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Michael Kalina Employee Medical Disciplinary Action Appeal and Report 1997

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~ DEPARTMENT OF CORRECTIONS
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POLiCy'Du~EcnvE
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~ONDUCTREPORT

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'NO.'SS7.005 -

INSTRUCTIONS AND TIME UMITS:
, 1. The person making the report shall provide a clear description of the incident under "Oescription 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.

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2. The torm shall be submitted to the employee involved who shall complete the "Employee's Statement" and
return ll!e repo~to hislher supervisor within sevenV) 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.

I

Kal ina'. Michael
PO$I1lOH nnE

ORGAHlZA~UMT

Hpal'th C::erl[icoc: - c::OC ra;;"'''';:,'''

RN 2
DESCRIPTION OF INCIDENT:

~~b1 gt1)-tb tIl

pressure was r_cor e aL au
physical condition required that he be transDorted to VGH for evaluation.
t is issue you statea that you had noticed a difference in
medication and had hesitated before aivina it to him. You
tnere must nave been a med change.~ You then gave I
chec~ing on the accuracy of the CUDS contents.

cup

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ihiS lnmate overdosage was not apparent to you until the 10:00 Pm narcotic count was cQnducted
nd 2 Kloncpin lmg tablets were noted as missing. You called me at home tQ advic:~ me af tJe
ml SSl ng: med~ .'" I i nstructec. yCiu,~ ,t~at _:the j,nfi,rmary staff i nvo 1 ved in this incident should write
a memo 'concernin this situation. !' also instructed vou to i. m 1
r./n
, r.e~tment.. ::~or- Kepo!"t:~. - I-_di J:ected ,you -to· complete the memo's and error· report
to '. .
,.1eav.ing-the";,"ins,titut:lon~.tha.t
....same·-evenin ,:":.·YQ "did~ n i . , I I . 'r ;
reatrnent Error Report" prior to leaving the institution as instructed.
You also failed,to aoo;opriatelv document Qn I41111111Jmedi cal char+ ~he 8·40 pM adrlj~ional
dosage of Klonopin lmg.
,

INmATEOBY:
HAUE lJ'U.o'SC-n

RN 3 Tet~sa ~ eo III

nget'- .

RN 3

WlTHESS(ESI:
NAME

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:.;.,' DATE "DELIVERED or

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~YEe"SS1'ATEMEHT:

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SUP£lMSOR"S REPORT:

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DATE RECEIVED BY SUPeJMSO

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ADMIHISTRAllVECOMMENTS: DATE RECEIVED BY OFFICE HEAD

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~ Signature of : ~
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Attachment

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EMPLOYEE PROFILE

DEPARTMENT OF CORReCTIONS

PaQe One of Two

Amount

PID Date (Affects?)

PROPOSED ACTION: ....2~rPi.artL:L1J.~~~"tt-:-=-::2...:&.~~.=2:..crl.!.~~
DAlES From

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RANGEISlEP From

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J/ J.f-5 P
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No. of Months
To

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TOTAl LOSS

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($)

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A. PERSONNElJPAY ACTIONS llnfqrmatlgn gbtained
pea !JggJmems): Original date of hire, date(s) of agency/institution
transfer(s), date(s) of promotian(s), dale(s) of pay change(s) due to disciplinary adlan(s), etc. List only infonnation which is ,s'svant to
the action being propossd.

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lYPE OF ACTION

EFFECllVE DAlE

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OATE OF HIRE

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DISCIPUNARY?

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Above section continued on Page Two

EMPLOYEE PERFORMANCE EVALUAllONS
DATES (MoIYr)
From

ft(~llb

To

t06/&1I'7

16It- lis toft./(; /tih
b~;/tltf-to 1v/6 h~
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Ratings *
Exceeds

Ratings •

Far Exceeds

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Ratings
Normal

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Ratings *
Minimum

Ratings *
Falls MIn.

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Type

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Commenta (Note If EPE Is par1
of Disciplinary Letter)

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Above section continued on Page Two

• Ust Perlonnanca Dlmanslons:
A .. Aocamplishment of Job Requirements
B .. Job Knowledge and Competence
C .. Job Reliabirlty
o .. Personal Relations
E .. Communications Skills
F .. Performance as SupeNisor

• Ind/cats Type of Evaluation:

P .. Probationary
A .. Annual
T .. Tiial
S .. Special

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(C ··ll<.Cc.. V

Ch.Q/Yj I V
2

BEFORE THE 'pERSONNEL APPEALS BOARD

3

STATE OF WASHINGTON

4

s

~CHAEL

) Case No. RED-9S-0033
)
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NOTICE OF SCHEDtJLING
)

T. KALINA,

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Appellant,

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v.

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DEPARThlENT OF CORRECTIONS,
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Respondent.
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RECEIVED
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Notice is hereby given Of scheduling the hearing on the appeal before the Personnel Appeals Board.
The hearing will be held in the ~1ain Conference Room. Special Offender lJnit. Monroe
Correctional Complex.. Monroe, Washington, on Wednesday, June 16, 1999, beginning at 9 a.m.

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The parries shall arrive at the hearing location thirty (30) minutes before the hearing time for the
purpose of exchanging copies of. and when possible, stipulating to exhibits. Tae parries shall bring
sL"{ (6) copies of the premarked exhibits which they intend to offer into evidence. V....henever
possible, the parties should exchange witness lists prior to the day set for the he:lring.

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If the services of an interpreter are needed, notify Personnel Appeals Board staff at least two weeks
prior to the hearing. The hearing site is barrier free and accessible to the disabled.

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DATED this 9th day of~ovember. 1998.

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WASHINGTON STATE PERSOl'iNEL APPEALS BOARD

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Teresa Parsons, Hearings Coordinator
(360) 664-04i9

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cc:

Michael T. Kalina, Appellant
Mark A. Anderson. Teamsters
Roosevelt Currie, Jr., AA.G
Jennie Adkins, DOC

06

Pcr.;onnc:l Appe:l!s Board
: . 2828 C:apitol Boulev:ud
s:SmPi:l. W3Shington 98504

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#' ~~i'yola (360) 586.1481

·1828 ~tol8lvd.

FAX (360) iS3-0139
E..\otAIL infOoJnbfJp;ib.state.wa.us

PO Sox 40911
Olympia, WA 98SQ4.ll911

STATE OF WASHINGTON

PERSONNEL APPEALS BOARD
August 12, 1998

HOME PAGe www.wa.gov/pab

Roosevelt Currie, Jr.
Assistant Attorney General
P.O. Box 40145
Olympia, WA 98504-0145

RE:

Michael T. Kalina v. Deparanent of Corrections, Reduction in Salary Appeal,
Case No.: RED-98-0033

Dear Nir. Kalina and Nlr. Currie:
This letter is to advise you that this case has been assigned to- Jennifer Woods. She is a mediator
contracted by the Personnel Appeals Board. Ms. Woods will be contacting you for the purpose
of scheduling a mutually agreeable date and time for a mediation. We appreciate your
cooperation in scheduling mediation as soon as possible or the file may be returned to our office
to set a date for hearing.
Mediation is an opportunity to bring the parties together to attempt a settlement of the issues on
appeal without the need for a hearing. If settlement efforts are unsuccessful, the meeting will
move into the prehearing phase and the parties 'Will select a hearing date, attempt to narrow the
scope of the issues to be presented to the boar~ discuss wimess and exhibit lists, and possible
stipulations between the parties.
If you have any questions, please contact me.

Sincerely,

(·~dettJ1r{td-:­
~t~ennett
r

J

Executive Secretary

DB:py
cc:
lady Phillips
v1ennie Adkins
F:PaulettelMedialOlSIlcaer 10 plUties

I11AY Q 1 i998

CHASE RIVEl.ANO

Secruwy

DEPARTMENT OF CORRECTIONS
SPECIAL OFFENDER CE--:TER
P.o. BOil S 1... Park Pldce • Monroe. Wa.nmgcon 982 72..QS 14

April 28,1998
PERSONAL AND CONFIDENTIAL DELIVERY

Mr.

Kalina:

This is official notification that you will be reduced in salary within your
present class of Registered Nurse 2 at the Twin Rivers Corrections
Center-Special Offender Center (TRCe-SOC), Range N45, Step P,
$3801.00 per month to Step L, $3445.00 per month, effective May 15,
1998 through November 15, 1998, inclusive.
This disciplinary action is taken pursuant to th~ 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 356-34-010 (I-a) Neglect of duty, (I-d) rnsubordination, (I-h)
Gross misconduct, (l-i) Willful violation of the published employing
agency or department of personnel rules or regulations, and 356-34-020
Reduction in salary - Demotion - Procedure.

Specifically, you neglected your duty, were.insubordinate, committed an
act of gross misconduct and willfully violated published agency policy
when on October 14,1997, while performing your duties as a Register~d
Nurse 2, you were responsible for administerin an inappropriate dosage
during the
(overdose)of the drug Klonopin to inmate
8:40PM medline. Subsequently, after having ingeste the overdose of
Klonopin, inmate_blood pressure was recorded by LPN Leslie Young
as below that of acceptable baseline. Consequently, later that same
night, due to the onset of ongoing unstable vital signs, Linda Fluke,
ARNP. directed that inmat. be transported to Valley General Hospital
for a comprehensive evaluation of his condition and continued
monitoring.

n66!
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1828 ~itollUvd.
PO 80lI 40911

FAX (360) 753-0139
&MAIL info-paWpab.state.wa.us

Olympia. WA 985~911

STATE OF WASHINGTON

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

RECEIVED

JUN

9 1999

Oep~entofCOn9cdons

OAS Human Resources

June 7, 1999

Mark Anderson
Teamsters Local 313
220 S. 2-r Street
Tacoma. WA 98402·2701

RE:

~Uchael Kalina v. Department of Corrections, Reduction in Salary Appeal,
Case No. RED-98.Q033

Dear JVIr. Anderson:
Enclosed is a copy of the order of the Personnel Appeals Board in the above-referenced
.
maner. The order was entered by the Board on June 7, 1999.
Sincerely,

Don Bennen
Executive Secretary
DB:mt
Enclosure
cc:

rvUchael Kalina, Appellant
Rob Kosin, AAG
Jennie Adkins, DOC

0662

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JUfJ 0 4 1999

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BEFORE THE PERSONNEL APPEALS BOARD
STATE OF WASHINGTON

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~nCHAEL

K.-\LINA,

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Appellant,

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CASE NO. RED-98-0033

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. v.

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)

DEP.-\RDIENI OF CORRECTIONS,
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MOTION .~'ffi ORDER
OF DISi\tUSSAL

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Respondent.

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The appellant hereby notifies the Personnel Appeals Board that he!she wishes to
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withdraw the above~ntitled appeal.
Signed at Tacoma, Washington. this 2nd day of June, 1999.

~tR1L~~

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IS

Mark A. Anderson. WSBA # 26352
Attorney for Appellant

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This matter came on regularly before the Personnel Appeals Board on the

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consideration of the request of the Appellant to withdraw hislher appeal. The Board
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having re...iewed the files and records herein. being fully advised in the premises, and it
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IS

appearing to the Board that the Appellant has requested to withdraw hislher appeal, now
enters the following:

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MonON AJ.'fD ORDER OF DISMISSAL

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

1

ORDER

2
3
4

NOW. THEREFORE, IT rs HEREBy ORDERED that the Appellant's request to
withdraw hislher appeal is granted and the appeal is dismissed

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7

DATEDthisrdaYOf

jLl.A\ 0.1999.

WASHINGTON STATE PERSONNEL APPEALS BOARD

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2S

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MOTION AND ORDER OF DISMISSAL

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

066f

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RECE1VED

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2828 Clpilol Blvd,

PO 8Ga 40911
Olympia. WA 98S04-G911

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Dapanrnent or (;~ns
Division of Human R~

FAX(360)7SJ.013,

E-MAIL inro-pabOpab.stale.w~

STATE OF WASHINGTON

PERSONN EL APPEALS BOARD
HOME PAGE www.wa.gov/pab

November 19, 1998

PROPOSED liST OF CUT-OFF DATES

Michael T. Kalina v. Deparanent of Corrections
Case No.: RED-98-0033 (Reduction in Salary Appeal)

This statement is issued to record dates controlling the subsequent course of the proceedings in
the above-referenced appeal. The following dates for completing discovery, exchange ofUsts of
wimesses and exhibits and other prehearing matters are proposed.
1.

Discovery is to be completed by May 17, 1999. Requests for discovery must be
served with sufficient time for responses to be completed by May 17, 1999.

2.

Witness lists and exhibit lists are to be exchanged on or before June 9, 1999.
The parties reserve the right to supplement the lists.

3.

Pre-bearing briefs~ if prepared at the discretion of the parties, will be filed on or before
June 11, 1999 in accordance with WAC 358-30-045.

4.

The bearing in this matter will be held on June 16, 1999 beginning at 9:00 ~"{ in
Monroe, Washington.

The pre-bearing conference is scheduled for 9:00 A.a.\{ on June 9, 1999. At that time, the
Executive Secretary or designee will initiate a conference call with the parties' representatives to
discuss possible stipulations on wimesses, exhibits, and the issue to be presented for
determination by the Personnel Appeals Board.
The parties shall anive at the hearing location thirty (30) minutes before the bearing time for the
purpose ofexchanging copies of exhibits and. if possible, stipulating to admission of exhibits.
The parties shall bring six (6) copies of the pre-marked exhibits which they intend to offer into
evidence.

066~

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Statement of Results ofPre~g

November 19, 1998

Page 2

Any objections or corrections must be IDed with the Executive Secretary within 20 days of
the date of this statement and shaD, at the same time, be served upon each of the

participants named above. This statement becomes part of the official record of the
proceedings, and the stipulations will be binding on the parties, unless this statement is
modified for good cause.

Dated:

,<JOV.

I~, 199f'

PERSONNEL APPEALS BOARD

ByA~~
Don Bennett
Executive Secretary

f6S6

vOla (360) S86-1481
FAX (360)7S3~139

2828 Cqitol Blvd.
PO 80. 40911

E~"'AII. iniOolNb~~b.st.ue.w ...u~

Olympia. WA 98504-0911

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

June 18. 1998

RE:

CU·,·TfLLD

(f'\'\\~\.'"

CJY~j\ L;L·V1tt-t~

Michael T: Kalina v. Depanment of Corrections. Reduction in Salary Appeal,
Case No, RED-98-0033

Dear Mr. Kalina:
This letter is to acknowledge receipt of your appeal by the Personnel Appeals Board on June 12. 1998. The
Board will conduct a hearing of your appeal on a date to be determined. 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,
You may attempt to resolve this appeal with the assistance of one of the Board's contracted mediators. [f
mediation is jointly requested by the parties before July 10. 1998, a mediator will be assigned to meet with
the parties in a good faith effort to negotiate a resolution of the appeal.
If you are represented by a union representative or an attorney. please encourage them to coordinate a
request for mediation with the appoiming authority of the employing agency. or the assisum attorney
general who represents the agency. You may initiat~ 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 hearing 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,

~(;~Lt-~
Don Bennett
Executive Secretary
DB:lh
cc:

Linda A. Dalton. SAG
Jennie Adkins. DOC
lody Phillips, Steward

Z:lJhlncwappN<alina.doc

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APPEAL FORM
,.-\SHINGTON STATE PERSONNEL A?PE.,),LS BOARD
)~S Capitol Blvd.
0. Box ~0911
iympia, WA 98504-0911

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R.E?RE5E~ I.HiVE·S S.~~.IE. ADD~5S

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CHECK ONE OF inE i=OLLO\\"~G TO r.-;DIC.; 7~

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Exemption of ?osit!on.

066S

June 9.1998
Department of Personnel
Appe:lls Board
2828 Capitol Boule....ard
Olympia. Washington 98504Attention: Connie Gough
We would like to request an appe:l1 on the decision for the reduction in sabry on a Mr. Michael T. K.1lina.
RN2 at Twin Rivers Correction Center. Special Otfender Center Division.

Nwse K.:1Jina. has been employed at SOC since 6/9* and has proven himself to be dependable. personable
and professional. His personnel file reflects this.
Neglect of Duty
We believe that ~urse K.1lina protect_the
indi iduaJ to the extent possible in this incident. He did not
pour the dose ofmedic:1tion.:1 nurse
·ct yet she did not receive an ECR for this same .
incident. She 3dministered the 5 p.m. m coon but did not sign the medic:ltion out of the narcotic log.
Also. there was no sign:1nue from her on the medication record for the 5 p.OL medic:ltion having been
given. Nurse Kalina believed this medic:ltion was missed at the 5 p.rn. mediction tine. Nurse K.11ina
further checked the narcotic logbook :md found no enay for the Klonopin ha....ing been given.
The qu:mity of mediction gh:en was aCCUI:lte: the number of times giyen was not. However. this inmate
had been on:1 higher dosmg of Klonopin previously. 6mg the amount given in error.
The medication error was not discovered until 10 p.m. while doing narcotics count rt was at that lime that
Nwse K.:1Jina look every step possible to notify the appropriate people of this QC..'"UI'1'ence. He contacted the
UDit to find out if the inmate had been given In additional dose. He:ilso contacted his immediate
super.isor and placed a call to the on-ea11 practicioner.
There was no orientation sheet for ~urse Kalina to go by while orienting.1 new nurse to lhe 11oor. nor_had
there ever been one. It is common nursing pr.1ctice to sign out narcotics prior to giving lhem. ~urse
did not do this. Nurse K.11ina looked Jt the medications given at the 5 p.m. medication line. Due to the
vast numbers and types of medicuons. how would a nurse quickly identify a medicatiCiWliiwas out of
place or incorrect'? After discovering the Klonopin missing ~urse K.ilina c::l1led :'{urse~g if she
remembered gi...-ing lhe Klonopm dose. she could not
Gross ~lisconduct
Nwse I<alina checked lhe nar!E0l'
og prior to issuing !his inmate his Klonopin dose. However. due to lhe
logbook not reflecting Nwse
...-ing issued this e:ulier. he :ldministered the medication. The inm:lte
did not question gemng his secon dose of Klonopin that evening.
Willful Vio1:ltion
We do not find:l willfuJ ..iolation in this c:lSe. "This was an honest error.
After 3 review of Nwse Kalin:l' s personnel files Dennis That. Superintendent -moder.ued his decision
re1:ltiyc to the severity of sanction". Will ~....ery nurse who does a medication error get a 10% reduction in
pay for 6 months? 11tis would lnvol\'e sever:ll nurses <:'o'er:' month just in the ~(onroe Command alone.

e668

Appe:lJ
K3t.ina. Michael T.
Page 2

06/09/98

Funher. the decision to send the inmate to the bospitll was only done as a precaudon. The inmate was not
in grave medical danger. His vitll signs were stable, although slowed. This was a combiDarion of the
Haldol Deconoate injection as well as the Klonopin that lowered his blood pressure. according to Dr. Judy
Nelson. Stl1fPsychiattist at SOC.
.

Nurse~mitted a memo on this incident She staleS "I poured the meds and lake full responsibility

for thiS med error".

Nurse KaJina' sjob is not that of a supervisor. He was only orienting the above nurse to the new place of
employment ::md should not be held liable for her error. Only a cettified trainer can be held 3CCOUDtable for

a lr.Iinee·s error.
Insubordination
Nurse Kalina agrees that he did not finish the paper work that night prior to 1e:1Ving his shift. The requested
memo reg;uding the discrepancy was completed. However. he also car-pooled that evening ::md his ride
le:rves at 10: 15 - 10:30. The paper work needing to be done would hav!: taken ::m additional 20 minures to
compfere beyond the normal departure time of 10:30 of his car-pool.
Thank you for your considemtion in the above matter.
Sincerely.

Michael T. K:iliD:L RN2

'C67D

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EMPLOYEE CONDUcr REPORT-ADMINIsrRATlVE COMMENTS
RE: Michacl Kalina, Registered. Nurse 2
December 4, 1997

SandIa Moore, Personnel officer, and I m.et.~ you and Bany DeHaven, your
Union Representative, on November 25, 1997, to discuss the Employee
Conduct Report initiated on October 17. 1997, by Teresa Bollinger. RN 3.

The content of the Employee Conduct Report you received on October 17,
1997, for an incident that occurred on October 14, 1997, includes:

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1. You administered. an OVCIdose of Klonopin to Inmate .Who, as a result,
had an adverse physical reaction requiring an emergency visit to Valley
General Hospital;

2. This overdose was the result of inadequate supervision for on-the-job
trainingofRN
and

2_;

3. You failed to follow an instruction from your supervisor to fill out a
Medication andl or Treatment Error Report form· prior to leaving the
institution that same evening. In addition, you failed to appropriately
document the medication error in Inmate" medical chart
During our meeting, you clarified the d:i:fference between orienting a nurse and
training a nurse. You stated. that a nurse hiring into the position is trained to
pour medications. Your stated belief was, your job was to orient her to our
system. You noted to safely pour medications, a nurse should pour one
inmate's medications at a time while reading the medication sheet on that
inmate. You felt that RN~as responsible for the accmacy oithe
medications. You also noted there are no guidelines for orienting or traiIiing
new nurses. You mentioned showing RN~e Narcotics Log, but you did
not show her how to sign off on a medication sheet, once medications were
administered. Although you noted it is standard practice to sign off on
medication sheets after medications are administered.
You stated having a concem about being singled out when there have been
several other medication errors since the time you received this ECR. You said
you have heard this information by word. of mouth, but could not give me
,
specifics as to who has been making the medication errors. Furthermore, you :~
said. you have done some research on this inmate and noted that the overdose '
included a total of 4 mgs of Klonopin when in the past he has been preScribed

OS71
.Attachment
.:.IP I

•

n·

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EMPLOYEE CONDUcr REPORT
RE:' Micb:ae1 Kalina, Registered Nurse 2
Decem1?er 4, 1997

Page 2
6 mgs of Klonopin. You also mentioned that he received. his Haldol Decanote
injection the day of this incident which, you have been told in combination
with the increased dosage of laonopin can ~ecrease blood pressure, which is
why this inmate had. an adverse reaction. In checking the inmate's medical
rcconL I find your report to be acctuate. However, apparently it was the
additional dosage of Klonopin that caused Mr. _lowered. blood pressure.

At the 8:40 medication line, the time the overdose occum:d,.you said you
hesitated wben you saw the dosage because you did not think he received. an
8:40 dosage of Klonopin. Consequently, you looked at the NaI!=Otics Log which
indicated th.eIe was one dosage removed. at 5:00 p.m. You assumed. from this
information that he bad not received his 5:00 p.m. dosage. You did not further
verifY this by checking the medication card. You said. the medication card may
not have been signed offby 8:40 p.m. for the 5:00 p.m. medication line
inclicating checking the medication card may not have given you adequate
information. Since you did not verify this. it remains unknown.
After the inmate was having medical problems as a result of this overdose, you
contacted. your supervisor, RN 3 Bollinger, to tell her of the problem. She
instructed you to fill out appropriate documentation to include a Medication

and/or Treatment Error Report, medical chart entry, and memo. You wrote
memo about the incident; however, you failed to follow through with her
directive to fill in a Medication and/ or Treatment Error Report and document
in the medical chart. During our meeting, you said your reason for not
following through with this directive was that you were very angry at the time it
happened and could not gather your thoughts in order to put them down
reasonably.
Health Care Manager Norma Gray noted in her Investigative Report that there
are several procedural problems with the administration of medications which
are being corrected. However, in taking this mto consideration and after
reviewing all of the documentation and hearing your report of the incident,
nevertheless, I find neglect of duty with regard to administering an overdose of
medication to Inmate_because I feel you could. have taken further steps to
avoid the error by checking the medication sheet and checldng the narcotics
supply of Klonopin. Secondly, I find insubordination for failing to follow
through. with your suPerVisors directive to fill out
Medication andj or
Treatment Error Report and to complete the documentation in the medical
chart. Feeling -too angry tD gather your thoughts" is not an acceptable e."(cuse
for f~mng to carry out responsibilities as directed by your supervisor. Finding

the

C672
Attachment

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EMPLOYEE CO~DUer REPO~ .
RE: Micbae1 Ka1ina, Registcl:ed Nw:se ~ .

December 4, 1997
Page 3
appropriate methods for man.aging your ariger is an .area for further discussion
bet.wecn you and your su~r.

0673
Attachment

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November 4, 1997
Supervisors Report

An extension of the Supervisors Report was approved to November 5, 1997.
During my investigation. I came in and observed the medication
setup/administration procedure for the 7 ani medication delivery at SOC.

c;0
On October 30, 1997 I met with you and your Union Representative, oSgLBarry
DeHaven to discuss this ECR. During the discussion you wanted a statement in
the ECR clarified. The sentence reads -you were responsible for the on-the-job
training of RN _during your shift on 10/14/97 and for ensuring the accuracy
of her work.· You stated, -responsible for the on-the-job training" was inaccu~te.
You were orienting R~O the PM shift. Both R~and yourself agree
that RN ~ up the medications for both the 5 pm medline and 8:40
medline. ~said after you checked the medication she set up you and her
went to C-D units where she administered the 5 pm meds wh~u observed.
The 8:40 medications were administered by you while RN ~ passed the
medications in the lockdown area In your response you state you observed what
appeared to be K1onopin pills crushed in the inmates med cup at the 8:40
medline which should have been given at the 5 pm medline. You indicate you
checked the Narcotic Log Book and there was only one entry for K1onopin which
was at 5 pm. You did not check the medication card to verify that the 5 pm dose
had been given. You also stated at that time you did not question the inmate
about whether he had received his dose of K1onopin earlier in the day. Tne
inmate is regularly given this medication at' 5 pm and has been since September
16, 1997. The medication error was discovered at the 10 pm narcotic count by
RN Gray, LPN Young, RN Wagner and yourself present. You then contacted C
Unit and asked staff to ask the inmate if he had taken Klonopin at both 5 pm and
8:40 medline and the inmate indicated he did. Memos were written by RN
Wagner, LPN Young. RN Gray and yourself indicating the narcotic count was
incorrect by two 1 mg K1onopin tablets. After discovering the inmate had been
.given an extra dose of K1onopin you stated you did not initiate the Medication
and/or Treatment Error Report even though RN 3 Bollinger reports she
instructed you to nor did you chart anything in the inm~tes medical record. LPN
Young assessed the patient at approximately. 11 pm and found his blood
pressure lowered. She contacted the on-call PA and received instructions to
continue monitoring vital signs. At approximately 2 am the PA ordered the
inmate transported to Valley General Hospital because of unstable vital signs.
He returned at 2:50 am after vital signs were more stable. Inmate was then
admitted to Room 1 for close observation.

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ME-' 68-25 ·ii" " - ' . ".:
!0:4865 TYPE:'MEDICoAL °EHERGEr' .:::',. :.:. .. STAFF-'REPo'RTING:l"':- "aN~ W'OOD"~1°:f:~:"":~' ~/>:,. ,:).':"
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)CCURRED ON: -1'0/15/97 AT 61 :·45Mi·
REPORTED ON: 'i0/15/97 'AT' ej;'eG~M
.OCATION: SPECIAL OFFNDR
CONFIDENTIAL: NO
..
.
'LACE: HEALTH-HOSPITAL FACILITY
~TAFF INVOLVED
INJ HOS
OFFENDERS INVOLV
INJ HOS
.PN YOUNG
N N
N N
'A BARNES
N N
)R JONAS
N N

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:ESCRIPTION:
:N 16/15/97 AT APPROXIMATELY 020~ HOURS I
SENT TO
MONROE VALLEY HOSPITAL. IT WAS REPORTED
DOSE
"HAT EXCEEDED HIS PRESCRIBED AMOUNT. DUE TO HIS LOW BLOOD PRESSURE IT WAS
iECIDED TO SHIP THE INMATE TO AN OUTSIDE HOSPITAL BY PA PAT BARNES. TRce/soc
)UTY OFFICER RAY SIGMUND WAS NOTIFIED ALONG WITMOSTAN~N. MONROE
:IRE DEPARTMENT ARRIVED AT SEEN TO TRANSPORT I
I~WAS RETURNED
iT e245 AM AND ADMITTED TO SOC INFIRMARY CELL·Y.
DICAL FILE PLACED INTO
~VIDENCE LOCKER *2 PER DUTY OFFICER RAY SIGMUND.
.
DAMAGE: NO
APPROXIMATE COST: $
0
JTHER AGENCIES CONTACTED: DATE: 10/15/97 . TIME: 02:04AM
'11/SNO PAC
iOSP NAME: VALLEY GENERAL - MON FOLLOWUP RPT: NO AGAINST:
------------------------- OFFENDERS INVOLVED ------------------------.AMES:
DOC NO: ~S: CLOSE
.
_AST KNOWN ADDR:
~
WA
)08: 02/19/i973 SEX: M RACE: WHITE
HISP.ORIG: N REL.DATE: 09/24/1999
1SC: BURGLARY I
COUNTY: PIERCE
~ECEIVED WCC-R: 08/12/97
TRANSFER TO PRESENT FACILITY: 08/18/97
lIC/WIT ELIGIBLE: YES
FURLOUGH: NO
~BI'NO: 917413WA9
SSA NO:
SID NO: i7163505

~ROPERTY

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STATE OF WASHINGTON
DEPARTMENT OF CORRECTIONS
MEMORANDUM

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DATE:

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SUBJECT:

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
SPEOAl OFFENDER CENTER .
P.O. Box 514. Park Place • Monroe, Washington 9B272-Q514

November 6, 1997
TO:

Michael KaliDa, RN 2

FROM:

Ella Ray Sigmund; (Acting) Associate Superintendent'

SUBJECf:

ECR Administrative Level Meeting

I have scheduled a meeting on Wednesday, November 19, 1997, at 2:00 p.m.
in the TReC-Special Offender Center Superintendent's Conference Room to
discuss the allegations reflected in the Employee Conduct Repon initiated on
October 17, 1997. by Teresa Bollinger, Registex:ed Nurse 3.
Attached for your review is the Employee Conduct Report packet.
If you are unable to attend this meeting as scheduled, please advise Judi
Wheeler, 794-2204. as soon as possible.
ERS:jw

Attachment
cc:

Dennis Thaut, Superintendent
Sancha Moore, Personnel Officer
Teresa Bollinger. RN 3

(,6.91

.

STATE OF WASHINGTON.

. DEPARTMeNT OF CORRECTIONS
SPECJAL OfFENDER CENTER
P.o. Box 574 - Parle Place • ~nroe. Washington 9B272-OS74

November 19, "1997 .
Michacl
Kalina » .RN
.

TO:
. F~dM:
SUBJEcr:

2

~·R~ Sigmm1~ A~sociate Su~tendent -e'~~
ECR

Admin;s1ra~e Level

Meeting

[ have scheduled a meeting on Tuesday, November 25, 1997, at 2:00 p.m. in
the TRCC-Special Offender Center Superintenden.t's Conference Room to
discuss the allegations retlected in the Employee Conduct Report initiated on
October 17', 1997, by Teresa Bollinger, Registered Nurse 3.
Attached for your review is the Employee Conduct Report packet.
If you are unable toatt.end this meeting 'as scheduled, please advise Judi
Wheeler, 794-2204, as soon as possible.

ERS:jw
Attachment

cc:

Dennis Thau~ Superintendent
Sandra Moore, Personnel Officer
Teresa Bollinger, RN 3

'('692
Allachment

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-.

STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
TWIN RIVERS CORRECTIONS CENTER
P.O. Box 888 • Mon~ Washington 982n.o888 • 060) 794-2400

TO:

Whom it May Concern

FROM:

Lany M. Conner

DATE:

11/17/97

S1JBJECT: RN2 Kalina, Michael

At the request of C/O Barry DeHaven, I am writing this letter to express my opinions
and observations of RN2 Michael Kalina. During my tenure as the Watch m Shift
Lieutenant at the Special Offend~ Center (Soq, I worked very closely With RN2 Kalina.
I began working at the SOC in May 1990 as the Watch III Shift Commande:-. I worked
in that position for approximately 3 Y:1 years prior to my current assignment as the Twin
Rivers Corrections Center (I'RCC) Training Coordinator.
Approximately one year after I began working at SOC, RN2 Kalina began working at
SOC as an intermittent nurse, and subsequently hired and assigned to Watch III as an
RN2. During this time, I worked very closely with RN2 Kalina and other nurses
assigned to Watch III at SOC. As the Shift Lieutenant I have found RN2 Kalina to be
very professional, and reliable regarding his duties during those times where our duties
overlapped. His honesty, and forthrightness was something I valued as a Shift
Lieutenant. E'len in our disagreements he was always professional, and prese::lted.
medical information in such a way that I could understand it and apply it to my duties
as the Watch. Commander.
In the t:iI:le I worked with RN2 Kalina. I have never known him to misrepresent ::he
facts, compromise his credibility, or do anything that would place his licensure at risk.
In all the times I have worked with him, he has always attempted to follow procedures
outlined in policy.
In conclusion, t have nothing more than the utmost respect for RN2 Michael Kalina and
would welcome the opportunity to work with him again.
-

~~d~ !/Plf97

Lany

,Conner

ate

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STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
SPECIAL OFFENDER CENTER
P.O. BOX 514 Park Place Monroe, Washington 98272-0514
November 18, 1997

Since being employed at TRCC-SOC in 1995, I have witnessed RN2 Kalina, Mike on
m:my occasions and have worked closely with him. He has been an asset to custody
staff, inmates, and Supervisors. RN2 K;Jljna is able to work with a broad range of
people under a variety of c:in:um.st:mces. RN2 Kalina has always been consistent in
coverage for. codes, team work, assisting other nurses when neede~ and asking for
assistance when needed. RN2 Kalina c:m be relied upon to complete written and
oral directives from supervisors, as well as his excellent writing and communic:ltion
skills with staff and inmates.
On many occasions when an inmate has refused to comply with taking medic:ltions
for another nurse, RN2 Kalina has been asked to try and work with the individual
to get the inmate to comply. On most of the situations RN2 K:11ina is able to
communicate and has developed a excellent r:1pport with inmates and staff and the
inmates will comply for him.
RN2 Kalina has e~cellent interpersonal skills, demonstrates quality in all he has
done that I have witnessed while working with him. RN2 Kalina manages resources
effectively, establishes safe work unit environment, is very organized, and takes
ownership appropriately when required to do so. I have also witnessed many
occasions personally RN'2 Kalina's ability to train others and do effectively and
professionally. RN2 Kalina is a high promoter of positive moral and team work.
RN2 Kalina is an asset and a excellent contribution to any agency and facility he is
employed with. RN2 Kalina can be depended on by fellow staff, supervisors,
inmates, and the general public in how effective he is as a nurse professional ~nd a
representative to the agency.

Attachment

_#;...-_1__

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November28, 1997
To:

Whom It Concerns

Rc:

Michael I<:ilin.a. R.N.

In my capacity as psychiatric consultant to the Special Offender Center ofthe Department of
CoITeCtions, I have known the abOYe individual and worked closely with him. for over two years.
It is a privilege to be able to write a letter ofrecommendation in support ofsuch a person.

TbIoughout the entire duration of my work at Soc. I have noted Mike to be ch~
knowledgeable, bard. working. efficient, compassionate. and caring. Although I try not to consider
31rf one person to be indispeusable to the team. it is signifiemu: that it is marc dif6.cnlt for me to
do fmJ job when Mike is absent. I consider this a marker of the cxtcDt to which I rely on his skill
and helpful attitude.
For the past yC3'l and marc. Mike has been responsil?le for coordinating and publishing the
schedule for all 24 hours per week of the psychiatric consultmts. This involves 'not only a
thorough background knowledge of the work routine of myself and the other psychiatrist. but upto-date information, both clinical and demograpbic. about all 80-100 inmates in the facility. I
have often admired his ability to juggle the myriad. schedules involved (nursing. psycbiatry,
psychology, counseling and administration) and deal with all the ruffled feathers-to me an
indiettion of IlWl3gerial expertise.
Above all I value in Mike or any coworker his integrity. I trust Mike implicitly and he has never
betrayed my or anyone's trust that I have observed while working at SOC. Our job situation
requires us to work with some very difficult people. and I consider it the bighest praise that I have
never observed ~1ike to behave inappropriately towards anyone. I have also on more than one
occasion seen him go out afbis wa:y in support of someone he felt was being unfairly tre:ued.

I am available to answer any questions r~ding the above or to provide additional infocrnation if
required. Any staff :mswering the infirmaIy line at (360) 794-2236 should be able to contact me.
Sinc..'"fely,

'(: 6 9~

Atr~d1ment _Jfr_/

Il

..• -.-:.:":..0;-

TO:

DOC-pP-G1-~MB 29-0CT-97.:· 69: ~a :"1:9 ":.::.;,:~'

MOORE SANDRA
SPECIAL OFFE. :R CENTER
16730 177TH AVE
. MONROE
WA 98272-0000

FROM: MOORE SANDRA
DOC-DP-G1-SMB 29-0CT-97 09:34:48
SPECIAL OFFENDER CENTER
16730 177TH AVE
MONROE
WA 98272-0000
SUBJECT: RE: MIKE KALINA ECR

DOC-DP-G1-SMB/MA¢949S453

-------------------------------------------------------------------------TO:
GRAYBEAL RICHARD
FROM: MOORE SANDRA
DATE: THURSDAY 23-0CT-97 AT 3:00PM
SUBJECT: MIKE KALINA ECR
CC:
THAUT DENNIS

DOC-DP-G1-DG7
DOC-DP-G1-SMB
DOC-DP-G1-DT2

HI DICK,
.
KALINA TURNED HIS RESPONSE INTO TERESA ON 10-21 AND·BECAUSE WE WEREN'T
SURE WHO WAS TO BE INVESTIGATING THE INCIDENT, TERESA BROUGHT THE ECR TO
ME. IT WOULD BE NICE IF NORMA GRAY'S WORKLOAD COULD ACCOMMODATE THE
INVESTIGATION AS SHE WOULD BE VIEWED AS A NEUTRAL ENTITY, ALTHOUGH I
UNDERSTAND THAT THE RN 3 AT TRCC-MI, ANN, HAS BEEN MENTIONED AS THE
POSSIBLE PERSON TO CONDUCT THE SUPERVISORY INVESTIGATION. SO, WHO DO
YOU AND DENNIS WANT TO ASSIGN IT T07
DENNIS,
AS THE RESPONSE TO THIS WOULD BE DUE ON 10-28-97 NORMALLY, AN EXTENSION
APPROVAL FROM YOU FOR COMPLETION OF THE SUPERVISORY INVESTIGATION IS
NECESSARY. I KNOW THAT IN ORDER FOR NORMA TO HANDLE THE INVESTIGATION,
YOU WOULD NEED TO TALK TO KEN, BUT I SUGGESTED HER ,~s SHE IS FAMILIAR
WITH THE SETTING/PLAYERS, AND ANN IS NOT •
....••... MESSAGE AMENDED BY: DOC-DP-Gf-DG7 GRAYBEAL RICHARD
ON: FRI 24-0CT-97 AT: 8:44AM
I MUCH PREFER HAVING NORMA GRAY DO THE INVESTIGATION ALTHOUGH ANE
IS CERTAINLY COMPETENT TO HANDLE IT. A TIME EXTENSION ALSO SEEMS
APPROPRIATE.
CC:

DOC-DF'-Gi-DT2

THAUT DENNIS

MESSAGE AMENDED BY: DOC-DP-G1-DT2 THAUT DENNIS
ON: TUE 2S-0CT-97 AT: f :42PM
EXTENSION APPROVED .
.•.•...•• ROUTED ON: TUE 28-0CT-97 AT:
FROM: DOC-DP-G1-DT2 THAUT DENNIS
TO: DOC-DP-G1-SMB MOORE SANDRA
DOC-DP-Df-NGA GRAY NORMA

1 :43PM

••.•••••. MESSAGE AMENDED BY: DOC-DP-G1-SMB MOORE SANDRA
ON: WED 29-0CT-97 AT: 9:34AM
DENNIS THAUT HAS APPROVED AN EXTENSION TO THE COMPLETION OF THE
SUPERVISOR'S REPORT TO NOVEMBER 5, t997.
PAGE

~I

DEPARTM~OFOO~REcnONS

EMPLOYEE RIGHTS PURSUANT TO ARTICLE 8.2 OF INSTITUTIONS CBA

ltis alleged thatyou havecommittedmisconduet. As part oftheinvestigation you maybe interviewedabouttheallegedincident
In accordance with Article 8.2 of the Collective Bargaining Agreement between the Department Of Corrections and the
Washington P~blic Employees Association. you have the following rights:

1. To have representation by the Union dUring an interview;

2. To receive written notice of the allegation(s) and an opportunity to respond;
3. To decline to respond to questions dUring an interview; however, Management may proceed without
benefit of your comments;
4. To refuse under state law to submit to polygraph examinations except as provided by applicable statute;
and
.
5. To have the investigation concluded without unreasonable delay.

I have read the rights to which I am entitled.

Date

Employee SignalUre

/

Witness Signalure

Origina!: Personnel Office
YeI1ow: Supervisor
Pink:
Employee

C697
Attachment

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ElVIPLOYEE HANDBOOK

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FOR THE

STATE OF vVASHINGTON
DEPARThIENT OF CORRECTIONS
JUNE 1993

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Provide for restitUtion; .,

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Meet the natiooal stuidards appropriate to the St1fc ofWashinliton•.

,~ 'B~ ~ou~~ble ~ ~~ ci~ of the ~,
CODE OF ETBlCS

High mor:U :md ethic:u stolJldards 3Dlong correctional employees are
essential for the success of the department's progr:uns. The Depan'meat of Corrections subscribes to a. code of unfailing honesty.
respect for dignity :md individuality of human beings, and a. commitment to professional':md compassionate service:.
DEPARThffiNT EXPECTATIONS
As a new employee of the depanment, you will !lave many things to
leam, not the 1e:1St of which will be the expectations of your supervisor, your co-workers, and the agenC"J as a whole. To assist you with
this responsibility, following is a list of some depaianental expectations for your study. F:uniliarize yourself with the list so that you
~y un~rstand

and fulfill the duties of your position.

As :uepresent:uive of the Department of Com:aioos,vOti

win he

. expected to:
. ~, P!lsitively represent Washington Swe government to everyone you
. mCet. You arc our best public relations agent;' '. . ' .

'~,',~ ap~ropriateIY' for ~ourJo~ cIassffi:catio~':~~duties. OothiJig'
'.' may n~t have mottos. logos, or advertisements"that may be of-' .
feosive or in conflict with ~e goalso~ the ~~ent;

"•

• weiJr is~~ ~nifOl'DlS ooly as authorized; .
~ Be a good citizen. obey laws while on and ,?ff-d~~. Your conduct
off duty lD:ly reflect 00
. 'your fitness for.' duty;
. .

.• :' Tre:l1 'fellow s'Utt with digmty and

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.. ~ Be iinpartial~ nnd~ding and ~ to, ciff~~~
.: ~ SClYe e:u:b offender with appropriate do~cCm for'tiieir w.elface· and:,',:' .
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",' "~" R~ort all persoaal con~
offenders. cbcir fammcs. or
Ien.own assOciates. .outside y~ur joJJ in accordance ~th .department
proccdutcs;
• Report through the proper chain of command any corrupt or
unethical behavior wbich could affect an offender at the
• depaItmCnt'~ i~gzity;
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• Remain constantly alert in all situations;

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Custody staff: remain at your job/post until properly relieved;
~ your supervisor lenow about any personal. emergency use of
.~uipmcnt or ~oneSi "., ..'
.

., Obtain appropriate permission before removing any'state property
from state Premises;
.
Conduct yourself and perform your duties safely;'
Smoke only in dcsigna£ed smoking

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It is also important as a new employee, that you understand some of
the specific prohibitions that the department must enforce. You are
not aUowed to:

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Discrimin:lle against any offender. employee. prospective employee. or volunteer on the basis of race. color. religion. gender.
sexual orienlation. age. creed. national origin. marital SlaWS.
. veteran status or disability;
Use profanity or inflammatory remarks with offenders or individuals with whom you work;
• Report to work under the influence of alcohol or drugs;
• Tmffic or bring any article of contraband into an institution.
facility or office;
Barter or make personal deals with offenders. offender families or
visitors;
• Engage in personal relationsbips wich offenders. their family
members. or close personal associates;

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11/27/92

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MEDICATION MANAGEMENT

AUiHORITY:
PURPOSE:

Division of Prisons audi"t cheddis"t IlDrugs, syringes, needles and
hazardous surgical instruments."
To establish guidelines for procurement, storage, distribution and
.... disposal ~f medications.~t the Twin Rivers Corrections Center.

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APPUCABD..lTY:
All Twin Rivers _ Co~~ctions . Center
•
management of medications.
. '

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DEFINmONS:

Staff

involved

in

the

Controlled Substances Log: Log of TRCe controlled substances
activities, maintained by RN staff and kept in the medication room
controlled substances cabinet.
Crash Cart: Mobile cart containing emergency medications and
supplies, maintained by the Nursing staff and is used only in the e'/ent
of medical emergencies.
°
Disoensed Medication:
Those medications legally packaged and
labeled by a pharmacy by order of a licensed health care provider
with prescriptive authority, for an individual patient.

~
.~

Drug Profile: Individual patient record of all medications dispensed
to that patient by the facility maintaining the profile.
Floor Stock:' No more than a three day supply of medications prepackaged by pharmacy ~taff with par-Jal labeling. To be used (after
pharmacy hours) by RN staff to begin treatment until the full
prescription can be dispensed.
~

.

Medication Cart: Lockable cart containing (pharmacy) dispensed
medications. Kept in the TRce l'!1edication room.
Command C Controlled Substances Log:' Log. of all Command C
Pharmacy controlled. substances ac"tivities, maintained by Pharm~cy
staff and kept in the Command C controlled substances vault.
Multiple Dose Medications: These medications will be disPensed by
pharmacy staff in clear ziplock baggles and issued: to inmat~ patients.
All labels will be fixed to the baggy and contain the following
information:
.

P2

1.
2.
3.
4.

Inmate name and number
Medication strength.
.
Number of pills dispensed (contained in the baggie)
Direction for use

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0701

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D~IS10N OF PRISONS
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Dates for which prescription is valid; to. include expiration date'
Prescribing practiti()ner
Pr~scription number, ~hen applicable.
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These medications include:

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Antibiotics - full course (e~cep·tio~: Minocin) - 10 day supply
Anti-inflammatory agents ~ as ordered,. up to 10 day. supply
Antihistamines/Decongestants (except those mentioned below),
as ordered, up to 10 day supply
Asthma medication - 30 day supply
Ulcer medication - 30 day supply
CardiaclAntihypertensive - 30 day supply
Topical medication - 30 day supply
Optic/Opthalmic preparations - full course
Over-the-counter medications (i.e., vitamins, antacids), as
ordered
Seizure medications - 7 day. supply (except. controlled
substances)
Miscellaneous medications re.quiring monitoring:.. 7 day supply
a.
Acyclovir
' . .
.
b.
Accutane
c.
Midrin
d.
Ergotomines

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Single Dose Medications: Medications considered to be abusable
which must be .dispensed by. single dose only and are ingested at the
time issued. These medications are: ..
1.
2.
3.
4.
5.
6.
7.

Controlled substances (C~deine, De~eron
Psycho tropics
.
Restricted antihistamines (Benadryl, Hydroxizine, Pilenergan)
Anticoagulants
..: ~. -~:-:-::':'::::.'.
Muscle relaxants (Flexedl, Parafon Forte, Phenergan)
Restricted anti-inflammatory agents <Oolobid)
Antituberculin

FlELD INSTRUCTION:
Responsibility:
The Health Care Manager 1 is responsible for the management of all
medications stored and distributed by Health Services•. The Monroe
Command Pharmacy Supervisor is responsible for all medications
procured, stored, dispensed and disposed of by the Command C
Pharmacy. (B.1)·
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Phannacy Mariual:
The Command C, Phannacy Manual <See Attachment "A" -Manual
_ .. Index) establishes 'a, system f9r' purchase, records maintenance,
'. -;"" 'inventory, sto'rage, security, audits and disposal of all medications
stored in and managed by the Command C Pharmacy located in
";',;.,.::
'-,.
Washington S,tate RefoE!l1atory Health Services. (8.3; C.l, .2, .4; 0.1;
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Locations of Medication Stor-age:
1.

Medication room; where all dispensed medications, floor stock
medications and over the counter medications are stored. This
area 'also serves as the distribution site for medication Lines.

2.

Crash cart; stored in the treatment room, containing no more
than one to two doses per medication.

3.

Lab: Medications stored here are refrigerated injectable insulin
(for daily patient use), ov.er the counter iSSuables per: standing
order, nebulizer solutions and tetanus serums. (C.3)

Security Access:
l~

Med Room. Keys to this area are restrIcted per Twin Rivers
Corrections Cente,r Policy lj.l 0.0 11 to one RN per shiite It is a
two door system requiring that one door be locked prior to
unlocking the second. Additionally, aU controlled ,substances
are .kept in a cabinet in this medication room with keys
restricted to one RN per shift.

2.

Crash Cart:
Padlocked with a tamper proof se'al that is
checked and logged daily by RN staff (See Attachmerit "B" J
Daily Equipment Checks). Treatment room is locked whenever
unoccupied. Keys to the treatment room and the crash cart are
restricted to designated health care staff per Twin Rivers
Corrections Center Policy 410.011.

3.

Nurses Stat.\ott: Keys are restricted to designated health
staff per TRCC policy 410.011. (C.2, D.l)

car~

;

Records:

1.

DNg profile: Stored on the hard disc of the commOand/L
Pharmacy computer.
. :

'i
070~
Attachment

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Medication Record: .:All medications distributed or issued by
TRee health services staff are recorded on the individual's
medication record, noting: rQedication dosages, date and time,
and staff initials, (see Attachment C). Medication records are
a permanent document ¥1 the' inmate's Health Record. (F.1.f.)
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Custody staff·, 'sJ1all .Jnaintain .. records:, of over the counter
medications issued per TRee 'polity 6l0;,990. (J.2)

Annual Review:
1.

The .Health Care Manager'1 shall prepare an annual report for
the Superintendent noting status of the medication management
,system and correction at any deficiencies identified in the
'quarterly audit described above. (L.!)

2.

The Superintendent and .the Health Care Manage"r 1 shall
annually review the' "Medication Management" policy and
procedure. All modifications shall be reviewed for approval by
the A.ssistant Director, Division of Prisons, Command C. (L.2,
3)

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qT~in Rivers C~rT~ons'C~ter'

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'CONTROLLED SUBSTANCES MEDICA nONS

PROCEDURE:

ACTION BY:

ACTION:

1.

Pharmacist

Will

order controlled substances utilizing
DEA form which is mailed directly to
vendor.
~dard

Command C Medical
Supply Technician

2..

Pharmacist

3.

Will·verify, store in pharma.cy vault, and log in
(Command C Pharmacy Log) all controlled
substances. <See Attachment D). (a.3., C.2.,
F.l.a.b.e.)

4.

Maintains copie~ of all inVOiCeS in the
ControUed Substance Vault. DuplIca.tes kept
by Medical Supply Technician and Command
Accountant <F.l.a.b.e.)

Physician/Dentist/
Physician Assistantl
Accredited Registered,
Nurse Practitioner
.

5.

Will prescribe controlled substances as authorized by licensure. Controlled substances will
be ordered for no more than 72 hours.

RN/LPN

6.

WiU process con trolled substance oreers

. .

....

,-..

Phannacist

Receives and delivers medication directly to
pharmacy staff.

.

by~

A.

Noting on Medication Record (DOC
Form fJ L3-16) (Attachment "C"), the
,patient's name, number, prescribing
authority and
inclusive
dates of
prescriptions.

B.

Completing the numbered IIControlled
Substance Order Form ll (see example Attachment liE") and forwarding to the
Phannacist.

I.

Will log . in the numbered form o~ the
Controlled Substance Order Form Log <See
Attachment IIF").

8.

Prepares requested supply of controlled substances.

0705
-.

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Att3Chrr.ent - - - - -

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Signs. order fonn verifying order filled.
Issues to Norsing staff.

11•

Obtains 2 RN/LPN signatures verifying their
receipt of requested controlled substances.

12.

Forwards copy of completed order form to the
.Health Care Manager I.
.
.-, ..
- ...-;.:::_.. -....
. Maintains file of originaf' (completedro~der
forms in the Command C Pharma-cy.

.:..

13.

"-.

14.

Places controlled substances in the medication
room cabinet and logs in controlled substances
in the C::;ontrolled Substances Log (See
A ttachment "Gil).

15.

Logs out ~nd dispenses medications as order.e.;i
and record same on patient's profile.
Medications will be issued in crushed form Or
in water at tt:e waiting room medications slot.

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10.

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RN/LPN

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pan ....

.

16.

Observe
inmate
medications. (J .1.)

17.

Record date and time of medications
dispensed on appropriate inmate's medication
record and initial same. (F .l.f.)

18.

Will inventory all controlled substances at the
end of shift with oncoming RN/LPN and note
same on the Controlled Substances Log. (I. 1.)

19.

Will return to the pharmacist any -unused or
outdated controlled substances and cosigns
with pharmacist log entry in the Controlled
Substances Log. (C.lI-.)

compliance

of

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10/27/92

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ITwin ~'="S Co~ons Center

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11/27/92

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--

PROCEDURE:

Physician/Dentist/

7

of

8

NON-CONTROLLED. SUBSTANCES

1.

Ph~dan A:ssistant/

Will prescribe medications as authorized by
. licensure.

Accredited Registered

Nurse Practitioner

RN/LPN

Pharmacy

RN/LPN

2.

Will process medication orders by:
A.

Noting on Medication Record the
patient's name,. number, prescribing
authority, and inclusive dates of the
prescription.

B.

Forwarding
pharmacy.

the

prescription

to

the

3.

Will prepare medications as prescribed, either
in "single .dose" or "multiple dose n pac:kages.

4.

Note prescription on patient'S drug profile
(computer entry).

5.

Deliver medications to, RN/LPN statio

6.

Store medications in locked medication cart in
the medication room. (C.l.)

.
.- 7.

8.

Will dispense medications as ordered:
A.

Medications will be given at the
medication window four times daily•

B.

.Will witness the patient ingesting all
single dose medications. 0.1.)

C.

Will record on the medication card the
date, time, medication dispensed or
issued, and initial the same. (F.l.i.)

Will return all unused, outdated medications to
the . Pharmacist when prescription expires.
(C.4-., H.i.)

07·J7
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AttaChment..........;_----

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TRce Policy 410.0H ._.'.....
...
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TRce:FQlicy 610.990
Board o~ 'Pharmacy Rules and Regulations
Division of" Prisons Audit Ch~~klist "Drugs, Sy.ringes, Needles and
Hazardous Surgical InstrumentS;!1
CSB 13.27
ACA 2-4317
WAC-36
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SUPERCEDe,5:

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IUJ7IALS

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MEDICATION RECOR'j;)"~':

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'TIME:

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:ACILITY:
JE.PARTMENT:

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'l"e request the: !,harmac)' suppl)' the. foUo~in& con.trolle.~ ;ubstances. This quantity i~ not te ex~eed a::
estima ted four day supply. Of one unll. whlchever lS the grea ler amount: Al.L CHANCES OR ERRORS
MUST BE IN1TlALED.
.

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SUPPLY' "'NEED'" ._. :.- _'l.
hand .' -., (Check)
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:'DESCRIPTiON
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"..... _ ..,.' . :.: Unit/eat
Iri£r unit

'PHARMACY
. Qt)· Sent.
Lot 0.1 Ex? da

ORAL

....

-

, Acetaminophe.n with Codeine )0 mg Tab. 25/Unit
Cloli2zepam 2mg (Klonopin) each
Diazepam .smg Tab (Valium) 10/unit
Diazepam 10mg Tab (Valium) 10/unit
'Methadone tabs 10 mg each"
, .,
Oxycodone with Acetaminophen (Tylox) 25{uoit;
Phenobarbital JOmg Tab 10/unit
Pentazocine .50mg (Talwin NX), 25/unit
Other
_

INJECTABLE
Diaze?l:ll lO/mg/2ml inj. (Va.lium) I/each
M~peridine ..50mg Inj. (Demerol) IO/unit
Meperidine'75mg Inj. (DemeroJ) IO/unit
Mer>eridine IOOmg lnj. (Dernerol) 10/unit
.. Morphine 504 lO.~g In). 10/~jt
, .
Other"
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CONTROLLED SUB. ORDER FOR1.lS. 1 ea •.
SIGNA TURE OF TVa AUTHORlZED H~LTH C~RE PROVIDERS:

SJ ~.\.ht ri\.:C
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WASHINGTON STATE SPECIAL OFFENDER CENTER
l:fEALTH CARE OPERATlONAL MANUAL
INFIRMARY PROCEDURE

SUBJECT:

MEOlCA~ION AND/OR T.REATMENT ERROR

INCIDENT REPORTING:

DEFINITION:

PROCEDURE:

1.

To ensure that dispensing and distribution of medication and
treatment conform to state and federal regulations as· well as
good pharmacy and clinical practices.

2..

To ensure that' health care providers are performing at a
level of good professional quality.

3.

To ensure that if medication or treatment errors are made,
there is a method for following up and provide for minimum
risk to the patien t, the facili ty, and the pro fessional staff.

Medication and/or treatment errors will be deemed to exist when
one or more of the following conditions are met:
1.

When medication is not received by the right person, at the
right dose and/or at the right time.

2.

When a treatment or medication was not processed currently
from the health record and therefore not done as ordered.

3.

When medication was given to a person for whom it was not
ordered.

1.

Medication errors will be reported to supervisors
immediately. After hours, either the Nurse Practitioner or
the Physiciants Assistant, whoever is on call, will be notified.

2.

The PA or NP will make a decision regarding health risks as a
result of the medication error and be responsible for
follow-up for any health care needs resulting from that
medication error.

3..

The staff person making the error will fill out Medication
Error Incident Report (see form attached) before leaving
shift.

4.

Medication will be charted in the Health Record as gi-ren.

0714
..jJ.b
Attachment - - - - - - -

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5.

The Supervisor will complet~ the fonn on the neXt·'schedui~d.
day. Immediate action will be taken if necessary to rectify
any potential ~gerous' procedural admission of personnel
problem, if that was deemed to have caused this error.

6.

A copy of the medication and/or .Treatment Error Incident
Report will be distributed to the Chair Person, the Health
Care Manager, and the Prescribing Provider for review.
.

"

7.

The original mediCation and/or Treatment Error Incident
Report will be kept in the supervisor's personal personnel file.

8.

Repeat or serious medication or treatment errors will result
.in letters of eprim d or Employee Conduct Reports.

&WLJdt~}3"
F ran Bartley

.,-

Nursing Supervisor, SOC
FB:se
fJ JB Infirmary

:

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0715
~S

Attachment . - . : - - - -

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Statement of"peqon discQvering Error. Name
How was error discovered '1

1.

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Statement of person(s) who made the error. Name
Dare~~
_
Oeelli of incident. Patient name(s). medication(s) or type of error - Medications or Treatment. date,
location etc., what happened ?

2.

..

-'.

3.

What could have been done to prevent the error ?

--

071S
(page 2 on other side)

Attachment _Jb_b_s-

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Reviewing Suneryiso-:-. Name:
Dam
Brief statement of action and/or Changes made 1Q-PrevCm: fumie mcldex-=--ms--:.'-'-~"""~-':.--

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St:ltement of reviewing Practitioner. Name.
Result of error. future recommendations.

5.

6,

Date._·

PhanmlCY & Theraoeutics Committee Revie,".
".

_

Date
Recommendations if any. changes in policies and/or proc...cadures. AI:: there trends developing.

SignatUre P&T Chair

------

_

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0717
Attachment

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MONROE COMMAND CENTRAL PHARMACY
POLICY AND PROCEPlJRE
MANUAL

Table of Contents
Title

Chapter

I.

Pha;macy

.. ....

Adm±Bis~ration

6

A.

Pharmacy Organization Chart

6

B.

Pharmacy Hours of Operation

7

C.

Pharmacy Phone Numbers

7

D.

Pharmacy Personnel

8

-

......

Page

1.

Pharmacy Supervisor

8

2.

Pharmacist Staff

8

3.

Pharmacy Assistant

9

IL

Monroe Ccmmar.d Pha:macv and Therapeutica Committee

III.

Procurement of

Pharmaceutical~

A.

Product Selection/Formulary System

8.

purchasing and Receiving

10

11

11

1.

Contracts/Wholesalers

11

2.

Emergency Situations

11

3.

Prescriptions from Oucside Sources

12

4.

Delivery from the Wholesaler

12

UQdated 3/97

0718
Attachment .-:.Jl._,,_ _
-

.......

P.

Adverse Reaction

Health care sta~f must be alert. to the potential for or
presence of, ad~~rsedrug reactions. All significant a.d.r. wiil ce
recorded in the pa~ient' s health record with a copy fonarded to th~
pharmaci~t, ,the l?resc:rJ.bing practitioner, and the nursing supervisor~
If ~nd~cated, tne pharmacy supervisor will make wri=~en report
to the Food a.nci Drug ACministrati.on, the Monroe CoR1l'l\at1d Pharmacy and
Therapeutics Co~ttee. and the drug manu£acturer.
The xeport will include:
~

fatiene's ase. sex and race
Descripeion of the ~~g reac~ion and suspected cause
Name of drug{s) suspected of causing the reaction
Administration route and dose
Name(s) of ocher drugs received by patient
Treatment of the reaction, if any

•
~

•

*

•

O.

'--

Medica tion Error:

All drug errors shall :lpon discovery, be recoraea in an incident
=eport:. and reported co the prescribing practitioner ar-d to the
Pharmacy, WAC 246-873-050 .
•n. t';edice:.tion Errer is defined aa a dose of medication ~hat:
deviates f=om the prov~ders oreer as ~~it~en in :he patient'S cha~~.
Except for errors of emission, the medication' must:. ac;:,ually reach the.
patient; i.e., a ~rong dose t~at is detected and correcc~d befor~
administ=at~cn to the patient is not a medication error.
The !ollowing ar~ categcriasiexamples of medications errc~:
1.

ODdssion Er:::'or: the failuJ:e to administeJ: an ordered dose. t:
che dose is nc~ administered because of patien.t refusal or
recogni:ed =ontraindications, no error has occurred.

2.

Uoauthori:::ed D:":S: ;.,dw.i:list:raeion eo a patient of a medication
dosage not aut:.horized for that patient. I.e .. dose given to the
wrong patient, duplicate dose, acministration et an ~ordered
drug or dose given outside of clinical parameter9 (mee. oreer
to be administered or-ly if the patients's clooe pressure falls
below a predet.er:ninad level) .

3.

Wrona Doss: Any dose t~at is a.i wrong nurrb~~ of units (i.e ..
tabs) or b.1 above ~r below the ordered dose.

4.

wrong Race:

5.

wrong 20utej
that: crdered.

E.

wrong Dosage Fcr:l.:
Adtr.inist=ation of a drug by to!'! cor=ec~
route, but incorrec:: fo=m.
Example =
use of an. Ophthalmic

Admi~istration

of a drug at: the wrong rate.

Ad~~~stration

of a drug by a route

ot:~er cha~

solution when an oi:lcment was ordered.
7.

w=onq

TiMe:

Admini6cra~ion of

a drug outside of the sCheduleri

administration time.
Updated 3/9 7

27

071'!3
Attachment

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·'

... .
-:

. :,.

.

Whenever a. ;aedication,' error i:s Cletected.. the patient's
primary proviCler (JUZBP, PA., or MD) must be info::med i.mmedia~el.y
A written report will. be initiated by the staff member .who ;aad~
or discovered. the error f depend; rig on the circwustances. usi:19
the Medj.c;:ation and/or Treatment: Error Report: F91.:m and submitted
to his /her supervisor who wil~ i.nvestigate the. incident and
complete the supervisor portion of the form. The MTBR. fOrtll shall
then be routed to the provider involved. in the treatment of the
patienc, for comment. A copy will then be forwarded to the
Pharmacy. Sach institutt·ion will escab~i.sb a procedure for
anal~ing each incident. ·~ese reports will be forwarded by the
pharmacy to the Me P&T Co~ttee for final review.

See Followi.J1.g page f"or:

Medication and/or Treatment Error Reporc Form

'-

........

updated 3/97

28

0720
AUsehment _#_~--

N~~

EMPLOYEE'CHECKLIST

cl=-"~:....:::.'---"..£k""4,,",fw~""'!!"","''''-- _ _DATE,_&,,,,,~Iv~/9:z..:£/L-_POSITION /?fJ:J..

NAME_.:2fV1-'.-..:;

OFFICE! INSTITUTION--"o=9:X:""",=_~

1.

,SOPERVISOR,-,-{Q,UL",~==--<R-"()./v=",-;/---,(,",.L"'''1'10=---

r

STATE'",o1IDE ACKNOWLEDGMENTS

•.
n

RECEIPT OF ~~D800K:
! acknowledge receipt of the Employee Handbook,
Washington state DepartItent of Corrections, and agree to become
familiar with and have a thorough knowledge and understanding of ~~E
contents.

8.

PERSONlf;:;"-L POLICY DIRECTIVE ACXNOWLEDGE11ENT:
I have revie·..red ~nd UI'lderstanc
that I am responsible for knowing and follow; ng the Depar"Cllent of
corrections' Personnel Policy Directives.
I
was told ....here ~'1€
Depart.!I1ent Policy Directive Manual is kept and realize i:hai: I a:

exnected to be familiar with t.'1e manual and to keeo cur:::ent on colic'.
directives. If I have any questions, I understand ~hat I am to c;r.tac:
my supervisor or my personnel officer.
EmployeeSignature
C,

,DATE,

_

am. not currently related to Cl
CONFLICT OF INTEREST DECU..RATION: I
residing with any employee of the State who is in my supe~isory cnai!
of command or in an adult relationship over or below me. ! unders~ar.(
that I must report to my supervisor in writing any current or poter.~~a
conflic~ of
interest in accordance with the laws of t~e St.ate 0
Washin~on, and local institution/office policies/procedures.

Employeesignacure

~da--f'~--u

D".TE

(,,//7J:! v

2.

FIELD LOCATION ACKNOWLEDGEMENTS

A.

COR,.1U:CTIONS ACADEHY:
All Correctional Off icers will be requirec. t
attend the Washington State Criminal Justice Training Commission (CJ'!'C
Corrections Officers Academy, and all Correc~ional Counselors and Communi~
Corrections Officers -..rill be required to attend the CJ-orc Correction.::
Services Academy.
I understand that a passing score from the CJ~C Acace~
is required for continued employment. The academies are no~ally schedule
for a two-we~~ period ·for counselors and a four-week academy fc
correctional Officers,
Classes are conducted Monday ~~rough Friday, 8:0
a.m. to 5:00 p.m.
I understand that, subsequent to the training and/c
institution/office training, I will be assigned to my permanent schedule c
either day, swing, graveyard, or turnaround shifts with any 2-day perie
scheduled off.
Employeesignature,

Ol:iqi.nal ~
cc:

DATE

_

Personnel File
Employee

0721
Attachment

.Jb1

..:""":-.e---

,

-.

W:n..~."'l'.E:1I'

0:

COro<~},.05 _0 NEl; EY.tLOYEF. areacr. 1srO

l':a:' e
Page 3

5eetlon A.

Person.~l/Pavroll

St.:t~ide

or NlA)

F'crr.s Cor.cletee:

~ Ap?lication

~

+

_
Verification of Military Service
Intermittent Staff - Informational Letter
~ _oEr-=i~e=n~t::a~t~i:=07::n-==sc=hfedfu~le==::::,
_
~ Automat1c Deposit Forms

~

X.

~

Felony Recore Oisclosure ,

IRCA Form (Identification noted)

~ -;Ar;:c::,k::,nT°'E'w~led=-::,gfe:::m::,e_n::,t:::--;o:,:fT;"'S:-e::-a:-r::c~h~:--~
~

n-ot•

t.~

Per sonnel Q,Jes:ionnai re
Em;loyee I.O./Er.:ergenC',i carc
Union En:ollr..e;,t card
Mecica..~./De."1t.al Enrol1lrent

--:L LTD Enro!.1.ment
~

Life Im;urance Enroll.m:!nt
Pe rr.anent Record
(Retirerent· E:::ollJrEr1tl Copy
of Soc. sec. c::rc attached.

-:£... Er.tE=loyee

Section E.

Persc~~l/Pavroll

Stat"",i';.

(

'if

------------------

-

Yaterials Receivea

c·: 1!I~.l

Rel~tionshiPs with.. offenders

~ (c:x.tOr-u.c)

poli

-.2S:... "A C-uiee to the Washineton State
DefErt:&ent of Correctior..s"
~ Employee BanCbook

~ Collec~ive Ba:gaining As::~er.t
--.::£.. WhistJ eblow'er Procedure
(10-62 Reec menc)
--K secretary' s S""...a~e..'"le.rtt on
Affirr.-=.tive h:tian/CalIlI:1ittee
X In~e:nal Disc:imination
--::;z Non-DiscrL.':'nat.ion Polic,{ 100.500

~ Eq";Jal ~l~rr.e~t/Affianative
Ac~:on

Polici 810.005
~ se~U21 Ea:a$~t Pelie:' 853.025
--X. Li~ of Ste-.-:~cs, officE!:S,
Onion/~~rege::cnt CoItr.',i ttee
n~~:s (union may pr~!ide)
..K f-Ecical/Den:.a: Benefit
Ne....-s-....a:.:e r

~ L~ Certificate of Covera~e
~ Life !nsura!"lCe Certificate of
Coverace
Retirer.e."1t Ne'---s-t:Cpe~

let:~e!, inducing st.atu£,
classification, startinc salarv/\o;aoe,
~...arting date, length of probation; PID,
/
benefits
Payroll dates liSt
~ "Join Os" (Wast. St. Er.:p. Creeit Unio:1i
/
_~_ 1C eferred <:cu.;:e!'.satian fCliiphlet and ::-e:"':':C
/
/Na~ianwice Automobile L~sura=lC= ~~~e~
J /t~tiQl'1W'iOe HareOwTlers InSol:a.fiCE p=...: pr.let
~ployee }b.yisary service ~":?=-.let
~)Drug~ree work Place Poli~l
~ Reasonable Accommodation ~olicv
-.
. _. ir:b':".ent

~personal Dry Cleaning Service memo
~(Lawsuit Processing memo
~Disabilitv Insurance information
~cancer Insurance Information
Brainstorm forn

><

~ Emulovee Accessibilitv Policy

~ Co~ti~uation of Medic~l/Dent~l Coverage
The above checkee topic~ ha"'e beer. revieweC wit..'

lIe.

~~

E:n::lovee Sicr.atu,e
CePt."Re\·iee:.er Sig:-.ature(s)

~

'/:ft-rif"i

Date
Date

---------------

t::ate

Attachment

""•

.. .
.

•.-a

I undeJ:St3nd it is my responsibility to familiarize myself with the local
institution/office policies and procedDres, o:x: policies and procedDres,
pertinent post orders, the duties descr1bed in my classification questionna; re
and the expectations of my work unit.

I understand that tile above is not intended to be inclus!ve but to ensure that
basic infOJ::ma.tion is provided.
EIJployee Signature

_~~=.
~ ~_......;
..

Date

---=~.....0_'7...L..t1....;..19.:....Y

_

Section C. Topics Covered by Personnel/Payroll Office

Paycheck (when, where, overti.De, autcma:tic deposit, paydates)
- - (leave and types explained on pay cbeck:and according to policy)

- - Mandatory deductions: CASI,

FICA, Re1::i.reJEnt, Union .. Medical Aid

_ _ Copy of ClassifiC3.tion Q.Iestionna.i.re Pesition NlJlIIber

_

-- Perlonnance Evaluation Process
-- Accident Reporting,

L & I Claims, Workers I Ccmpensation, Assau1t legislation

Intra-IDStitutional Transfer Requests (Article 9, Transfers, IDStitution
- - Collective Baxgain:ing AgTee:a:nt)

- - Bole

of Pe....s onnel Office

Recrui tlDent Announcenents/ Applications (p1."'OIX)tional opportunities, local
- - list veISUS Depa.rt:IIE!lt of Personnel registers)

- - State employment reg1-Sters
- - Affil:mative Action/Non-Discrimination/Sexual Ha.r3ssment
Local of Merit System Rules, Revised Code of Washington, Washington Ad:nisist!'"
- - Code, Departmental Policies

The above checked topics have been reviewed wi.tll

lIE.

Employee Signature
Date
- ; ) : - - - - - - - - - - - na:....
e -------· ----:-(Dept. Reviewer S~gna1:Ure
5
,..
_ _ _ _ _ _ _ _ _ _ Date
_

0724
Attachment _:II=~_1
......__

Page 2
Kalina - 4/28/98

During a telephone conversation initiated by you that night to advise
Teresa Bollinger, RN 3, of the situation, she directed you to immediately
complete a memo addressed to her describ~e incident and events of
the evening of 10-14-97 concerning inmate_ Ms. Bollinger also
directed you to complete the "Medication and/or Treatment Error Report"
form, stating to you that both these documents should be completed
prior to your departure from the institution that night.
You failed to complete the "Medication and/or Treatment Error Report"
form prior to your departure from the institution the evening of 10-1497. You also failed to appropriately adhere~licy by not documenting
the 8:40 Pf14 dosage of Klonopin on inmate_medical chart.. An .
Employee Conduct Report completed 12-5-97 (Attachment #1) describing
this incident in greater detail is attached hereto and incorporated herein.
The Department of Corrections Employee Handbook of June, 1993,
CODE OF ETHICS, page 2, (Attachment #2) states in part:
"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 commitment to professional and
compassionate service."
The DOC Employee Handbook also states, in part, on pages 2 and 3
(Attachment #3) under DEPARTMENT EXPECTATIONS:
"... you will have many things to learn, not the least of which will
be the expectations of your supervisor, your co-workers, and the agency
. as a whole.
As a representative of the Department of Corrections, you will be.
expected to:

Conduct yourself and perform your duties safely."
Twin Rivers Corrections Center (TRCC) Institution Field Instruction TR
610.900 MEDICATION MANAGEMENT (Attachment #4) page 4, states,
in part:

"Records:
2. Medication Record: All medications distribu ted or issued
by TReC health services staff are recorded on the individual's
medication record, noting medication, dosages, date and time, and staff

072£

Page 3
Kalina - 4/28/98

initials (see Attachment C). Medication records are a pennanent
document in the inmate's Health Record."
On page 5 of this same Institution Field Instruction TR 610.900 under
CONTROLLED SUBSTANCES MEDICATIONS, it states, in part:
"6.

(RN/LPN) will process controlled substance orders by:
A. Noting on Medication Record (DOC Fonn # 13-16)
(Attachment "C"), the patient's name, number,
prescribing authority and inclusive dates of
prescriptions."

The Washington State Special Offender Center Health Care Operational
Manual Infirmary Procedure (Attachment #5) regarding MEDICATION
AND/OR TREATMENT ERROR under PROCEDURE states, in part,
"3.
The staff person making the error will fill out Medication
Error Incident Report (see fonn attached) before leaving shift.
4. Medication will be charted in the Health Record as given."
The Monroe Command Central Pharmacy Policy and Procedure Manual
(Attachment #6) under Q. Medication Errors. states, in part:
"A Medication Error is defmed as a dose of medication that
deviates from the providers order as written in the patient's chart....The
following are categories/examples of medications error:
2. Unauthorized Drug: Administration to a patient of a medication
dosage not authorized for that patient, Le. dose given to the
wrong patient, duplicate dose, . .. .'
\

A written report will be initiated by the staff member who made or
discovered the error, depending on the circumstances, using the
Medication and/or Treatment Error Report Form and submitted to
his/her supervisor who will investigate the incident and complete the
supervisor portion of the form."
On June 17,1994, you signed the New Employee Checklist (Attachment
#7) in which you aclmowledged receipt for the Washington State
Department of Corrections Employee Handbook, agreeing to become
familiar with and have a thorough knowledge and understanding of its
contents. In this same document, your signature further indicates
aclmowledgment that you understood you were to be responsible for
familiarizing yourself with local institution/office policies and

07J.'" .

Page 4
Kalina - 4/28/98
procedures, including DOC policies and procedures. Copies of the
previously identified numbered attachments 2 through 7 are attached
hereto and incorporated herein.
As a Registered Nurse 2 at Twin Rivers Corrections Center - Special
Offender Center and an employee of the Department of Corrections, you
have a duty, responsibility, and obligation to act with a high degree of
professionalism in all aspects of performance, especially those aspects
related to the accuracy of medical service, safety and well-being of the
clientele you serve. You must be aware of and unfailingly adhere to the
policies and procedures prescribed to by the Department for the
continued success of the programs it manages.
During this incident, you admittedly were responsible for appropriately
orienting newly hired RN 2 " Though she prepared the medications
for delivery to specific inmates, you actually administered the 8:40 PM
medications. In so doing, you said that you noted what appeared to be a
discrepancy in the medication prepared for inmat~ 8 :40 PM dosage.
However, prior to giving the medication to inmate'-you failed to
adequately ensure the accuracy of the prescribed dosage. Consequently,
your negligence in not pursuing appropriate follQw-through procedures
to circumvent a dosage error resulted in the eventual transport of inmate
_ t o Valley General Hospital for assessment and monitoring of unstable
vital signs due to an overdose ingestion of the drug Klonopin 1 mg.
Upon advising RN3 Teresa Bollinger by telephone conversation of the
incident involving inmate. she directed you to complete two actions
before leaving the institution that evening. Ms. Bollinger told you to
complete a memo addressed to her relative to the incident involving
inmate", as well as complete a Medication and/or Treatment Error
Report form. Also, per written policy, you should also have documented
the overdose of Klonopin 1 mg. on the individual's medical chart, which
you failed to do.
You purposely did not complete either the medical chart entry or the
Medication and/ or Treatment Error Report prior to leaving the institution
on 10-14-97. You stated to Ms. Sigmund during the Administrative
Comments review meeting that you were too angry that evening about
.the situation to be able to collect your thoughts and comply with Ms.
Bollinger's directions to you.
By your behavior in this incident you have clearly demonstrated:
1) a neglect of your duty to act professionally and responsibly,
thereby placing at risk an individual whose health care you are

0728.

PageS
Kalina - 4/28/98
charged with providing and protecting from harm to the extent
possible within your realm of professional expertise;
2) a neglect of your duty to be responsible for the procedural
orientation of a new RN 2 employee and the expectation of that
responsibility includes overseeing the accuracy of the new hire's
performance of duty;
3) an act of flagrant insubordination in that you consciously
chose to ignore your supervisor's directive to complete
appropriate documentation of the incident prior to leaving the
institution the night of 10-14-97;
4) an act of gross misconduct in that you endangered the health
and well-being of an individual in your care by failing to
thoroughly research your suspicion relative to the possibility
that the 8:40 PM dosage of medication provided by you to
inmatell was inaccurate; and
5) a willful violation of published Institution Field Instruction, the
Washington State Special Offender Center Health Care
Operational Manual Infumary Procedure, the Monroe Command
Central Pharmacy Policy and Procedure manual, and the
Department's Employee Handbook in that you have failed to
perfonn your duties appropriately per the Department's written
expectations and rules.
In considering the ramifications suffered by this individual as a direct
result of your neglect of duty coupled with the potential magnitude. of
adverse consequences this type of situation could have additionally..
presented to an individual in your professional care as well as to the
Department as a whole, I have given careful consideration to the
_
severity of sanction I would deem appropriate to address this level of
misconduct. A review of your personnel me has moderated my decision
relative to severity of sanction and therefore, I have determined to
.
.reduce your salary as a Registered Nurse 2 as indicated in paragraph
one of this letter.

/

I must forewarn you that future acts of misconduct could result in
further corrective and/or disciplinary action up to and including
dismissal.
Under the provisions of Washington Administrative 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,

07~9

\

.""""*"",,,,~.'"

. .d%iWWMMP.c.C..t..

.$../

u.t.C&.. .€.oJ..k,..;.:;;.. . .zA.:;;:....,.,QtQ",tQ,,( ..

Page 6

Kalina - 4/28/98

within thirty (30) days from the effective date stated in paragraph one of
this letter. As an alternative, you may file a grievance under the
provisions of Article 10 of the Collective Bargaining Agreement between
the Department of Corrections and the Washington Public Employees
Association.
The Merit System Rules (WACs), Department of Corrections' policies,
Twin Rivers Corrections Center-Special Offender Center Field
Instructions and the Collective B aining Agreement are available for
your review upon request.
.

DT:sm
Attachments
cc:

Jennie Adkins, Human Resources Administrator, Office of
Administrative SeIVices
.
Phil Stanley, NW Regional Administrator, Office of Correctional
Operations
Linda Dalton, Senior Assistant Attorney General
Cheryl Landers, NW Area Personnel Manager
Robert Riordan, Personnel Officer
Sandra Moore, Personnel Officer
Personnel File

\

0730

***

CONFIDENTIAL ***

@ ~ ~ ~ UVI ~ \D)
DISCIPLINARY ACTION AUTHORIZAT10~ \l MAR .11 1998 .
DEPARTMENT OF CORRECTIONS

OffiCE OF THE ATIORNEY GENERAL
LABOR & PERSONNEL O\VlSlON

Mid1ael T Kalina
~loyeq'S Nama

RECOMMENCED ACTION:

319198
Data RllC8iYed at Heac1quaners

Reduction in Pay:

RIP/5% for 3 month!1 $

Registered Nurse Z

~~--:=,:","----:::--

Demotion to:

Employee'S Job Classification

S'S2- .

(Teul S ATount)

(Percentage/Length)

_

(JOD C:assdicaoon)

TRCC..'oI1HC

(LengUlI

-:/s~-;:"7" _ _
(Total SLoss)

=

------

Suspension: _ _--::_-.-

Emgloyee's JOD Locaoon
i

.

Dismissal:

IJ
-I

Sanoy MooreJ794-22C6
Assigned P'!ISonnel Officer/Phone :I

r::: d {E!feClVel
-}7/Cj Q

Date completed :onn faxeo

:0 PO

The attad1ed disciplinary aoon has been reviewed as noted below. "This infcrmation is ~roviced under the
attorney/dient relationship and invokes that privilege. It should be considered CONFIDENTIAL :n natlJre.~

InitialsiTiUe

DHRDi~

Date

Aporove

v

C..,mments

Disapprove

I
I

and deliver to all reviewers and return to Leslie Carrigg, DHR , 8th Floor, upon cx:lmpletion.

C731

/~.(..

'

.

APR 0 7 1998

0732

~
," , , ",- , , , , , , , , ~
,
-~-~~-~~~

\.

.

'QiU.4i£it.£"&.tQISZ.Q.$,SiJ..i.u..s.s.u.msh.i.v..' ...... .1 J.Wi ..J.,.itS.. .t.Ji.w.Q,~.t.Q®M,J,Q,4d h 1 i m&QM%%.. 144l&% . ..... ... ..... . .... ....... .... ..

.._116..6,;';.&.1" ( ;; J&Gf4QM...t=MZ4:;;m;;x8.Mi6.a$,,,ii,... .Q........ ,pg:;;;a::ii

v .

CHASE RIVELANO
Secretary

L

j

STATE Of WASHINGTON

DEPARTMENT OF CORRECTIONS

DfiAfT

SP~C:Ai.IJ;:;::';oeR CENTER

February

, 1998

PERSONAL AND CONFIDENTIAL DELIVERY

Mr. Kalina:
This is official notification that you will be reduced in salary within your
present class of Registered Nurse 2 at the Twin Rivers Corrections
Center-Special Offender Center (TRCC-SOq, Range N45, Step P,
$3801.00 per month to Step N, $3617.00 per month, effective
______ through
, inclusive.
This disciplinarj 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 356-34-010 (I-a) Neglect of duty, (I-d) Insubordination, (l-h)
Gross misconduct, (I-i) Willful violation of the pUblished employing
., .I ....
agency or department of personnel rules or regulations, and 356-3f1--020 ~ ,(I~'~
g. t-t-- 1 .,
Reduction in salary - Demotion -Procedure.
,~J:-'"
~ u:'··
•

. . .--:-: . . . ', .:

\:.

I

,.."

./

•

.,

I.i i..\.L\.(~'

Specifically, you neglected your duty, were insubordinate, committed an Y
act of gross misconduct and willfUlly violated published agency policy
when on October 14, 1997, while perfonning your duties as a Registered
,
Nurse 2, you were res~~ble for administering an inappropriate dosage(cverdo=-l!.,)
of the drug Klonopin Img. tb inmat~ S~uently, after
havino'jp.gest~g. the o~dose of Klonopin-:l.~g,·inmate_blood
~re was _~ecord~as below that of acceptable baseline.
bJh ? Consequently, later that same night, due to the onset of ongo&
\Y. Ct-'-.
unstable vital signs, Linda FLUke, ARNP, directed that inmat~e
transported to Valley General Hospital for a comprehensive evaluation of
his condition and continued monitoring.
• ',J' 0

;y''; )(.11.. ~-

During a telephone conversation that nighi.;t~id~ise Teresa Bollinger, RN
3, of the situation, she directed you to immediately complete a memo
_
addressed .to her describing the incident and events of the evening Qf Ie I'~ 1(.11-

073'3

D~9~9'

concerning inmat_ Ms. Bollinger also directed you to complete the
. "Medication and/ or Treatment Error Repo~ form, stating to you that
both these documents should be completed prior to your departure from
the institution that night.

You failed to complete the "Medication and/ or Treatment Error Report'
form prior to your departure from the institution the ev;;~g of 10-1497. You also failed to approp~ adhere t~cy bYl'dOcumenting the
8:40 pm dosage of Klonopin\ ~j~n inmate~edical chart.. An
Employee Conduct Report completed 12-5-97 (Attachment # 1) describing
this incident in greater detail is attached hereto and incorporated herein.
The Department of Corrections Employee Handbook of June, 1993,
CODE OF' ETHICS, page 2, (Attachment #2) states in part:
"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 commitment to professional and
compassionate service."
The DOC Employee Handbook also states, in part, on pages 2 and 3
(Attachment #3} under DEPARTMENT EXPECTATIONS:
"... you will have many things to learn, not the least of which will
be the expectations of your supervisor, your co-workers, and the agency
as a whole.

As a representative of the Department of Corrections, you will be
e.yected to:

Conduct yourself and perform your duties safely."
Twin Rivers Corrections Center (TReC) Institution Field Instruction.TR
610.900 MEDICATION MANAGEMENT (Attachment #4) page 4, states,

in part:
"Records:
2. Medication Record: All medications distribu ted or issued
by TRCC health services staff are recorded on the individual's
medication record, noting medication, dosages, date and time, and staff
initials (see Attachment C). Medication records are a pennanent
document in the in~ate's Health Record."

0.731
"-~._o::;o;s;;

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On page 5 of this same Insqtution Field Instruction TR 610.900 under
CONTROLLED SUBSTANCES MEDICATIONS, it states, in part:
"6.

.~_ ~

_1

(RNjLPN) will process controlled substance orders by:
A. Noting on Medication Record (DOC Form #13-16)
(Attachment "C"), the patient's name, number,
prescribing authority and inclusive dates of
prescriptions."

The Washington State Special Offender Center Health Care Operational
Manual Infirmary Procedure (Attachment #5) regarding MEDICATION
AND/OR TREATMENT ERROR under PROCEDURE states, in part,
(13.' The staff person making the error will fill out Medication'
Error Incident Report (see form attached) before leaving shift.
4. Medication will be charted in the Health Record as given."
The Monroe Command Central Pharmacy Policy and Procedure Manual
(Attachment #6) under Q. Medication Errors, states, in part:
"A Medication Error is defined as a dose of medication that
deviates from the providers order as written iIi the patient's chart....The
following are categories/ examples of medications error:
2. Unauthorized Drug: Administration to a patient of a medication
dosage not authorized for that patient, i.e. dose given to the
wrong patient, duplicate dose, ...."
A written report will be initiated by the staff member who made or
discovered the error, depending on the circumstances, using the
Medication and/or Treatment Error Reoort Form and submitted to
his/her supervisor who will investigate the incident and complete the
supervisor portion of the form."
, On June 17, 1994, you signed the New Employee Checklist (Attachment
#7) in which you acknowledged receipt for the Washington State
Department of Corrections Employee Handbook, agreeing to become
familiar with and have a thorough knowledge and understanding of its
contents. In this same document, your signature further indicates
aclmowledgment that you understood you were to be responsible for
familiarizing yourself with local institution/ office policies and
procedures, including DOC policies and procedures. Copies of the
previously identified numbered attachments 2 through 7 are attached
hereto and incorporated herein.

0735

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Nurs~at

As a Registered
Twin Rivers Corrections Center - Special
,
Offender Center and/employee of the Department of Corrections, you
have a dUty, responsibility, and obligation to act with a high degree of
professionalism in all aspects of performance, especially those aspects
related to the accuracy of medical service, safety and well-being of the
clientele you serve. You must be aware of and unfailingly adhere to the
policies and procedures prescribed to by the Department for the
continued success of the programs it manages.
DUring this incident, you admittedly were responsible for appropriately

orienting newly hired RLl\f 2 _
Though she prepared the medications
for delivery to specific inmates, you actually administered the 8:40 pm
medications. In so doing, you said that you noted what appeared to be a
discrepancy in the medication prepared for inmat~ 8:40 pm dosage.
However, prior to giving the medication to inmate. you failed to
adequately ensure ~ accuracy of the prescribed dosage. Consequently,
your negligence ~rsuing appropriate follow-through procedures to
circumvent a dosage error resulted in the eventual transport of inmate
. t o Valley General Hospital for assessment and monitoring of unstable
vital signs due to an overdose ingestion of the drug Klonopin 1 mg.

.~O

teleph~ne conversatio~~~

Upon advising RN3 Teresa Bollinger by
incident involving inmate. she directed you to complete~';
before leaving the institution that evening. Ms. Bollinger tol'l:t-yoU to
complete a memo addressed to her relative to the incident involving
inmate. as well as complete a Medication and! or Treatment Error
Report form. \.p~r written policy, you should a¥.!o have documented t~e . )
overdose of K~nopin 1 mg. on the individual's medical chm-:-~;,..n.:v 0-0: ~.

(\\?';)

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et0 .{l

You purposely did not complete either the medical chart entry or the
Medication and/or Treatment Error Report prior to leaving the institution
on 10-14-97. You stated to Ms. Sigmund during the Administrative_
Comments review meeting that you were too angry that evening about
the situation to be able to collect your thoughts and comply with Ms.
. Bollinger's directions to you.
By your behavior in this incident you have clearly demonstrated:
1) a neglect of yo ur duty ia tfiat ) 0 t1 : .. avc jaiied to act
professionally and responsibly, thereby placing at risk an
individual whose health care you are charged with providing
and protecting from harm to the extent possible within your
realm of professional expertise;

(.736

2) a neglect of your duty1Rtl~wereresponsible for the
procedural orientation of a new RN 2 employ~ .the
. expectation of that responsibility includes overseeing the
accuracy of the new hire's performance of duty;
3) an act of flagrant insubordination in that you consciously
~hose to ignore your supervisor's directive to complete
appropriate documentation of the incident prior to leaving the
institution the night of 10-14-97;
4) an act of gross misconduct in that you endangered the health
and well-being of an individual-in your care by failing to
thoroughly research your suspicion relative to the possibility
that the 8: 40 pm dosage of medication provided by you to
inmat.was inaccurate; and
.
5) a willful violation of published Institution Field Instruction, the
Washington State Special Offender Center Health Care
Operational Manual InftnnarJ Procedure, the Monroe Command
Central Pharmacy Policy and Procedure manual, and the
Department's Employee Handbook in that you have failed to
perform your duties appropriately per the Department's written
expectations and rules.
In considering the ram;ifications suffered by ¢is individual as a direct
result oryour neglect~utycoupled with the potential magnitude of
adverse consequences this type of situation could have additionally
presented to an individual in your professional care as well as to the
Department as a whole, I have given careful consideration to the
severity of sanction I would deem appropriate to address this level of
misconduct. A review of your personnel me has moderated my decision
relative to severity of sanction and therefore, I have determined to
reduce your salary as a Registered Nurse 2 as indicated in paragraph
one of this letter.
I must forewarn you that future acts of misconduct could result in _
further corrective and/ or disciplinary action up to and induding
dismissal.
Under the provisions of Washington Administrative 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. As an alternative, you may file a grievance under the
provisions of Anicle 10 of the Collective Bargaining Agreement between
the Department of Corrections and the Washington Public Employees
Association.

0731

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The Merit System Rules (WACs), Department of Corrections' policies,
Twin Rivers Corrections Center~Special Offender Center Field .
Instructions and the Collective Bargaining Agreement are available for
your review upon request.

Dennis Thaut
Superintendent
DT:sm
Attachments
cc:

Jennie Adkins, Human Resources Administrator, Office of
Administrative Services
Phil Stanley, NW Regional Administrator, Office of Correctional
Operations
Michael Sellars, Assistant Attorney General
Cheryl Landers, NW Area Personnel Manager
Robert Riordan, Personnel Officer
Sandra Moore, Personnel Officer
Personnel File

.0.738

/
CHASE RIVELAND
Secretary

MAY Q1 1998

DEPARTMENT OF CORRECTIONS
SPECIAL OFFENDER CE'>:rei
....

P.O.80x 514. Park Pldce • Monroe. wasilingron 982i2-0S14
.
f

:.

April 28, 1998
PERSONAL AND CONFIDENTIAL DELIVERY

..........
Michael T. Kalina

Mr. Kalina:
This is official notification that you will be reduced in salary within your
present class of Registered Nurse 2 at the Twin Rivers Corrections
Center-SpecIal Offender Center (TRC~SOC), Range N45, Step P,
$3801.00 per month to Step L, $3445:00 per n;onth, effective May 15,
1998 through November IS, 1998, iIIClusive.
•

I

This disciplinary action is taken pUlSuant to the Civil Service Law of
Washington State, Chapter 41.06, Revised Code of Washington, and the
Merit System Rules, Title 356 Was4ington Administrative Code (WAC)
Section 356-34-010 (I-al Neglectiduty, (I-d) rnsubordination, (I-hI
Gro§s misconduct, (I-i) Willful viliation of the published employing
agency or department of personxel rules or regulations, and 356-34-020
Reduction in salary - Demotic» - Procedure.

Specifically, you neglected yourauty, were -insubordinate, committed an
act of gross misconduct and wMully violated published agency policy
when on October 14, 1997, w}ile performing your duties as a Registered
.Nurse 2, you were responsib~ for admin~ppropriate dosage
(overdoselof the drug Klonopjl to. inmate_during the
8:40PM medline. Subseque~y, after having ingested the overdose of
Klonopin, inmate _blooe pressure was recorded by LPN Leslie Young
as below that of acceptablebaseline. Consequently, later that same
night, due to the onset of l1iiiing unstable vital signs, Linda Fluke,
ARNP, directed that inmate. . be transported to Valley General Hospital
for a comprehensive evaluation of his condition and continued
monitoring.

0738 .

 

 

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