unit staff to check on him until approximately 8:30 PM; and
your failure_todocument his medical complaint in the
lag
and Inmate
medical chart. This lack oC documentation failed to
provide the next shift nurse with necessary information needed to
properly assess Inmate. later that evening.

infirmarY

In reviewing your personnel file I find:
1. A Memo of Counseling dated 9/24/98, from your supervisor. R.~ 3
Bollinger. which addressed your behavior of 8/31/98, dispensing
medication to Inmat
, and failing to immediately chart that
inforTlU!-tion, as required by law and as further directed by Ella Ray .
Sigmund, CMHPM in a memo to RN's dated 8/13/98. 8y your failure to
do so, you were directly responsible for an overdose of medication
received by Inmate. (Attachment #9)
A copy oC the foregoing document from you.:- personnel
(Attachment Jl9) hereto and incorporated he:"cin.

rue is attached

On 11/24/98, I met with you at a pre-termination meeting. Alsopresent
was Mike Wilson, Business Agent. Teamsters Local #313, and your employee
representative; Mark AndeT'son, Attorney, Teamsters Local ##313; Dinnie
Burnham, Teamster Local #313 Shep Steward; Bob Riordan, Human
Resource Manager, Monroe Correctional Complex (MCC); Linda Gilstrap,
PeI1lonnel Officer at the Special Offender Unit (SOU); and Chris Graham.
newly appointed Personnel Office:- at the Special Offender Unit, as an
observer. The purpose of the meeting was to give you the opportunity to
present me with any information that you wanted me to consider prior to my
making a decision.

0._1 \( At the meeting, Mr. Wilson indicated that six out of the seven registered

)V ._~,z ~ nurses at SOU had indicated that they had not received the verbal directivs.
'. a~I
from RN 3 Bollinger to physically assessany inmate who complained of any
.~~ ~
Jv

ta....of

physical abnormality at the meetings or. 5/18. 5/19, and 5/20/98. He
~~ r/ additionally indicated that 7/22/98 was the hottest day oC the year and that

'}J" . your decision not to physically assess Inmate_complaint of not getting air

t~?~~ was based to an extent on that fact. Mr. Wilson also indicated that Inmate"

'.1/"

/'ijfl"

I'

had been at SOU for (our years and had many similar complaints, which
when physically assessed, were determined to be medically unfounded. Mr.
Wilson also indicated that later in the evening of 7/22/98, CO Benda
reported that Inmate.was tying on the floor and when asked if he was
okay, Inmat.esponded "Yes, I'm a little hot.. .I took a show~r, I'm OK."

..

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P'inally, Mr. Wilson presented a magume article that spoke to the physical
aspect of dehydration <?fpatients who were on psychotropic drugs.

Mr. Wilson went on to indicate that there was no reason for you to document.
Inmate.omplaint, as when RN 2 Mike Kalina checked on Inmate.at
8:30PM, Inmate. reported that he was OK. Mr. Wilson stated that physical
complaints are only documented when the inmate is not okay. He further
indicated that if you had received more complaints from Inmate. you would
have gone to physically assess him, but, since you· hadn't received any and
RN2 Kalina had reported that Inmate.was okay, there wasn't a need to
physically assess him.
In response ta Mr. Riardan's indication that physical assessment and
medical charting of Inmate. physical complaints were essential to the
attending physician in fannulating medical history and follow-up and were
required by nuning practice and standards "r nursing practice, Mr.
Anderson indicated that you had not violated nursing practices or laws as
RN2 Kalina was the one who assessed Inmate. discussed his report to you
that the Inmate had said he was okay. and it should have been RN2 Kalina
who should have documented/charted that assessment.
•

Ms. Burnham indicated that the manner in which you responded ta Inmate
complaint through Correctional Officer McLellan, Le., phone triage, was a
standard practice throughout Monroe Correctional Complex.
Finally, Mr. Wilson indicated that you had worked within Monroe
Correctional Comple:c at· the Washing~on State Reformatary and SOU for the
past 11 years, had no previous co~ective/disciplinaryactions noted in your
personnel record. and, in fact, your performance evaluations were above
average. Accordingly, he asked that the misconduct be withdrawn.
With respect to the foregoing issues/information presented to me at our
meeting, the following is provided:
1. Issue: Six out of seven registered nurses at SOU indicated that
they had not received the verbal directive from RN 3 Bollinger to
physically assess any inmate who complained of any physical
abnormality at meetings on 5/ lB, 5/19) and 5/20/98.
Mr. Wilson indicated that he could get signed statements from the
six of the seven RN's he spoke with (which included you and RN 2
Kalina) to suppo~t his claim. Mr. Wilson subsequently provided
copies af three memorandums signed by you and four other RN2's
. 'J

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Wagner - Page 12
indicating that they were present on the dates of the meetings, but
did not recall hearing the verbal directive from RN 3 Bollinger to
physically assess any inmate complaining of a physical
abnormality; another memorandum signed by Linda Fluke,
Corrections Health Care Specialist 2, that indicated that she may
have been at the meetings on 5/18 and 19, but, not on 5/20, and
did not recall hearing or hearing about the directive from RN 3
Bollinger; and a memorandum from RN 2' Roy Darnell, that
indicated that while he was not at the meetings, he did not recall
hearing about the alleged directive from RN 3 Bollinger.
Based on the foregoing, I am ma..'cing a finding of no misconduct.
reJative to the allegation that you failed to follow the verbal directive
Cram RN 3 Bollinger to physically assess an inmate any time they
complained of a physical abnormality.
Copies of the foregoing memorandums submitted regarding this
issue are attached (Attachment 1# 10) hereto and incorporated
herein.
2. Issue: Many similar complaints from Inmate! which when

physically assessed, wer-e determined

to be me

ically urJ"ounded.

It is interesting to note that, while on the one hand Mr. Wilson
made the indication that six of seven registered nurses indicated
that they had not received Ms. Sollinger's ver-bal directive to
physically assess inmate complaints, on the other hand he made
this statement re.din g previous "similar'" physical complaints
made by Inmate
It should be noted here, that when I had
medical staff review Inmate
medical file for a one year period,
documentation revealed that he was seen, on average, 1-2 times per
month by nursing staff; at least one time per month by a
Correctional Health Care Specialist; and only one entry
documenting a medical encounter by nursing staff while he was on
his living unit. It is apparent to me from this statement, that if
nursing staff had been physically aAea.IDI Jnmatollmedlcal
complaints, they were not appropriately documenting! charting
those complaints in his medical me, which as previously indicated,
would not meet WAC 246-840-100, Sta2ldarcla or Nurabll Conduct
or Practice.

II

Additionally, in speaking with Ms. Sigmund regarding mentally ill
inmates, which is the reason for Inmat.being treated at SOU,

I1s7

MAR-el-99 84:34 PM

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Wagner· Page 13
she reiterated to me that those inmates oftentimes have difficulty in
verbalizing/communicating the exact nature of their medical
complaints, and, accordingly, that is the verj reason that their
physical complaints should always be medically assessed.

3. Issue: There was no reason for you to document Inmate.
complaint, as when RN 2 Kalina checked on him at 8:30PM, Inmate
~dicated. he was okay; Mr. Wilson's further indication that .
physical complaints are only documented when the inmate is not
okay; and that, according to Mr. Wilson. should you have received
%!lore complaints from Inmate. you would have gone to physically
assess him.

Neither Mr. Wilson nor t are medical professionals. Accordingly, I
spoke with Dr. Jonas, WSRU contr=\ct physician, who in tum
indicated to me, that, in his opinion, [nmates.physical
complaint 1ft. ot medical liIDJ11cance to him and that, pven
lmDat• • oQra11 medical eond1tioD, such a complaint should
not oal,. have be.n documented. but, physically •••elled, aa
well.
Issue: Phone triage being a standard practice throughout Monroe
Correctional Complex.
. While phone triage may be appropriate in non·ernergent situations,
i.e.• a cold, headache. toothache, severe ankle pain from an ankle
injury, etc., as I indicated to Ms. Burnham during our me~tingl it
has always been my e:cpec:ation, during my tenure as
Supe~.ntend.entof the Washington State Reformatory, that nursing
etaif' would physically assess inmate physical complaints that could
be potentially life·thrcatening. As I indicated to you in Issue #4, it
was the medical opinion of Dr. Jonas. that given the ove:-all medical
condition of lnma. his physical complaint of not being able to
-get air", was of medical significance. should have been physically
assessed. then documented. Accordingly, phone triage in this
incident demonstrated poor nuning jUdgment on your part, a
failure of you to meet acceptable standards of nursing care
expected of a licensed registered nurse, and was an inappropriate
response to his physical complaint.
I

In conclusion and full consideration oi the foregoing, I have determined to
dismiss you from your position as a Registered Nurse 2 with the Department

11.81

"~~-e1-99

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36e 794 2569

•
Wagner - Page 14
of Corrections at Monroe Correctional Complex as indicated in paragraph
one of this letter.
Under the provisions of Washington Codes 358-20-010 and 040, you have
the righl to"appeal this action to the Personnel Appeals Board, 2828 Capitol
Boulevard, Olympia, Washington, 98504, within thirty (30) days Cram the
effective date stated in paragraph one of this letter.
The Merit S}"3tem rules (WACS), Department of Corrections' policies, Monroe
Correctional Complex-Special Otre.~er Center Field Instructions and the
Collective Bargaining Agreement are available for your review upon request. -

.~~
Superintende:lt
KDC:cg
Attachments
cc: Dave Savage, Deputy Secretary, OCO
Eldon Vail, Assistant Deput'"j Secretary, OCO
Phil Stanley, NW Regional Administrator
Jennie Adkins, Human Resources Administrator, OAS
Linda Dalton, Senior Assistant Attorney General
Cheryl Landers, NW Region Human Resource Manager
Bob Riordan, MCC Human Resource Manager
Personnel File

P.l~

"

.»

..
'

.

'!

.....

-

*** CONFIDENTIAL ***

. DEPARTMENT OF CORRECTIONS
DISCIPLINARY ACTION
_ _ _ _ _---.,;G~lo:;.:.n:.=·a

@~ ~ ~ nVI ~ In)

AUTHORIZATIO~tl

:"'"W~a.>Lgn"-er'-------

employee'S Name

FEB 0 9 1999

OFFICE OF THE ATIORNEY GENERAL
LABOR & PERSONNa DIViSION

RECOMMENDED ACTION:

214/99
Date Received at Headquarters

Reduction in Pay:

IS
(PereentageJlength)

RN2

Demotion to:

Employee's Job Classification

SOC

Suspension:

Employee's Job Location

(Total $ Amount)

-----:-:--=--=--~---(Job Classification)

IS

--~:--~---~~~--

(Length)

Dismissal:
Chris Graham

(Total SLoss)

Susp f/by dismissal
(Effective)

------"..;;..;.:;"=':'--'~....;..;."'------

Assigned Personnel OfficertPhone #
Date completed form faxed to PO

The attached disciplinary action has been reviewed as noted below. "This information is provided under the
attorney/dient relationship and invokes that privilege. It should be considered CONFIDENTIAL in nature:

InitialsITIUe

I

AAG

Date

1"2/11

Approve

Disapprove

.i

Comments

I

/'19

~====-' -----i....--~
I

Appropriate Deputy
Seaetary

DOC Secretary

Please hand deliver to all reviewers and return to Leslie Carrigg, HR ,8th Floor, upon completion.

1190

FE3-19-99 e4:se PM

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PERSONNEL OFFICE

:;6e 794 2:569

p.e:s

With ~~ct to ~e forcgOUti issuesfUlformation presented to me at our meeting, the
foJlowmllls provIded:
1. lss~: Six out of sev~ ~gistered nurses at SOU indicated tIult they had not
~c:elved the verbal ~uve frorn RN J Bollinger to physically assess any
Inmate who complamcd afmy physical abnonnaJity at meetings on 5/18,
5/19, and 5120/98.

Mr. Wilson indicated that he could iet 9igned statements from the six of the
seven RN's he spoke with (which included you and R&'l2 Kalina) to support
his claim. However, he never produced those statements at our mectins, nOf
at any subsequent meetings I had with him concerning you. Additionally. in
spcakinll with RN J Bollinger. she emph3tieaJly recalls presenting that
.
. directive from Ms. Sigmund at mcetinas on the dates indicated. She further
recalled writing a notc on a copy of the email fromMs.SiiOlund thnt the
directive bad been presented to all nursing staff. which Ms. Sigmund infonned
me, she recalls receiving and reviewing.
2. Issue: Many similar complaints from Inmatellwhich when physically
assessed, were determined to be medicaUy unfounded.
It is interesting to note: that, while on the one hand Mr. Wilson made the:
indication that six of seven regi~red nurses indicated that they had not
received Ms. Bollinaer' 3 verbal directive to physically assess inmate:
complaints, on the other hand h~ mnde this stlUcment regarding previous
"similar" physical complaints made by Utc.1t should be noted here. that
when I had medical staff review Inmate.medical file for a one yC:1f period.
documentation revealed that he was secn, on Olverage, 1-2 times per month by
nursing staff; at least one time per month by a Correctional He:llth Care
Specialist; and only one entry documenting a medical encounter by nursinQ
staff while he was an his living WliL It is apparent to me from this statement,
that if nursing staff had been pbyslc:slly asawing Inmatellmedlc:"
complaints, they were not appropriately docurnentinglchaning those
complaints in his medical file. which as previously indicated. would not me.:t
WAC 246-840-700, Standard. of~ursiDl: Conduct or Practice.
Additionally. in 9peaking with Ms. Siamund regarding mentally ill inmates.
which is the CC3Son for Inma. being treated at SOU, she reiterated to me:
that those inmates oftentimes have difficulty in verbalizing/communicating the
exact nature of their medical complaint3, and. accordingly. that is the very
reason that th~ir physical complaintS should always be medically assessed.
3. Issue: There was no reason for you to document lnmat~complaint.l1S
when R.'l2 KalinA checked on him at 8:30PM. Inmntel"iiidicnted he WIlS

119'1

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P.G4

•

okay; Mr. Wtlson's further indication that physical complaina are only
documented when the inmate is not okay; and tha~ accomiPe to Mr. Wilson.
should you have received morc complaints from Inmat~ou would have
lone to physically assess him.
Neither Mr. Wilson nor I are medical professionals. Accordingly, I spoke
with Dr. Jonas. WSRU contract physician, who in turn indicated to me, that.
in his opinion. rnmatcs.p.lica1 complaint was of medicil signiflcance to
him and tha~ pveD IDmate
overallmedleal conditioD, such a complaiat
.bould Dot ably have been documented, but, phYljally I.tsesaed, as WC~.
4. Issue: Phone triage being a stnndard practice throughout Monroe Correctional

. Complex.
While phone triaie may be appropriate in non·emergent situations. Le., a cold.
headache, toothache, severe ankle pain rmm an ankJc injury, etc., as I
indicated to Ms. Burnham during our meeting. it has always been my
expeetadon, during my tenure as Superintendent of the Washington State
Reformatory. that nu~ing staff would physically assess inmate physic:ll
complaints that could be potentially life-threatening. As [ indicated to you in
Issue #4, it was dte medical iiinion of Dr. Jonas, that given the overall
medical condition ofInmat~is physical complaint of not being able 10 "get
air", was of medical significance, should have been pbysicaJly assessed. then,
documented. Accordingly, phone triage in this incident demonstrated poor
nursinu jUdgment on your part, a failure of you to meet acceptable: standards of
nursing care expected of a licensed registered nurse, and was an inappropriate
response to his physical complaint.

f\~~' _:~{lfI1~

,119-2""

DRAFT
Date

PERSONAL AND CONFIDENTIAL DELIVERY

Ms. Wagner:
This is official notification of your suspension without pay from your position
as a Registered Nurse 2 with the Department of Corrections at the Special
Offender Unit of Monroe Correctional Complex from _date_ to _date_ to
be followed by your immediate dismissal at the end of your regularly
scheduled shift on _date.
This disciplinary action is taken pursuant to the Civil Service Law of
Washington State, Chapter 41.06 Revised Code of Washington, and the Merit
System Rules, Title 356 Washington Administrative Code (WAC) Section 35634-010 (1) (a) Neglect of duty, (d) Insubordination, (h) Gross misconduct, (i)
Willful violation of the published employing agency or department of
personnel rules or regulations and 356-34-040, Dismissal- Notification,
and 356-34-050, Suspension - Followed by Dismissal.
Specifically, you neglected your duty, were insubordinate, committed an act
of gross misconduct and willfully violated published agency rule~
7/22/98, you failed to provide a physical assessment of Inmate.........,
and you also failed to document his medical complaint in the infrrmary log,
as well as, Inmat. medical rue.
.
The evidence indicates that you received a call in the infirmary at
approximately 6: 10 PM on 7/22/98 from Karen Mclellan, Correctional
Officer 2 0rtlunit, that Inmate S was complaining that he was having

1193

Wagner - Page 2
trouble getting air. You in turn asked C/O Mclellan iflnmatellwas having
a problem speaking, to which C/O Mclellan responded, "no You then
stated to C/O McLellan that you weistarting medication lines, that this
was a usual complaint from Inmate that his cell was probably hot and
stuffy, and told C/O Mclellan to have Inmate_take a cool shower to help
him. feel better. You also told C/O Mclellan, "if he continues to complain,
call me back. You continued with medication lines and heard no more from
the unit. As you finished medication lines, you informed RN 2 Mike Kalina
of C/O McLellan's call regarding Inmatell You and RN 2 Kalina decided it
was not an emergent situation and RN 2 Kalina agreed to check on Inmate.
at lockdown medication line, which was at approximately 8:30 PM. At that
time, Inmatelllwas snoring and there was no verbal communication between
RN 2 Kalina and Inmate"
lll

•

lII

At approximately 10:34 PM on 7/22/98, C/O 2 James Smith contacted the
inf1T1l1ary and asked RN 2 Leann Cave to check on Inmate" C/O Smith
further reported to RN 2 Cave that Inmatellhad not changed positions in
approximately ninety minutes and that his feet appeared pale. RN 2 Cave
indicated that she was unaware of any complaint from Inmatellas there had
been no documentation of that complaint.
During the Administrative Comments investigation of this incident, you
indicated to Ella Ray Sigmund, CMHPM and Acting Associate
Superintendent, that Inmatellhad made similar complaints in the past and
that they were not always documented. It should be noted that Inmate
died in his cell that evening.
An Employee Conduct Report initiated on 8/3/98 describing this incident in
greater detail is attached (Attachment # 1) hereto and incorporated herein.
On May 18, 19 and 20, 1998, you were present in the infll"IIlary when RN 3
Teresa Bollinger, your supervisor, gave a verbal directive to all RN 2's that
they were to physically assess any inmate who complained of any physical
abnormality. This directive was based on a memo provided by Ella Ray
Sigmund, CMHPM.
Inmat.complaint of having difficulty getting air is significant to his
documented physical problem of which all medical staff, including yourself,
were aware. The lmowledge of this medical significance is information you
should have responded to.
The Department of Corrections Employee Handbook states, in part, under
Department Objectives, on pages 1 and 2:
The department's main objectives are to:

11~

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Wagner·
Page 3

• EDaure .afety for•••offenders; (emphasis added)
- Treat

an offenders••.fairly and equitably; (emphasis added)

• Meet the national standards appropriate to the State of
Washington (emphasis added)

and also states, in part, under Code of Ethics on page 2:
High moral and ethical standards among correctional
employees are essential for the succesa of the department's
programs. The Department of Corrections subscribes to a
. code of unfailing honesty, re.pect for cliInity and
individuality of human beings, and a commitment to
professional and compassionate service. (emphasis added)

and further states, in part, under Departm.ent Expectations, on page 2:
As a. .. employee of the department, you will have many things
to learn, not the least of which will be the expectations of
your .upervisor..••and agency as whole... (emphasis added)

a.

As a representative of the Department of Corrections, you will be
expected to:
•

Be a good citizen, obey aU laws while on and off
duty.••(emphasis added)

•

Serve each offender with appropriate concern for their
welfare and with no purpose of personal gain. (emphasis

added)
On 11/24/93, you acknowledged receipt of the June 1993 Employee
.Handbook, further agreeing to become familiar with and have a thorough
lmowledge and understanding of its contents. Copies of pages 1 and 2 of the
1993 Employee Handbook (Attachment #2), and your acknowledgment of its
receipt (Attachment #3) are attached hereto and incorporated herein.
The classification questionnaire (CQ) for your RN 2 position, HB36, which
outlines its duties states, in part, under "Employee's Statement of Duties":

Wagner - Page 4
Provide ongoing nursing treatment and emergency
treatment as necessary. (emphasis added)
Maintains professional nuraing care integrity as it applies
to•••delivery of service. (emphasis added)

A copy of the CQ for your position, HB36, is attached (Attachment #4) hereto
and incorporated herein.
RCW 18.130, Regulation of Health Professions - Uniform Disciplinary
states, in part, under RCW 18.130.180, Unprofessional conduct,
subparagraph 4:

A~

The following conduct, acts, or conditions constitute
unprofessional conduct for any license holder or applicant under
the jurisdiction of this chapter: ~
(4) Incompetence, negligence, or malpractice which results

in injury to a patient or which creates an unreasonable
risk that a patient may be harmed. (emphasis added)

A copy of RCW 18.130.180 (4) is attached (Attachment #5), hereto and
incorporated herein.
WAC 246-840, Practical and Registered Nursing, states, in part, under
WAC 246-840-700, Standards of nursing conduct or practice:
.••Each individual, upon entering the practice of nursing,
assumes a measure of responsibility and public trust and
the corresponding obligation to adhere to the standards of
nursing practice. The nurse shall be responsible and
accountable for the quality of nursing care given to clients.
The standards of n11%Sing conduct or practice include, but
are not limited to the following:
FOR REGISTERED NURSES:

(1) Nursing process:
(a) The registered Ilurse shall collect pertinent objective and
subjective data regarding the health status of the client.
(c) The registered n11%Se shall communicate significant
changes in the client's status to appropriate members of

..

Wagner - Page 5
the health care team. This communication shall take
place in a time period cOlISistent with the client:'s need
for care.
(d) The registered nurse shall document, on essential client:
records, the nursing care given and the client's response
to that care.
(3) Other responsibilities:
(a) The registered nurse shall have knowledge and
lUlderstanding of the laws and rules regulat:ing nursing and
shall function wit:hiD. the lela! scope of nursing practice•
. (emphasis added)

A copy of WAC 246-840-700, Standards of nursing conduct or practice:
FOR REGISTERED NURSES, is attached (Attachment #6) hereto and
incorporated herein.
WAC 246-840, Practical and Registered Nursing, states, in part, under
WAC 246-840-710, Violations of standards or nursing conduct or
practice:
The following will serve as a guideline for the nurse as to the
acts, practices or omissions that are inconsistent with
generally accepted standards of nursing conduct or
practice•..Such conduct or practice includes, but is not
limited to the following:
(1) Failure to adhere to the standards enumerated in WAC
246-840-700(1) which may include:
(a) Failing to assess and evaluate a client's status or
failing to institute nursing intezvention as required by
the client's condition.
(b) Willfully or repeatedly failjng to report or document: a

client'. symptoms, responses, progress, medication, or
other nursing care accurately and/or intelligibly.
(c) Willfully or repeatedly failing to make entries,
altering entries, destroying entries, making incorrect or
illegible entries and/ or making false entries in records
pertaining to the giving of medication, treatment:s, or
other nursing care. (emphasis added)

11~~

Wagner - Page 6

A copy of WAC 246-840-710, ViolatioDa of standards of nursing 01'
practice, is attached (Attachment #7) hereto and incorporated herein.
WAC 246-840, Practical and Reptered Nursing, states, in part, under
WAC 246-840-960, Accountability, Uability, and coercion, sUbparagraph
1:
(1) The registered nurse and nursing assistant are
accountable fOl' their own individual actions in the
delegation procea. The delegated task becomes the
responsibility of the person to whom it is delegated but
the registered nurse retains overall acco1UltabUity for the
nursing care of the patient, blc1nding nursing
.
• uessment, evaluation, and assuring documentation is
completed. (emphasis added)

A copy of WAC 246-840-960, Acco1U1tability, liability, and coercion, is
attached (Attachment #8) hereto and incorporated herein.
You were aware, or should have been aware of the foregoing provisions of
RCW 18.13.180 and WAC's 246-840-700,246-840-710, and 246-840-960,
as evidenced by the fact that you have been a licensed Registered Nurse
within the State of Washington since gaining employment with the
Department of Corrections on 9/21/87.
As an employee and Registered Nurse 2 with the Department of Corrections
at the Special Offender Unit of Monroe Correctional Complex, you have a
duty and obligation to:
1. Adhere to its policies and procedures, which are designed to
ensure the efficient and effective management of the Department's
programs;
2. Ensure the safety for offenders; to treat all offenders fairly and
equitably; and to meet the national standards appropriate to the
State of Washington;
3. Ensure the high moral and ethical standards the department
e.~ects of its employees to ensure the success of its programs;
4. Perfonn your duties in a professional, competent and
compassionate manner;

1198 -

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Wagner - Page 7

5. Meet the expectations of your supervisor and the agency as a
whole.
6. Serve each offender with appropriate concern for their welfare; and
7. Meet the department's expectations that you would meet the laws
and regulations of the State of Washington regarding nursing care
and the standards of nursing conduct or practice, required for
licensure as a registered nurse, which includes: the accountability
for the quality of nursing care given to a client; and the gathering
and documentation of pertinent data regarding the health status of
the client in essential medical records.

By your behavior in this incident, you have·clearly demonstrated:
1. A neglect of your duty and obligation to meet the reasonable

expectations of the Department that you would adhere to its
policies and procedures; that you would ensure for the safety of its
inmates and treat all offenders fairly and equitably; to meet the
national standards appropriate to the State of Washington; that you
would perfonn your duties in a professional, competent and
compassionate manner, serving each offender with appropriate
concern for their welfare; and that you would meet the laws and
regulations of the State of Washington regarding nursing care and
the standards of nursing conduct or practice required for your
licensure as a registered nurse. These charges are based on your·
behavior of failing to appropriately provide a physical assessment of
Inmatearter receiving a call from a correctional officer who said
Inmat.was complaining that he was having trouble getting air#
After asking the correctional officer if the inmate was having a,
problem speaking and being told "no", you told the correctional'·.
.officer that you were starting medication lines, that this was aJ.
usual complaint from Inmate.that his cell was probably hot an\ '.
stuffy, and that the inmate should take a cool shower to make hiln.
feel better. ¥ou told the correctional officer "if he continues to
complain, call me back." You then continued with the medication
lines.
'. ~:. "'.
2. A neglect of your duty to meet the reasonable expectations of the
Department that you would obey all laws while on duty, which
included the laws and regulations of the State of Washington
regarding nursing care and the standards of nursing conduct or
practice required for your licensure as a registered nurse, to

'.

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Wa8ner - Page 8
include: accountability for the quality of nursing care given to a
client; and the collection and documentation of pertinent data
regarding the health status of the client in essential medical
records. These charges are based on your failure to document his
medical complaint in the inf1l"I11ary log anq Inmate_medical file.
This lack of documentation failed to provide the next shift nurse
with necessary information needed to properly assess Inmate.
later that evening. During the Administrative Comments meeting
with Ms. Sigmund, you also indicated that you did not document in
his medical file any of the numerous similar complaints that he had
made about his difficulty getting air and that his complaints were
many and delusional in nature and that you did not document
them as well.
3. Insubordination by your failure to follow your supervisor's verbal
directive on May 18, 19, and 20, 1998 at the noontime nursing
meeting, that all RN's were to phy~ically assess any inmate who
complained of any physical abnormality. These charges are based
on your failure to document his medical complaint in the infumary
log and Inmate IImedical file. This lack of documentation failed to
provide the next shift nurse with necessary information needed to
properly assess Inmate .later that evening.
4. A willful violation of the Department of Corrections Employee
Handbook by your failure to: assist the department in meeting its
objective of ensuring the efficient and effective management of its
programs, the safety of its offenders, that all offenders would be
treated fairly and equitably, and that the national standards
appropriate to the State of Washington would be met; meet the
moral and ethical standards of the department that you would
perform your Registered Nurse 2 duties in a professional and
competent manner; meet the expectations of the department that
you would obey all laws while on duty, which includes the laws and
regulations of the State of Washington regarding nursing care and
the standards of nursing conduct or practice required for your
licensure as registered nurse; and to serve each offender with
appropriate concern for their welfare. These charges are based on
your behaviors of f~ to appropriately provide a physical
assessment of Inmate. after receiving a call from a correctional
officer who said Inmate~as complaining that he was having
trouble getting air; and your failure to document his medical
complaint in the infirmary log and Inmate_medical fIle. This lack
of documentation failed to provide the next shift nurse with
neces~ary infonnation needed to properly assess Inmate.later that
evening.

12CO

Wagner - Page 9

5. A willful violation of the duties of your Registered Nurse 2 position's
Classification Questionnaire, 'HB36, to provide ongoing nursing
treatment and emergency treatment as necessary; and to maintain
professional nursing care integrity as it applies to...delivery of
service. These charges are based on your behaviors of failing to
appropriately provide a physical assessment of Inmatellai!er
receiving a call from a correctional officer who said Inmate' was
complaining that he was having trouble getting air; and your failure
to document his medical complaint in the infirmary log and Inmate
_medical file. This lack of documentation failed to provide the
ne."'rt shift nurse with necessary information needed to properly
assess Inmate later that evening.

II

7. Gross misconduct by your blatant and flagrant disregard for the
stated objectives and ethics of the Department of Corrections to
ensure the safety of offenders; to treat all offenders fairly and
equitably; to meet the national standards appropriate to the State
of Washington; and to subscribe to a code of unfailing honesty,
respect for dignity and individuality of human beings, and a
commitment to professional and compassionate service, all of which
adversely impacts its ability to carry out its mission and functions.
These charges are based on your behaviors of failing to
appropriately provide a physical assessment of Inmat'-ter
receiving a call from a correctional officer who said Inmate.was
complaining that he was having trouble getting air and your failure
to document Inmate_medical complaint in the infirmary log and
Inmate_medical file. This lack of documentation failed to provide
the next shift nurse with necessary information needed to properly
assess Inmate' later that evening.
In reviewing your personnel file I find:

1. A Memo of Counseling dated 9/24/98, from your supervisor, RN 3
Bollinger, which addr~ehaviorof 8/31/98, dispensing
medication to I n m a t e _ , and failing to immediately chart that
information, as required by law and as further directed by Ella Ray
Sigmund, CMHPM in a memo to RN's dated 8/13/98. By your failure to
do so, you were directly responsible for an overdose of medication
received by Inmate"
A copy of the foregoing document from your personnel me is attached
(Attachment #9) hereto and incorporated herein.

l

_':lill
.
..)

Wagner - Page 10
On 11/24/98, I met with you at a pre-termination meeting. Also present
was Mike Wilson, Business Agent, Teamsters Local #313, and your employee
representative; Mark Anderson, Attorney, Teamsters Local #313; Dinnie
Burnham, Teamster Local #313 Shop Steward; Bob Riordan, Human
Resource Manager, Monroe Correctional Complex (MCC); Linda Gilstrap,
Personnel Officer at the Special Offender Unit (SOU); and Chris Graham,
newly appointed Personnel Officer at the Special Offender Unit, as an
observer. The purpose of the meeting was to give you the opportunity to
present me with any information that you wanted me to consider prior to my
making a decision.

t:
J
-tv

L
At the meeting, Mr. Wilson indicated that six out of the seven registered
nurses at SOU had indicated that they had not received the verbal directive
0 3",1..~
from RN 3 Bollinger to physically assess any inmate who complained of any C·(Y'
physical abnormality at the meetings on 5/18, 5/19, and 5/20/98. He
additionally indicated that 7/22/98 was the hottest day of the year and that
your decision not to physically assess Inmate. complaint of not getting air
was based to an extent on that fact. Mr. Wilson also indicated that Inmat~
had been at SOU for four years and had many similar complaints, which
when physically assessed, were determined to be medically unfounded. Mr.
Wilson also indicated that later in the evening of 7/22/98, CO Benda
reportec;1..that Inmate.as lying on the floor and when asked if he was okay,
Inmate.responded "Yes. I'm a little hot.. J took a shower, I'm OK." Finally, .
Mr. Wilson presented a magazine article that spoke to the physical aspect of
dehydration of patients who were on psychotropic drugs.

Mr. Wilson went on to indicate that there was no reason for you to document
Inmatellcomp.laint, as when RN 2 Mike Kalina checked on Inmat.at
8:30PM, Inmate_reported that he was OK. Mr. Wilson stated that physical
complaints are only documented when the inmate is not okay. He further
indicated that if you had received more complaints from Inmate. you would
have gone to physically assess him, but. since you hadn't received any and
RN2 Kalina had reported that Inmate~as okay, there wasn't a need to
physically assess him.
In response to Mr. Riordan~dication that physical assessment and
medical charting of Inmate. physical complaints were essential to the
attending physician in formulating medical history and follow-up and were
required by nursing practice and standards of nursing practice, Mr.
Anderson indicated that you had not violated nursing practices or laws as
RN2 Kalina was the one who assessed Inmatell discussed his report to you
that the Inmate had said he was okay, and it should have been RN2 Kalina
who should have documented/ charted that assessment.

1202

Wagner - Page 11
Ms. Burnham indicated that the manner in which you responded to Inmate

II complaint through Correctional Officer McLellan, i.e., phone triage, was a
standard practice throughout Monroe Correctional Complex.
Finally, Mr. Wilson indicated that you had worked within Monroe
Correctional Complex at the Washington'State Reformatory and SOU for the
past 11 years, had no previous corrective/ disciplinmy actions noted in your
personnel record, and, in fact, your performance evaluations were above
average. Accordingly, he asked that the misconduct be withdrawn.
In ~~nclusion and full consideration of the foregoing, I have determined to
~~sSJoUi9om your position as a Registered Nurse 2 with the Department
~---Gl,..I,:,4:ttf'TIICC1t:1:ttonSat Monroe Correctional Complex as indicated in paragraph
one of this·letter.
.

Under the provisions of Washington Codes 358-20-010 and 040, you have
the right to appeal this action to the Person!1el Appeals Board, 2828 Capitol
Boulevard, Olympia, Washington, 98504, within thirty (30) days from the
effective date stated in paragraph one of this letter.
The Merit System rules (WACS), Department of Corrections' policies, Monroe
Correctional Comple.'"t-Special Offender Center Field Instructions and the
Collective Bargaining Agreement are available for your review upon request.

Kenneth DuCharme
Superintendent
KDC:cg
Attachments
cc: Dave Savage, Deputy Secretary, OCO
Eldon Vail, Assistant Deputy Secretary, OCO
Phil Stanley, NW Regional Administrator
Jennie Adkins, Human Resources Administrator, OAS
Linda Dalton, Senior Assistant Attorney General
Cheryl Landers, NW Region Human Resource Manager
Bob Riordan, MCC Human Resource Manager
Personnel File

12D3

Jennie - Please excuse the delay in processing this letter ofdiscipline. The superintendent
bas vacillated back and forth in deciding ifMs. Wagner should be terminated or heavily
reduced in salary·and reassigned to TRee. He has met with the union on numerous
occasions, the last meeting being on 1122. He decided at that time to terminate Ms.
Wagner.

,

12&4

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•

STATE OJIWA$1lNGlQN

OEPARTMENT OF CORRECTIONS
0FFIa OF CORRECT1CHAL 0PeRA11ONS
MONROe COAaCT1OMAL COMPUX-IP!CW. Qllfl!NDtR UNIT'
P'O BOX 514 • I.Ioftroe. W8IIllnlIIDn lIZT2~t4

May 6, 1999
PDSOtfAl, ABD COlU'IDPTJAL DItLIVBaT

Ms. Wagner:

111is is omcial notification that you will be reduced in sala.ty within your
p~t c.la3sification as a Registered Nurse 2 with the Department of
Corrections at the Special Offender Unit of Monroe Correctional Cample:c,
Range 45N, Step P, $3801 per month, to .Step N, $3617 per month, effet:tive
May 24, 1999 to November 24, 1999 inclusive.
This disciplinary action is taken punuant to the Civil Service Law of
Washington State, Chapter 41.06 Revised Code· oCWashington, and the Merit
System Rules, Title 356 Washington Administrative Code (WAC) Section 35634-010 (1) (a) Neglect of dUty, (hI Gross misconduct, (i) Willful violation of the
published employing agency or department of personnel rules or regulations
and 356·34-020, Reducticm.1D. Saluy - D8JI&otioll - Procedure..
Specifically, you neglected your duty. committed an act of gross misconduct
and willfully violated pUblished age~cy _~~~7/22/98,you failed.
to provide a physical a:ssc:s:unent of ~ and you also failed
to document his medical complaint in the infirmary log. as well as, Inmate
llmedical r1le.
The evidence indicate:s that you received a call in the infirmary at
approximately 6:10 PM on 7/22lJ8 from Karen McLellan, Correctional
Officer 2 ani uni~ that Inmate.was complaining that he was having
trouble gemng air. You in turn asked C/O McLellan if Inmat.a.s having
a problem speaking, to which C/O McLellan responded, C no•. You then
stated to C/O McLellan that you were starting medicatton lines, that this
wu a usual complaint from Inmatell that his cell was probably hot and
stuffy, and told C/O McLellan to have Inmate.take a cool shower to help
him feel better. You also told C/O McLel1a n, -if he continues to complain,
call me back! You continued with medication lines and heard no more from

1 ')("6
.... •J

•
Wagner - Page 2

IIue

stuffy and told C/O McLellan to have InmeM
a cool shower to help
him ~ better. You also told C/O McLeUan, Ilif he continues to complain.
call me back." You continued. with medieatinn lines and ~eard no more from
the unit. As you finished medication lines. you informed RN 2 Mike Kalina
oCC/O McLellan's call regarding Inmate
Without phyaic:aJlyanessing
~ complaint and as you had heard nothing more from the unit stafi'
complaint, you and RN 2 Kalina decided it we not an
regarding
emergent situation and RN 2 Kalina agreed to check on Inmate.at
lockdown medication line. which was at approximately 8:30 PM. When RN2
Kalina checlccd on Inmate. he was observed to be u1eep and snoring.
'1'11ere was no indication that RN2 Kalina communicated with Inmate' to
check his p~cal status or with unit staff regarding any further cOmplaints
that Inmate • may have made.
.

I

Inmatell

At approximately 10:34 PM on 1/22/98. which was after your shift and you
were no-longer in the institution, C/O 2 James Smith contacted the
infirmary and asked RN 2 Leann Cave to check on Inmatell C/O Smith

further reported to RN 2 Cave that Inmate. had not changed positions in
approximately ninety minutes and that his feet appeared pale. RN 2 Cave
indicated that she was unaware of any complaint from Inmate.as there
had been no documentation of any complaint from him in the infirmary log
nor in Inmate.erlical record. It should be poted that Inmate. died in
his cell that evening.
During the AdminisO'ative Comments investigation of this incident, you
indicated to Ella Ray Sigmund CMHPM and Acting Associate
Superintendent, that Inmatejhad made similar complaints in the past and
that they were not always documented.
An Employee Conduct Report initiated on 8/3/98 describing this incident in
greater detail is attached (Attachment #1) hereto and incorporated herein.

Inmate"
complaint of having difficulty getting air was significant his
documented physical problem of which all medical staff. including yourself,
to

·were aware. The knowledge of this medical significance is information you
$bould have responded to.
The Department of Corrections Employee Handbook states. in part, under
DepartmeDt Objectivea, on pages 1 and 2:
The department's main objectives are to:
- BARre

"'ety for•••oll'enden; (emphasis added)

120~

.•

•
Wagner - Page 3

• Treat all off'eaden....IJdzly aDd equitably; (emphasis ad4cd)
_ lIeet tile utioaal ltaW'" appropriate to the State of
Wuhinctaa (empbasis added)
.

and also states, in part, under

eo. of BthiQ on page 2:

JIi&la DlOn! NUl.thica1 ata ndar• &mOq comac:t1oDal
employee. are eaelltial for the auceeu of the cteputmellt'a
prapama. The DeputmeDt of Conectiau nbacri1Ma to a
code of lJpfafllDI hosIe8ty. respect for cUpity ael .
blcUvtduaJitJ" ollaqmu betnp, aacl • commitment to
. proteuioul and comp!!!ioaate ..mce. (emphasis added)"
CUld further states, in Part. under D4partmCDt Ezpectatio~on page 2:

-

As a representative of the Department of Corrections. you will be
expected to:

• serve each otfend.er with appropriate concern for their
we1!al'e••• {empha:si3 added}

On 11/24/93, you acknowledged receipt of the June 1993 Employee
Handbook, further agreeing to become £aroma r with and have a thorough
knowledge and understanding of its contents. Copies of pages 1 and 2 of the
1993 Employee Handbook (Attachment '2). and your aclmowledgment of its
receipt· (Attaehment #3) are attached hereto and incorporated herein.
The classification questionnaire (CQ) for your RN 2 position. HB36, which
outlines its duties states. in part, under "Employee's Statement oC Dutia:

Provide oqoiDc 1l1lJ'll1Di treatment ud emera_Dey
treatment as neceauy. (emphasis added)
JIab1taina pl'OCeaaiaDa1 nu:raiuc cue iDtepity .. it appliea
to••• de1iftry of Mme•• (emphasis added)
A copy of the CQ for your position. HB36. is attached (Attachment '4) hereto
and incorporated herein.

A3 an employee and Registered Nunc 2 with the Department of CoITections
at the Special Offender Unit of Monroe Correctional Complex, you have a

120e..,·

.

•
Wagner - Page 4

duty and obligation to:
1. Adhere to ita policies and. procedures, which are designed to
ensure the efficient and eB'ective management of the Department's
programs;

2. Ensure the safety for offenders; to treat all offenders fairly and
equitably; and to meet the national standards appropriate to the
State o(Washington;

3. Ensure the high moral and ethical standards the department
expects of its employees to ensure the success of its programs;

.

4. Perform your duties in a professional, competent and
compassionate manner;
.
5. Meet the expectations of the agenc-f a:s a whole; and
6. Serve each offender with appropriate concern for their welfare.
Inma~complaint of having difficulty getting air is significant to his
documented overall medical condition, which ~ medical staff, including
yourself, were aware or should have been aware. Given his overall medical
condition. there was, according to Dr. Jonas, WSRU <:Cntract Ph~cian. who
I had review this incident, medical significance to his complaint, which you
should have responded. to. Even though you indicated during the course of
the investigation of this incident that Inmate.had. made numerous medical
complaints of a similar nature, it was noted in a review of his medical chart
that those ·siInilar' complaints had not been charted.

.

\

Additionally, while you relied on the observation of a correctional officer that
be wu able to speak. it should be noted that correctional officers are not
medical staff and arc not qualified QOr are they expected to conduct m~dical
assessments or inmates. Also, while you did not hear back fTom unit .
,
correctional staff of any further complaints from Inmatea you too~ no .
affinnative action after completing medication lines to ascertain his'ph~ical
status in person or by camcg unit sta1l' to check on him. Instead. you vjaitcd
until approximatelY 8:30 PM to have Inmate~eckedon by RN2 Ka.lli1a...
Finally, even though you bad received an indication from correctional stair of
Innia.physical complaint. you failed to appropriately document that'
complaint in either the infirmary log or his medical chart.
",

120~'

•

Wagner. Page 5
By your behavior in this incident. you have clearly demonstrated:

1. A neglect of your duty and obligation to meet the :reasonable
expectations of the Department that you would adhere to its
policies and procedures; that you would ensure for the safety of its
inmates and treat all offenders fairly and equitably; to meet the
national standards appropriate to the State of Washington; and
that you would perform your duties in a professional. competent
and compassionate manner, serving each oaender with appropriate
concern for their welfare. These charges are based on your
behavior of failing to appropriately provide a physical assessment oC
Inmate. after receiving a call at 6:10 PM on 7/22/98
a
con"cctional officer who said Inmate.was complaining that he was
having trouble getting air, your failure to take any affirmative
action. after completing medication lines, to ascertain his physical
status or calling unit staff to check on him until approximately 8:30
PM; and your failure to document his medical complaint in the
infirmary log and Inmate
medical file. This lack of
documentation failed to provide the next shift nurse with necessary
information needed to properly assess Inmate.later that evening.
During the Administrative Comments meeting with Ms. Sigmund,
you also indicated that you did not de<rument in his medical tile
any of the numerous similar complaints that he had. made about
his difficulty getting air and that his complaints were many and
delusional in nature and that you did not document them as well.

from

II

2.

A neglect of your duty to meet the reasonable expectations outlined
in your Registered Nurse 2 position's Classification Que$tionnaire,
HB36. to provide ongoing nursing treaonent and emergency
treatment as necessary; and to maintain professional nuning care
integrity as it applies to delivetY of service. These charges are

based on your behaviors of failS to appropriately provide a
physical assessment of Inmat.after receiving a call at 6: 10 PM on
7/22/98 from a correctional officer who said lnmac.was
complaining that he was having trouble getting air; and your failw-e
to take any affirmative action. after completing medication lines, to
uccrtain his physical status or callillg unit staff to check on him
until approximately 8:30 PM; and your failure to document hi3
medical complaint in the infirmary log and Inmate medica11ile.
This lack of documentation failed to provide the next shift nurse
with necessary information needed to properly assess Inma.
later that evening.

1210

.
Wagner - Page 6

3. A willful violation of the Department of Corrections Employee
Handbook by your !allure to: aasist the department in meeting ita
objective of ensuring the efficient and dectivc management of its
programs; to ensure the safety of its offcndcr.s and to treat all
oft'enders Cairly and equitably; meet the national standards
appropriate to the State of Washington; meet the moral and ethical
standards of the department that you would perform your
Registered Nurse 2 duties in a profeRional and competent manner;
and to serve each offender with appropriate concern for their
welfare. These charges are based on your behaviors of fAiling to
appropriately provide a physical assessment of Inmate after
receiving a call at 6: 10 PM on 7{22/98 from a correctional officer
.who said Inmatel was complaining that he was having trouble
getting air; YO'W' failure to take any affirmative action, after
completing medication lines. to ascertain his physical status or
caJUng unit staff to check on him until approxima.tely 8:30 PM; and
your failure to document his medical complaint in the infirmary log
and Inmate.edical chart. This lack of dO<:Umentation failed to
provide the next shift nurse with necessary information needed to
properly ass~s Inmate • later that evening.

I

4. Gross misc:onduct by your blatant and flagrant disregard for the

stated objectives and ethics of the Department of Corrections to
ensure the safety of offenders; to treat all offenders fairly and
equitably; to meet the national standards appropriate to the State
of Washington; and to subscribe to a code of unfailing honesty,
respect for dignity and individuality of human beings. and a
commitment to professional and compassionate service, all of which
adversely impacts the Department's ability to carry out its mission
and functions. These charges are based on your behaviors of
failing to appropriately provide a physical assessment of Inmate.
after receiving a call at 6:10 PM on 7/22/98 from a correctional
ofiicer who said Inmate~s complaining that he Was having
trouble getting air; your failure to take anya.ffirmative action. after
completing medication lines, to ascertain his physical status or
calling unit stafi' to check on him until approximately 8:30 PM; and
your failure to document his medical complaint in the infirmary log
. and Inmate_medical chart. This lack of documentation failed to
'provide the next shift nune with necessary information needed to
. properly assess Inmate.later that evening.

1211

..

.. .
Wagner ~ Page 1
In reviewing your penon.nel file I find:

tnmate_

1. A Memo of Counaeling dated. 9/24/98, from your sUpervisor, RN 3
Bollinger, which ad~bavior of 8/31/98 7 dispensing.
medication to
and f.gj]jng to immediately chart that
information, as required by law and as further directed by EUa. Ray
Sigmund, CMHPM in a memo to RN's dated 8/13/98. By your failure to
do so, you were ~ responsible for an overdose of medic:ation
received by Inmate.
A copy of the foregoing document from your personnel file is attached.
(Attachment '5) bereto and incorporated herein.
:

In concluSion and full consideration of the foregoing, I have determined ~
reduce your salary as a Registered Nurse 2 as indicated in paragraph one of
this letter.
Under the provisions o{Wasbjngf:on Codes 358-20-010 and 040, you have
the right to appeal this action to the Personnel Appeals Board. 2828 Capitol
Boulevard. Olympia, Washington, 98504, within thirty (30) days from the
effective date stated in paragaph one of this letter.

The Merit System rules (WACS), Department of Corrections' policies, Monroe
Correctional Comple.~~Specia1 Ofi'ender Centu Field Instructions and the
Collective Bargaining Agreement are available for your review upon request.

~~.....-:.-~ ..

Kenneth DuCharme
Superintendent
KD:cg
Attaehments

cc: Dave Savage. Deputy Secretary, oeo
Eldon Vail, Assistant Deputy Secretary, oeo
Phil Stanley, NW Regional Administrator
Jennie Adkins. Human Resources Administrator. OAS
Linda Dalton, Senior Assistant Attorney ~neral
Cheryl Landers, NW Region Human Resource Manager
Bob Riordan. MCC Human Resource Manager
Personnel File

1~12

•

STATE OF WASHINGTON

OEPARTMENT OF CORRECTIONS
OFRCEOFCORREcnONALOPERAnONS
MONROE CORRECTIONAL COMPLEX - SPECIAL OFFENDER UNIT
PO BOX 514 • Monroe. W3shingum 9827200514

May 6,1999
PERSONAL AND CONFIDENTIAL DELIVERY

Ms. Wagner:
This is official.notification that you will be reduced in salary within your
present classification as a Registered Nurse 2 with the Department of
Corrections at the Special Offender Unit of Monroe Correctional Complex,
Range 45N, Step P, $3801 per month, to Step N, $3617 per month, effective
May 24, 1999 to November 24, 1999 inclusive.
This disciplinary action is taken pursuant to the Civil Service Law of
Washington State, Chapter 41.06 Revised Code of Washington, and the Merit
System Rules, Title 356 Washington Administrative Code (WAC) Section 35634-010 (1) (a) Neglect of duty, (h) Gross misconduct, (i) Willful violation of the
published employing agency or department of personnel rules or regulations
and 356-34-020, Reduction in. Sala1'Y - Demotion - Procedures.
Specifically, you neglected your duty, committed an act of gross misconduct
and willfully violated published agency rules, when, on 7/22/98, you failed
to provide a physical assessment of Inmate
and you also failed
to document his medical complaint in the infirmary log, as well as, Inmate
•
medical file.
The evidence indicates that you received a call in the infumary at
approximately 6: 10 PM on 7/22ti.8 from Karen Mclellan, Correctional
Officer 2 onllunit, that Inmatellwas complaining that he was having
trouble getting air. You in tum asked C/O Mclellan if Inmate.as having
a problem speaking, to which C/O Mclellan responded, "no". You then
stated to C/O McLellan that you were starting medication lines, that this
was a usual complaint from Inmate. that his cell was probably hot and
stuffy, and told C/O McLellan to have Inmatelltake a cool shower to help
him feel better. You also told C/O Mclellan, "if he continues to complain,
call me back You continued with medication lines and heard no more from
lll

~cltd

pap..

"Working Together for SAFE Communities"

121~

.
Wagner - Page 2
stuffy, and told C/O Mclellan to have Inmate. take a cool shower to help
him feel better. You also told C/O Mclellan, "if he continues to complain,
call me back." You continued with medication lines and heard no more from
the unit. As you finished medication lines, you informed RN 2 Mike Kalina
of C/O McLellan's call regarding Inmate. Without physically assessing
Inmate.complaint and as you had heard nothing more from the unit staff
regarding Inmate" complaint, you and RN 2 Kalina decided it was not an
emergent situation and RN 2 Kalina agreed to check on Inmat.at
lockdown medication line, which was at approximately 8:30 PM. When RN2
Kalina checked on Inmattjl he was observed to be asleep and sno~
There was no indication that RN2 Kalina communicated with Inmat.to
check his p~sical status or with unit staff regarding any further complaints
that Inmat. may have made.
At approximately 10:34 PM on 7/22./98, which was after your shift and you
were no longer"in the institution, C/O 2 James Smith contacted the
infirmary and asked RN 2 Leann Cave to check on Inmate. C/O Smith
further reported to RN 2 Cave that Inmate8had not changed positions in
approximately ninety minutes and that his feet appeared pale. RN 2 Cave
indicated that she was unaware of any complaint from Inmate.as there
had been no documentation of any complaint from him in the inflmlary log
nor in Inmatell medical record. It should be noted that Inmate.died in
his cell that evening.
.
During the Administrative Comments investigation of this incident, you
indicated to Ella Ray Sigmund, CMHPM and Acting Associate
Superintendent, that Inmat.had made similar complaints in the past and
that they were not always documented.
An Employee Conduct Report initiated on 8/3/98 describing this incident in
greater detail is attached (Attachment ## 1) hereto and incorporated herein.

Inmat.complaint of having difficulty getting air was significant to his
documented physical problem of which all medical staff, including yourself,
were aware. The knowledge of this medical significance is information you
should have responded to.
The Department of Corrections Employee Handbook states, in part, under
Department Objectives, on pages 1 and 2:
The department's main objectives are to:
- Ensure safety for...offenders; (emphasis added)

W~er-Page3

• Treat all offenders••• fairly and equitably; (emphasis added)
- Meet the national standa%ds appropriate to the State of
Washington (emphasis added)
and also states, in part, under Code of Ethics on page 2:
High moral and ethical standards among correctional

employees are essential for the success of the department's
programs. The Department of Corrections subscribes to a
code of unpiUng honesty, respect for dignity and
individuality of human beings, and a commitment to
professional and compassionate service. (emphasis added)
and further states, in part, under Department Expectations, on page 2:
As a representative of the Department of Corrections, you will be
expected to:
•

Serve each offender with appropriate concern for their
welfare...(emphasis added)

On 11/24/93, you acknowledged receipt of the June 1993 Employee
Handbook, further agreeing to become familiar with and have a thorough
lmowledge and understanding of its contents. Copies of pages 1 and 2 of the
1993 Employee Handbook (Attachment #2), and your acknowledgment of its
receipt (Attachment #3) are attached hereto and incorporated herein.
The classification questionnaire (CQ) for your RN 2 position, HB36, which
outlines its duties states, in part, under "Employee's Statement of Duties":
Provide ongoing nursing treatment and emergency
treatment as necessary. (emphasis added)
Maintains professional nursing care integrity as it applies
to... delivery of service. (emphasis added)
A copy of the CQ for your position, HB36, is attached (Attachment #4) hereto
and incorporated herein.
As an employee and Registered Nurse 2 with the Department of Corrections
at the Special Offender Unit of Monroe Correctional Complex, you have a
•

1215

Wagner - Page 4
duty and obligation to:
1. Adhere to its policies and procedures, which are p.esigned to

ensure the efficient and effective management of the Department's
programs;
2. Ensure the safety for offenders; to treat all offenders fairly and
equitably; and to meet the national standards appropriate to the
State of Washington;
3. Ensure the high moral and ethical standards the department
expects of its employees to ensure the success of its programs;
4. Perform your duties in a professional, competent and
compassionate manner;

s.

Meet the expectations of the agency as a whole; and
.'

6. Serve each offender with appropriate concern for their welfare.
Inmat~omplaint of having difficulty getting air is significant to his
documented overall medical condition, which all medical staff, including

yourself, were aware or should have been aware~ Given his overall medical
condition, there was, according to Dr. Jonas, WSRU Contract Physician, who
I had review this incident, medicpJ significance to his complaint, which you
should have responded to. Even though you indicated during the course of
the investigation of this incident that lnmat.had made numerous medical
complaints of a similar nature, it was noted in a review of his medical chart
that those "similar" complaints had not been charted.
Additionally, while you relied on the observation of a correctional officer that
he was able to speak, it should be noted that correctional officers are not
medical staff and are not qualified nor are they expected to conduct medical
assessments of inmates. Also, while you did not hear back from unit
correctional staff of any further complaints from lnmat~ you took no
affinnative action after completing medication lines to ascertain his physical
status in person or by calling unit staff to check on him. Instead, you waited
until approximately 8:30 PM to have Inmat.hecked on by RN2 Kalina.
Finally, even though you had received an indication from correctional staff of
Inmat. physical complaint, you failed to appropriately document that
complaint in either the inIll"111ary log or his medical chart.

12t6

WagJ1er - Page 5
By your behavior in this inciden4 you have clearly demonstrated:

1. A neglect of your duty and obligation to meet the ;reasonable

expectations of the Department that you would adhere to its
policies and procedures; that you would ensure for the safety of its
inmates and treat all offenders fairly and equitably; to meet the
national standards appropriate to the State of Washington; and
that you would perform your duties in a professional, competent
and compassionate manner, serving each offender with appropriate
concern for their welfare. These charges are based on your
behavior of failing to appropriately provide a physical assessment of
Inmate.after receiving a call at 6:10 PM on 7/22/98 from a
correctional officer who said Inmate.was complaining that he was
haVing trouble getting air; your failure to take any affIrmative .
action, after completing medication lines, to ascertain his physical
status or calling unit staff to check on him until approximately 8:30
PM; and your failure to document his medical complaint in the
infnmary log and Inmat_medicar me. This lack of
documentation failed to provide the next shift nurse with necessary
infonnation needed to properly assess Inmate.later that evening.
During the Administrative Comments meeting with Ms. Sigmund,
you also indicated that you did not document in his medical file
any of the numerous similar complaints that he had made about
his difficulty getting air and that his complaints were many and
delusional in nature and that you did not document them as well.
2. A neglect of your duty to meet the reasonable expectations outlined
in your Registered Nurse 2 position's Classification Questionnaire,
HB36, to provide ongoing nursing treatment and emergency
treatment as necessary; and to maintain professional nursing care
integrity as it applies to delivery of service. These charges are
based on your behaviors of failing to appropriately provide a
physical assessment of Inmat_after receiving a call at 6: 10 PM on
7/22/98 from a correctional officer who said Inmat.as
complaining that he was having trouble getting air; and your failure
to take any afflIIIlative action, after completing medication lines, to
ascertain his physical status or calling unit staff to check on him
until approximately 8:30 PM; and your failure to document his
medical complaint in the infirmary log and Inmatamedical file.
This lack of documentation failed to provide the next shift nurse
with necessary information needed to properly assess Inmat.
later that evening.

1217

Wagner· Page 6
·3. A willful violation of the Department of Corrections Employee
Handbook by your failure to: assist the department in meeting its
objective of ensuring the efficient and effective management of its
programs; to ensure the safety of its offenders and to treat all
offenders fairly and equitably; meet the national standards
appropriate to the State of Washington; meet the moral and ethical
standards of the department that you would perform your
Registered Nurse 2 duties in a professional and competent manner;
and to serve each offender with appropriate concern for their
welfare. These charges are based on your behaviors of failing to
appropriately provide a physical assessment of Inmatellafter
receiving a call at 6: 10 PM on 7/22/98 from a correctional officer
who said Inmat.was complaining that he was having trouble
getting air; your failure to take any affirmative action, after
completing medication lines, to ascertain his physical status or
calling unit staff to check on him until approximately 8:30 PM; and
your failure to document his medical complaint in the infirmary log
and Inmatell medical chart. This'lack of documentation failed to
provide the next shift nurse with necessary information needed to
properly assess Inmat.later that evening.

4. Gross misconduct by your blatant and flagrant disregard for the
stated objectives and ethics of the Dep8.rtment of Corrections to
ensure the safety of offenders; to treat all offenders fairly and
equitably; to meet the national standards appropriate to the State
of Washington; and to subscribe to a code of unfailing honesty,
respect for dignity and individuality of human beings, and a
commitment to professional and compassionate service, all of which
adversely impacts the Department's ability to carry out its mission
and functions. These charges are based on your behaviors of
failing to appropriately provide a physical assessment of Inmatell
after receiving a call at 6: 10 PM on 7/22/98 from a correctional
officer who said Inmat.was complaining that he was having
trouble getting air; your failure to take any affirmative action, after
completing medication lines, to ascertain his physical status or
calling unit staff to check on him until approximately 8:30 PM; and
your failure to document his medical complaint in the infirmary log
. and Inmatellmedical chart. This lack of documentation failed to
provide the next shift nurse with necessary information needed to
properly assess Inmat.ater that evening.

1218

...

W8.iIler - Page 7
In reviewing your personnel tile I find:
1. A Memo of Counseling dated 9/24/98, from your supervisor, RN 3
Bollinger, which addresse~haviorof 8/31/98, dispensing.

InmateJI

medication to
~and failing to immediately chart that
information, as required by law and as further directed by Ella Ray
Sigmund, CMHPM in a memo to RN's dated 8/13/98. By your failure to
do so, you were directly responsible for an overdose of medication
received by Inmat.

A copy of the foregoing document from your personnel file is attached
(Attachment #5) hereto and incorporated herein.
.
In conclusibn and full consideration of the foregoing, I have determined to
reduce your salary as a Registered Nurse 2 as indicated in paragraph one of
this letter.

Under the provisions of Washington Codes 358-20-010 and 040, you have
the right to appeal this action to the Personnel Appeals Board, 2828 Capitol
Boulevard, Olympia, Washington, 98504, within thirty (30) days from the
effective date stated in paragraph one of this letter.
The Merit System rules (WACS), Department of Corrections' policies, Monroe
Correctional Complex-Special Offender Center Field Instructions and the
Collective Bargaining Agreement are available for your review upon request.

U~~
... -

Kenneth DuChanne
Superintendent
KD:cg
Attachments

cc: Dave Savage, Deputy Secretary, aco
Eldon Vail, Assistant Deputy Secretary, OCO
Phil Stanley, NW Regional Administrator
Jennie Adkins, Human Resources Administrator, OAS
Linda Dalton, Senior Assistant Attorney General
Cheryl Landers, NW Region Human Resource Manager
Bob Riordan, MCC Human Resource Manager
Personnel File

~

.

DEPARTMENT OF CORRECTlONS

EMPl fEE CONDUCT REPORT

THIS FORM TO BE USED IN COMPLIANCE WITH POLICY DIRECTIVE NO. 857.005
INSTRUCTIONS AND TIME UMITS:

1. The person making the report shall provide a clear description of the incident under "Description of Incident"
and, with any witness(es) or person(s) having knowledge, shall sign in the space provided and submit to the
supervisor of the involved employee within fourteen (14) calendar days atter the date of discovery of an
employee's alleged misconduct.

2. The form shall be submitted to the employee involved who shall complete the "Employee's Statement" and
return the report to his I her supervisor within seven (7) calendar days following the date of receipt.

3. The appropriate supervisor shall review the facts of the incident, complete the "Supervisor's Report" and
submit the report to the Office Head within seven (7) calendar days following the date of receipt.
4. The Office Head or designated representative shall review and within thirty (30) calendar days following the
date of receipt determine whether misconduct has occurred. This shall be reported under"Administrative
Comments" and shared with the employee. When the supervisor and Office Head are the same person, the
supervisor'S supervisor shall complete the Administrative Comments.
;;IotI'I.OYIlE INVCLVEO

I

Gloria Wagner

IJIlGAHIZAnONAI. UNIT

~CC

I

RN2

- Special Offender Center

OATE OF lHC:CEltT

I ""'" OF lNCIlalT

17/22/98

6 :10 PM

1

DAM DpM

DESCRIPTION OF INCIO ENT:

ON 7/22/98 AT APPROXIMATELY 6: 10 PM, YOU WERE NOTIFIED BY CO
KAREL'! MCLELLAN IhAi I N M A I _.....W
.....A ST'>""----------

COMPLAINING THAT HE "WAS HAVING TROUBLE GETIING AIR." YOU
INSTRUcrED CO MCLELLAN TO HAVE INMATE"'TAKE A COLD
SHOWER

IN A MEMO 'IOU PREPARED 'fO RN3 TERESA BOLLniQE~, YOU HlfDrCATEV
THAT "INMATE~ HAD COMPLAINED SEVERAL TIMES IN THE PAST
ABOUT HOw HE COOLDNT BREATHE IN HIS CELL" AN'D THAT AS YOU
"ASSUMED IT WAS THE HEAT AN'D STUFFINESS IN HIS CELL" YOU TOLD co
MCLELLAN -A COOL SHOWER MIGHT BE HELPFUL." AS YOU WERE DOING

INFORMING RN2 MIKE KALINA OF INMATE
COMPLAINT A1\fD FOR
HIM TO CHECK OH HIM wliEti HE om Ullfff LOCKDOWi<f MEDS.

ON ~718719720 1998, YOU WERE PRESENT WHEN RN3 BOLLINGER GAVE A
VERBAL DIRECfIVE TO ALL RN2'S PRESENT THAT THEY WERE TO
PHYSICALLY ASSESS ANY INMATE WHO COMPLAINED OF ANY PHYSICAL
ABt>iORMALITY,

I

POSITION

I

nnE

POsanON nn.E

Ii

II

SIGNATUllE

SIGNATUllE

=_

AttClchment _..;.../~
.. _........

1220

August 10, 1998

On 7/22198 at~proximatel
6: 10 p~ C/O Karen McLellen called the infirmary
and informed me IJM
complaining that he was "having trouble.
getting air'. I asked "Is e baving problems speaking?" she said "No". I told her I was
just starting med lines, that this was a usual complaint from him, that his cell was
probably hot and stUffy. I told C/O McKellen that a cool shower would probably help
him feel better. I also said "Ifhe continues to complain call me back". I then did med
lines and heard no more from the unit.

I informed Mike Kalina, R!'\( II ofC/O
McKellan's call. We decided it was not emergent and M. Kalina, RN II agreed to check
on him at lockdown med':line since he was doing that side anyway. At 8pm as we were
eavin to do lockdown medications, I reminded M. Kalina, RN II to check on IIM
He sciid he would. After checking with staff on the unit and listening to 11M .
usual
snoring, he noticed nothing amiss and returned to the infirmary.
•
As soon as we finished med-lines,

~ bad no history of respiratory or ~diac problems. He was very
somatic and often times delusional. He would frequendy say, '1 can't breathe in this cell,
could you talk to someone and see if I can go outside and get some fresh air." He was
never in any acute respiratory distress, his speech Donna! and clear, so I would give him
reassurance and apologize for having no control over his lock down statUs.
The incident was not ignored. Because of his history of many somatic
complaints, we did not feel it was emergent and since we received no call back from the
unit, we thought that the situation had resolved. It is common practice to assess 11M's,
especially those on lockdown statUs on the unit at lockdown med lines.

ql~

\/\ lJcqf1.'- eJ

Gloria M. Wagner, R..."f II
cc: Mike Wilson
Te3D1ster Business Associate
Local 313

1221

Employee Conduct Report: Gloria Wagner, RN 2
SepUttnber 21, 1998
Administrative Comments:

On August 3, 1998, you were issued an Employee Conduct Report (ECR) by Teresa
Bollinger, RN 3. It is alleged misconduct occurred by you on the evening ofJuly 22,
~failed to respond to provide a physical assessment on offender_
~ after receiving a call in the infirmaIj' at 6: 10 PM from Karen Mclellan.,
Correcnonal Officer o~Unit. It was later that same evenin~died in his cell

on~nit.

Findings or this Review:
According to RN 3 Teresa Bollinger, on the dates of May 18, 19, and 20, 1998, you were
present when she gave a directive to all RN 2's that they were to physically assess any
inmate who complained of any physical. abnormality. This directive was based on a
memo directive this writer sent to Mrs. Bollinger. Yo~ report not being aware of this
directive on July 22, 1998.
You assume~ascomplaining about his difficulty getting air because it was
a hot night an~CO Mclellan to hav~e a cold shower and to call
back if his problems persisted. Althoul!h by your own repon and the repon of others this
CO Mclellan did·not call back.
was a common complaint of
You were in the middle of doing med lines when you received the call from CO
Mclellan.
You did not document this call in the infirmary log o r _ medical file. Nor had
you documented in his medical file any of the numerous similar complaints that he had
about his difficulty getting air. You state
omplaints were many and often
delusional in nature and that you do not document them always. You acknowledge
lmowing that if nurses do not document offender's complaints in their medical files and if
offenders do not make the same complaints to their treating physicians, then they will not
have this infonnation.
You verbally repone~omplaint to R....'i' 2 ~like Kalina who looked in o .
_ a t approximately 8:30 PM to find him snoring as he slept. There was no verbal
communication at this time betwee~and Mr. Kalina.
CO Taylor observed_~ floor naked about 9:30 PM. According to
Mr. Taylor's report, at that time_indicated he felt better after taking a shower.

_was

a difficult offender to assess for medical problems because he
complained often about a number of medical. problems, some of which could be verified

1222

as not real and ne was delusional (his belief system was idiosyncratic and often could not .
be verified).
According to Dr. Jonas, MD.• _
treating physician, the afo~entioned
complaint of having difficulty getting air is significant to his documented physical
problem of which all medical staft: including yourself, were aware. The knowledge of
this medical significance should be information commonly known among nurses.
according to Dr. Jonas. You state mowing the problem becomes a medical concern at
the time s1he becomes neumoniatic.
Persons prescribed psychotropic medications are more susceptible to the effects of heat
than are the general population. You indicate not having knowledge of this on the date of
July 22, 1998.
You recently became certified as a psychiatric nurse and the above infonnation was not
included in the material you read for the exam you took to become certified.
You state you or any of the other nurses would never.deliberately harm an inmate.
Conclusion: This reviewer finds misconduct for failing to respond to an offender
complaining of having a medical problem (who later died), for the following reasons:

1. A CO is not a medically trained person therefore slhe relies on the medical expertise
slhe cannot be relied on to provide a medical assessment of an offender's physical
complaints, nor should s1he be placed in the position to assume legal liability for
having done so.
2. Although it was stated in Ms. Lareau's investigative report at the time RN 3 Bollinger
verbally gave the physical assessment directive, included was not a time frame for
meeting with the offender aft~r receiving a complaint, _
was not physically
assessed at any time during the evening of July 22, 1998.
3. The fact that it was an unusually hot evening is all the more reason why RN 2
Wagner should have been more concerned for the welfare o f _ Her
assumption he was having a minor reaction to the heat shoul~continned or
not by 3. physical assessment.
4. The fact tha~epeated1y made the same complaint about having difficulty
getting air should have raised a red flag to Ms. Wagner to (1.) do a physical
assessment and (2) document this complaint in his medical chart for the treating
physician to funher assess. And to provide recorded information to nurses working
the following shifts. As this information was not documented in any location. the fact
_
complained ofha...ing a physical problem did not get passed on to the next
shift of nurses. RN 2 Cave reports she did not know of this complaint when she was
called to look in o~ at 10:34 PM, by CO Smith.

c.

1223

•

s.

Although you were in the middle of doing med lines, you could have requested that
correctiooal officers bring ~ the iD:finDaIy for assessment while holding
offon having the next gro~ders sent to med line.
;

Additonal Comments:

In addition to this writer's findjngs of misconduct for fiUlure to respond to an offender's
physical complaint, your failure to document in
edica1 tile what according
to Dr. Jonas, MD. is pertineDt medical infoIIDation is also reason for misconduct. This
lack of documentation fail~e RN 2 Cave with necessary infoIIDation she
needed to properly assess~ that evening.

?#) .' .~t

I
.......
4

.•- .

•

DEPARTMENT OF CORREalONS
SPECIAL OFFENDER CENTER
P.O. BolC 514. Parle Place· Monroe. Washington

98272~S14

9/9198
TO:

Gloria Wagner

\

FROM:

Ray Sigmund
Acting Associate Suf(erintendent

SUBJEcr:

ADMINISTRATIVE MEETING

pf'd?Y ~
.

I am scheduling a meeting with you on 9/10/98 at 2:30 p.l11. in my office to discuss the Employee
Conduct Report initiated by your supervisor. Attached ple:1Se find copies of the following
documents:
•

Employee Conduct Report

•

Employee Rights Pursuant to Article 8.2 of Institutions CBA

The purpose of this meeting is to give you an opportUnity to explain your account of the incident
prior to my making a decision as to whether or not misconduct occurred.
'.

You are entitled to have an employee representative present at this meeting. No copies have
been sent to your representative. If you choose to have an employee representative present;::it is"·
your responsibility to forward these documents to himlher yourself.

aa
Att (2)
cc: Linda Gilstrap, Personnel

Chronological Description of Incident

C/O McLellan was. unit Booth Officer on Shift m, July 22 1998. It' was a v=..............
ni t and the air conditioners were not working well. C/O McLellan said th~
as acting normally during her shift and not yelling that night. At approximately
aaivated the cell intercom by yelling that he was having trouble getting
1810
air. C/O McLe Ian replied t~ she would notify the infirmary, and said that
she sent an officer to check o~ not corroborate this.) C/O McLellan said that
enough breath to activate the intercom. which took a fairly loud noise to
activate. C/O McLellan said that this was the only time that she knew of on this shift
whic~complained or activated the intercom. She said tha~
known to have many complaints, but could not recall exactly ifhe had~ of
trouble getting his air, or indeed any ofhis specific complaints, in the past. C/O McLellan
said that there was nothing i~resentation which was unusual or which .
alarmed her. She also said that the nurses had always been very attentive t
and had always evaluated his complaints in a timely fashion. For her part, she said, she
always relayed the inmates' complaints to medical w1ihout delay,

_had

That night, RN2 Wagner was conducting medication lines when she received the call from
IIUnit Booth C/O McLellan, staring that
as complaining ofhaving
trouble getting air. RJ.'\J2 Wagner asked C/O McLel an 1
as having problems
speaking, and was told that he was not. Since it was such a ot rug t, RJ.'\f2 Wagner
thought perhaps the heat was bothering_ and suggested to C/O McLellan that a
cool shower might help. RN2 Wagner further asked C/O McLellan to call her b a c k .
_ h a d any more problems; C/O McLellan's memo did corroborate this. R..:.'\J2 Wagner
said that she did not hear back from the unit, and so assume~was feeling
better.
RJ.'\12 Wagner said that ~tely trusted C/O McLellan and the rest of the unit staff
to follow through wid~ and let her know if he was having further problems.
She (and several other nurses- Atchison. Cooper-Schmidt. and Kalina) said that.
-=omplaint of having trouble getting enough air was a frequent complaint for him,
that he was never in any respiratory distress when evaluated for this complaint, and that he
frequently included the request to go outside and get some fresh air, saying that he could
not get enough air in his cell. RJ."f! Wagner said that she had no reason to believe· either
_fro~past medical history or the presentation of his complaint that night - that
~ any danger or that this was different in any way from previous similar
complaints.
At about 1830·1845. after finishing the dinner medication lines, RN2 Wagner told rvlike
Kalina, RN2, about_complaint and her conversation with C/O McLellan. The
Shift ill nurses split up their nursing duties, and that evening it was the responsibility of
Mike Kalina RJ."l'2 to respond to non-emergency complaints ontrunit. They decided that
since this was a frequent complaint and hitherto without objective findings f o r - . r

..

122S

:

2
and since they had not heard back from the unit, RN2 Kalina would check o~
at the 2000 medication rounds.
ClO McLellan stated that one of the officers who saw~ this time said that
he was puffing a little, but nothing out the ordinary for~ did take a cool
shower. and the officers could hear him "whooping and hollering" in the shower (which
did not, as RN2 Kalina later pointed out, indicate respiratory distress.)

Mike Kalina, RN2. and an officer checked o~t about 2030. RN2 Kalina said
th~ was asleep and snoring q~s was corroborated by C/O
McI:eUan's 7/23 memo) as was his habit. _respirations at that time were even
and regular and he appeared, when seen through the cell window. to be merely asleep and
in no distress. Attempts made to aWaken~y calling and knocking were of no
avail. RN2 Kalina said that since these medications were voluntary medications.
_
was known to sleep through this medication pass (despite the noise of the calling
and knocking) nothing seemed out of the ordinary.

an.

At some time between 1800 and 2200 (the e.xact time has not been detennined) a religious
volunteer ( Dan Dierdorff) visite~ He thought tha
was "really out
of it" that night. He was unable to comrnumcate with
or the rst time in
"numerous visits." The volunteer said that he did not think
as in a life
threatening situation and so did not ask an officer to check on m. In retrospect,
however, he said_"looked like a man with a high fever."
C/O Benda check~bout 2130 an~as lyin~ floor.
(Immediately after~h I asked several people who knew~,flying
on the floor and/or being naked was unusual for him. No one thought it was very out of
the ordinary for him. This was before my investigation and I do not remember who or
when I asked, though.) C/O Benda a s k e d _ f h e was feeling OK and according
to C/O Benda,_replied "Yes, I'm a little hot, I took a shower, I'm OK."

0_

I did not think it appropriate to interview, nor to include any infonnation from a
"declaration" written by SOC Inmate Sean Morin #912839. This is the inmate who could
cell the night he died. The
be heard yelling on the videotape of the entry
point of Mr. Morin's letter is to debunk and expose actions and inactions by the nursing
and custody staff. This memo is included in the packet of memos.

•

3

Nursing Interviews

RNJ Bollinger wrote the ECR. She alleges th~er chose not to go s e e .
_ o n the unit when C/O McLellan relay~complaint. RN3 Bollinger
stated that on May 18. 19. and 20. 1998 she announced at the noontime nursing meeting
that all nurses were to physically assess any inmate who complained of any physical
abno~ concern is that RN2 Wagner neglected her duty by failing to physically
a s s e s s _ at the time of his complaint.
In my interview with RL'iJ Bollinger on 8/24. she stated that she had infonned the nurses
that they must bring down to the clinic and physically assess aU patient complaints of
potentially severe problems such as chest pain, shortness of breath. severe abdominal pain.
etc. RN3 Bollinger says that she did not state a timeframe within which these problems .
were to be assessed. nor put her directive in writing. nor have the nurses sign that they had
received this directive. RN3 Bollinger estimated that the SOC nursing staff receives 10-20
notifications of physical problems each week. not all of them severe. Further. when asked
if she thought that the nurses should assess the 201h instance of a panicular complaint by a
particular patient like the 1st, she replied "yes."
I asked RN3 Bollinger what her thoughts were on the nurses perfonning "telephone
triage" of patient complaints. that is. trying to ascertain over the telephone which
complaints were significant enough to warrant physical assessment. While stating that the
nurses have to use their clinical judgment to ascertain which problems are significant
enough to warrant the patient being brought down to the clinic and assessed. she also
stated that it was not the officers' job to judge what was an emergency or even to describe
how the inmate appeared to them. (1 happen not to agree with this last thought - the
officers are trained observers and are well able to describe in layman' s tenns how someone
looks. This is not asking the officers to make a medical judgment or call.)
Every nurse interviewed expressed the deep frustration and concern that they did not have
enough time on their shifts to complete their tasks. and many thought the latter half of
Shift III was the busiest and most difficult (although nights was, as well.) The general
opinion was that there was no "slack" time between about 1615 and 2100; any urgency or
emergency must be carefully evaluated for its significance because of the impact on the
shift duties. Some examples given were: giving the"dinner" medications too late could
impact the .• bedtime" medications because many medications cannot be given too close
together. One nurse running late could adversely impact the" bedtime" medication line for
the whole institution. And many times there would be more than once special (timeconsuming) problem per shift, such as an inmate requiring an involuntary shot or other
medication as well as an urgency or emergency.
When asked. RJ.'l3 Bollinger stated that she had filed the ECR because Rl'l2 Wagner had
not followed the directive concerning physical assessment. and because she did not think
that RJ.'i2 Wagner had used good medical judgment. RN3 Bollinger, also when asked.

122S

4
stated that the reason she filed the ECR was for "someone else to investigate (the

situation) and make a decision on whatever needed to be done. n
In interviews with all of the seven full-time nurses at SOC, when specifically asked if they
remembered RN3 Bollinger "announcing the expectation that every time an inmate voiced
a physical complaint he would be visualized and assessed by a nurse," four - including
RN2 Wagner - replied no, one replied no but it was standard operating procedure to do
so, and two replied that they had heard her say this in the past but couldn't remember
where or when.

Included in the ECR packet were DOP Policy 620.020 and TRCe Field Instruction
620.020 ,. Inmate Deaths." Neither of these seems applicable to this pan of the situation.
Also included is TRee Field Instruction 610.020 "Inmate Health Emergencies" whicft
states "The following conditions constitute a medical necessity for emergency
transfer: ....Any clinical situation that presents as life threatening or requires physicianlevel intervention... i.e.... respiratory impairment..." ,

Investigative Statement
1. Appropriate communication occurred betw~ staff and custody staff.
Nursing staffhad asked for a "calI back" i f _ h a d any further problems and a
second call was neither made nor received.
2. Telephone triage is a necessary tool in this setting and must be used with accurate
observations and reporting by custody staffcombined with the use of good nursing
judgment.
3. None of the nurses or officers who wrote memos or were interviewed abou.
_omplaint of the evening of 7/22 thought he was having respiratory .
impairment or that he was experiencing a life threatening problem..
_
'·whoO ed and hollered" in his cool shower that evening. RN2 Kalin~
sleeping (snoring) respirations as "~d regular' on his (RN2 Kalina's)
30 follow-up of_complaint. ~old C/O Benda at 2130 that he
was OK. The one incongruity IS in the religious volunteers' description of his visit with
but the only potentially relevant observation which the volunteer made on
that was done in retrospect

ii

4. It is unclear whether RN3 Bollinger's verbal directive to visualize and assess every
inmate who complained of a severe physical abnonnality reached all the staff.

1229

.'_. • =.,;

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Sister Rene, SOC Monroe

~.'
Subject:
~:..:... 7122J98

cc:

I came in on W~. eve. and beg!!n my usuaJ.~ to aU four tiers in _unit.
.
When I was talldng to other inmates on the tier (where~ loCitedl, I cculd hear him moan
and talk inccherently. When I went to visit him I was su~as he had no 'dothes on. He was
lying on his bed, and 1said - _ are you 010He said something.1 cculd nclWllllrtand, moved quicldy to the floor of his cell,Jay on the floor,
and acted physically .and mentally upset. In retrospect, I would say he looked Oke a man with a
• 1don't think he knew I was visiting him. This was the first time in numerous visits that
d I were unable to talk to each other.
t ask
if he Wanted me to pray aboUt anything. He did not answer, so I p~t God
would glVe m pe"ace. When I left that tier I casuaJIy said to a woman officer that~.
really out of it tonite, and did not have a stitch of clothing on. I did not ask an officer to Check on
him, nor did I believe that he was in a life threatening situation.
Sister, I am available to talk to someone at SOC or to speak to the family.

,.

1230

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STATE OE=WASlo{INGrON
OEPA~eNLeFcoRRecnoNS

MEMORANDUM

0"

1231

EHSD ,
INMATE
To: . WAGNER GLORIA

From:

:...\" .' .:
. .

_...,~ .' ~~aa. f!Oae

HC:LELIh KAREN

Line:.L

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)c-Dp:"G1-GWii

1

DOC-DP-Gl-KS6

2

Date: Thursday 23-Jul-98 at 8 :53pm. .
Subject: INMATE _

3
4

ON 7-22-98 AX APPROXDfATELY 6:10 PM INMATE
CALLED THE.
UNIT BOOTH AND ASKED ME TO-'CALL THE INFIlOO\RY AND TELL ~ THAT HE WAS
HAVING TROUBLE GETT~ I CALLED AND TALKED TO R.N. WAGNER WHO TOLD
ME TO HAVE INMATE_ _ TAKE A COLD SHOWER. SHE ASI<ED ME TO LET HER
KNOW IF BE DID NOT GET BETTER: AFTER INMATE'" TOOK HIS SHOWER I HAD
C/O TAYLOR CHECK ON HIM. BE' WAS LAYING DOWN AND APPEARED TO BE KEY.
ABOUT A HALF HOUR LATER C/O BENDA CHECKED AND FOUND THE SAME THING.
DURING 8:30 MEDS. R.N. KALINA AND I WENT TO INMATE-' CELL AND FOUND
HIM ASLEEP AND SNORING.
AT APPROXIMATELY 9:30 P.M. C/O BENDA WENT TO INMATE--.r CELL TO
CHECK ON HIM, BE WAS LYING ON THE FLOOR. C/O BENDA SAID ARE YOU OK?
INMATE _ S A I I J "YES IIM JUST A LITTLE HOT, I TOOK A SHOWER AND· AM
FEELDlG BETTER". HE THEN LEFT THE TIER.
_.
C/O KAREN MCLELLAN
CC:
BOLLINGER TERESA
DOC-DP-G1-THA

5
6

*** End of Message ***

..

Function:
Functions(1/6): PF2=NExt 3=ENd 4=MEnu S=Find 6=AMend 7=BWd 8=FWD

7
8

9

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11
12
13
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pfl=help

1232

•

STATE OFWASHINGTON
OEPAR~ENTOFCORREcnONS

. MEMORANDUM

SUBJECT;

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STATE OF WASHINGTON

DEPARTMENT OF CORRECI10NS
SPECIAL OFFENDER CENTER.
P.O. BOX 514 -PARK PLACE - MONROE, WASHINGTON 98272 - 0514

TO:

Lt. Conner. Larry

FROM: Sgt. Milan. Tony

DATE:

07123/98

SUBJEcr~

--~

At or about Ooss.rs
I r e:ived a all (rom 00 Smith that the nurse was coming up to tile: Unit t? see
~ do t
having not moved :1t all aD our shift and he was being unresponsive.
At ~ [ ar"r"lvea on the Unit :lnd RN Todd stated that8lllllseemed to be breathing, bue was
unresponsive. RN Todd. 00 Brown :1nd 00 Taylor were trymg to ge~o response to them
ailing to him and they also tried throwing socks and water at him. StiI~ unresponsive. I asked
if he was asleep and breathing, RN Todd stated timt he ~ appeared to be breathing and
asleep. I recommended that we let him sleep, but would ~i..t. to get the olc1y to open the Cell.
Lt. Conner stated that he was on his way back to SOC and to wait for h.im to arrive. When the Lt.
did arrive the Video Camero :1ndMat w ibrou
l l r Itt
c up to the Unit and A Entry Debriefing was done.
At 0127hrs Lt. Conner attempted to get UM
a response to Staff. No Response was received
from~ So I g3ve the order to ope
Brown and CIO Tavlor with myself entered the
cell ~(was placed o n . at whtc: tim~did not mov~wasordered by CiO
Taylor to place his arms behind h.1S b:1ck, No resp~"': CIO Taylor too~by the right
:1rm and tried to place it behind his back. but the arm would not move that C:1sily ~onner had
R.N Todd come in and chec
out. At which time RN Todd stated that ~ a s Deceased
and th:1t:It tbis time CPR an any.'
First Aid would not help. At 0133hrs ~d stated that
" ' w a s Deceased. At 0145hrs
cell was closed as n Crime scene by Lt. Conner.
~Ohrs the Monroe Police Dept. Officer C. Martinez on grounds and at 022:2hrs he was on A·
Unit to view the crime scene.
At 0325hrs Snohomish County Coroner D. S~love MD arrived nnd wns taken to the crime scene.
At 0403hrs U~:ts removed from his cell by the Snohomish County Coroner :lnd at 0407ltrs
tbe cell was clo~nvestig:ltion.
At0422brs U M ~ eUnit.
At OS03hrs 1 1 M _ w a s removed from SOC grounds by tbe Snohomish
County Coroner.
Stafr [nvolved:
. Lt. Conner, L
Sgt. Milan. T.
C/O Deh:tven, B.
00 Brown, C.
00 T:tylor, M.
C/O Smitb, J.
00 Netberton, S.
RN Todd. R.
R.N Cave, L
End of Report:

Shirt Lt.
Shift Sgt.
Main Control
M:ttl RM
M:1t I Unit St:tff
Unit Stnff
Camera Oper:ttor
Medic:Il St:Iff
Medici Suff

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STATE .OFWASHINGTON
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DEPARnMENTOFCQRRECTIONS
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DEHliVEN BARRY
SPECIAL OFFNDR CTR
1673G FERRY ROAD
H9NROE

TO:

FROM: DEHAVEN BARRY
SPECIAL OFFNDR CTR
16730 FERRY ROAD
MONROE

'.:.: ".' . . :·~·:<~~f:t~>·.· '~~:~~j.

DOC-DP-C1-BD3
__ -,JUL-98 65: 29':'24.
.
..~

WA 98272-G0GEi
DOC-DP-C1-BD3 23-JUL798 05:14:54
INA

98272-00G0

SUBJECT: I/M

DOC-DP-G1-BD3/MA~

--------------------------------------------------------------------------/TO CONNE.R LARRY
/FROM DEHAVEN ~ARRY
/DATE THURSDAY 23-JUL-98 AT 5:23AM
/SUBJECT I/Ii
~

DGC-DP-G1-LC3 OK
DOC-DP-G1-B03 UK
U"r.
OK

AT APPRO X 0047 HUURS r RECE!VE~ A CALL FROM C/O JIM SMITH ASK!H~ WHERE
THE SCT. WAS HE INF'ORME:D /1E THAT INMATE _
HAl> NOT APPEAR!:::!} TO
MUVE
SINCE THEY CAME ON SHIFT.
I

CONTACTED lHE SG1. AND HE WENT TO THE UNJT. ALONG WITH RN 2

CAVE
HAD A

LEA ANN
I THEN CONTACTED Lf. CONNER aVER Ar TRee AND ADVISED HIM THAT WE
POSSIBLE SITUATION AT ~OC. HE ADVISED ME TO KEEP HIM POSTED.

-1:._

SHORrLY THERE AFTER LT. CUNNER RETURNED AND LT. CONNER SGT. MILAN. C/O'S
BROWN. NETHER rON ,. TAYLOR AND RN 2' S RICHARD TODD AND LEI; ANN CI~VE ltJENT
""j..J':'~l:: L Tn_ t~'n'l:'r:" ON
I
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1 0 £ \.'''E:i'~

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c/o SMITH NOTIFIED ME Al ei27 HOURS THAT THEY WERE ENTERING THE CELL. AT
APPRUX 0130 ! WAS NUTIFIED BY C/O SMITH THAT IT APPEARED AS IF THE
INMATE WAS DECEASED. AT 0134 Ll'. CONNER NOTIFIED ME THAT THE INMATE WAS
DECEASED. AT 0134 SNO PAC 911 OPERATOR 19S WAS CONTACTED BY ME AND
ADVISED THAT WE HAD AN lNMATE THAT WAS DECEASED AND WE NEEDED MONROE
POLICE AND THE SHO CO. MEDICAL EXAMINERA
Al 0150 POLICE OFF1CEk MARTiNEZ ARRIVED ON SIlEo AT 0200
COUNT WAS CONDUCfEO PSR POLICY. ALL INMArE~ ACCOUNTED FOR
0209.
AT

FIN ' I NFOF:i'~AL

CLEAI::INt;

1",0:

1 Hi::' C/O r~E.TH":~TON R£L lE."JED I'IE Or i'iAIN CONTROL
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AND
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AND
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TH.1S

A:;S~;;TEii

TO

THE

UNIT WITH IHE

M~DrCAL

£XAM!NER ANV SYOUD

BY

AW~lrIN~

~URTHER

INSTi'.'UCl rUNS '.

I ~SCORrED l!iE POL1C~ TO lHE UHXT TO rNT~RVIEW INMAlES AND OFF
UN!T. THIS ENDED MY PARfrCIPATION LN THIS EMERG~NCY S(TUAfrON.

THE

c/o BARRY DEHAVEN
---------------------------------------------------------~------------------

*

MEND CF MESSAGE

M

*

PRINTED ON

23-JUL-98 AT 05:29:29

MA~

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The Employee Haad~1c. is designed to acquliiDt you widl the
Department of Cori'cdi.oas and state ~IOymcnL Guidelines and
job·~u:dinfoemaiion arcgivcn to assist,you in the performance of
your assigned duties. It isiniended as a supplement to dcpamncntal
directiveS. ~ la~ Merit systetil Rules and facility or office
procedures. If you need further infocmation o,r.clarification. you
can
should contact your supervisor or'personnel CcprcscnW:ivc.
provide you, with :mswers or refer you to the location of the specific
IUles or source documents.

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DEPARTMENT OBJECTIVES
In May of 1981. the Washington State Legislature established the
Department of Corrections. separating it from the Dep:inment of
Social :utd He:l1th Services.
The depanment's mission is to promote public safety by providing
f:1cilities and services to evaluate. control. and redirect the behavior
of adult felony offenders committed to our jurisdiction by the courts.
In c::uT)'ing out our mission. the department cooperates with other
state criminal justice systems :utd ende:tvors to assure that offenders
charged to our ere arc prepared for re~ease and reintegration into the
community.
The de?arunent' s main objec:ives are to:
• Ensure safety for the public. staff and offenders:
• Punish the offender for violating the law, generally through the
deni:li of libeny:
Trc:lC all offenders :utd suff fairly and equitably:
• Reflec: in the system the v:liues of the community by avoiding
idleness. adopting the work ethic. providing opportunities for selfimprovement. providing tangible rewards for accomplishments.
and sharing the obligation of the community:
• Effectively:md efficiently manage resources;

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Provide for n::stiwtioa:

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Be accountable to the citizens of the stalC;

• Meet the aatiooal standards appropriate to the State ofWashiagton.
CODE OF ETHICS

\

High moral and ethical standatdsamoag correctional employees are

essential for the success of the department's programs. '):'he Depart•.
mcnt..Qf.COIlectiOns ~aibes to a code of unfailing honesty,
respect for dignity and inCiiVIQilality of human beings, and a commitment to professional and compassionate savicc.
---

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DEPARTMENT E.'TI'ECTAnONS
As a new employee of the department, you will have many things to

I~, not :~,~=.~~ of wh~will be_the e~tio~~.9.G2!!~P.:CJV~
sor. your co-workers. and the agency as a whole, To assist you with
this responsibility. following is a list of some departmental expectations for your study. Familiarize yourself with the list so that you
may understand and fulfill the duties of your position.
~

a. representative of the Department of Corrections. vou will be
expected to:
• Positively represent Washington State govemment 10 eve..ryone you
meet. You are our best public relations agen4
Dress appropriately for your job classifiC:luon and duties. Clothing
may not have mottos. logos. or advertisements that may be offensive or in conflict with the goals of the Department: "
• Wear issued uniforms only as authorized;
• Be a good citizen. obey laws while on and off-duty. Your condu~
off duty may reflect on your fimcss for duty;
Treat fellow suff with dignity and respect;

.-

• Be impartial. understanding and respectful to offenders;
• Serve e:1ch offender with appropriate concern for their welfare and
with no purpose of personal gain;

J_-t ~ 49

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Employee Name (please'Print)
..
ACKNOWLEDGEMENT OF RECEIPT OF
DOC El\1PLOYEE HANDBOOK

I acknowledge receipt of the June 1993 Washington State Deparnnent
of Corrections Employee Handbook and agree to become familiar
with and have a thorough lmowledge and understanding of the
'
contents.

lL\2tjlJ")
Date

Original - PersOIll1el File

Attachment .-;;-;;;;::~~. _

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HB 36

PttCINl!NO.

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23. lDM't.OVEE·S STArEMiHT Of GurlES

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~~~ose Dunes FIRST WHICi OCCtJpy MOST OF YCUR

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MOST ReSPONSl8l.E

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the sucerVISlon of the RN 3. the RN 2 Drovides comcrehensive
services in the clinical setting of the Soedal Offender ~:enter.
a LOg-bed adult correctional facility oroviding intensive theraceutic
. "'""',
communitv ser'/ices to mentallv ill offenders.
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nursin~ care

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such as major i~;i;;~:~:;<::··:·'·,;.;...
tranquilizers, n.eur~leptics, anti-parkinsonian meds~ antibiotics, and anti-I::" ;-S:.~.; .. .
I convulsant medlcatlons, as we!! as others as ordered.
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.nethod and document any side effects.
.-:#:~~~?~_~:;.,;. :~ "'~'"
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10% Assist psvchiatrist with med re'/iews on units.

Complete all orders and
relay ~'o' pharmacy. Assist P.A.s when needed.
Participate in case I.~;;':.>'::'::~:·"~... ·· ":~":'
management on all units.
.
.
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10%

i Enter

computer data for upcoming psychiatric appointments. Order bate,
reports.

,

10% i Provide ongoing nursing treatment and emergency treatment as necessary.
I

5%
5%

i Clear inmates for

food service and keep accurate documentation.

Obtain scheduled and emergency EKGs.
minor surgery.

Assist P•.61.. with sick call and
0.

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equipment~ and

5%

Pro.... ides for the safety, securi ty, and sani tation of supplies,
the lnfirmary area.

5%

Maintains professional nursing care integrity as it applies to appearance,
behavior, demeanor, and delivery of services. Performs other work as
required.
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substituted for general' nursing experience, but not for psychiatric nursing experience.
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STATE OF WASHINCTON

DEPARTMENT OF CORRECTIONS;
OFFICE OF CORRECTIONAL OPERATIONS

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lWlN RIVERS CORRECTIONAL CENTER I SPECIAL qFFENOER CENTER
PO BOX 514· Monroe. Washington 98272-0514· (360)794-2200
FAX (360) 794-2314

September 24, 1998

Gloria Wa@.er, Registered Nurse 2

TO:
FROM:

r::;;,Q. uiJu'

at

Teresa Bo~~st;rec?Nurse3

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Regarding: Memo of Counseling
An incident occurred during ~ d line on 8/31/98 in which you

dispensed medication to I / M _and then failed to immediately
chart this fact, as required by law and as further directed by Ella Ray Sigmund
in a memo to RN's dated 8/13/98. By your signature on Ms. Sigmund's memo,
you aclmowledged that you were aware of the directive prior to the occurrence
of this 8/31/98 incident.

an

I sent you
e-mail on 9/12/98 to refresh your memory relative to w.l.te content
of Ms. Sigmund's 8/13/98 directive.
By your failure to adhere to lawfully mandated and management reinforced
prescribed procedure in the process of medication distribution, you w~re
directly responsible for the overdose of medication received by I/~n
the evening of 8/31/98. Such neglect of duty at the least caused considerable
discomfort for liM_and if you persist in such practice, could present a
future situation of life-threatening proportion. .

I.am now advising you that any future disregard of Ms. Sigmund's 8/ 13{98
directive regarding medication charting procedures will result in further
corrective/ disciplinary action up to and including dismissal from your
employment with the Department of Corrections.
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