Report: Nurse’s actions ‘incompetent’ in Sussex inmate’s death

GEORGETOWN — A registered nurse’s supposed “incompetent” response prior to the 2016 death of an inmate brought a year’s license probation, according to a report issued by the Delaware Board of Nursing.

The incident occurred on April 10, 2016, at the Sussex Community Corrections Center as Lisa Roseanne Peace was working an overnight shift, an order said on Feb. 9, 2018.

According to the report, Ms. Peace arrived at the Work Release building at 6:13 a.m. after a “man down” call and found an unresponsive inmate devoid of bladder control with a white substance coming from his mouth, along with gurgling sounds. The man had a pulse of 60 and Ms. Peace supposedly “did not believe he would maintain those vital signs.”

While Ms. Peace claimed to have taken the inmate’s pulse, “a video of the events clearly demonstrated that she did not.” Ms. Peace didn’t believe a 911 call was warranted, according to the order, and left the chow hall at 6:15 a.m. after rendering no aid.

The nurse returned after leaving to get a glucometer, authorities said, and the man was seemingly experiencing a seizure. No blood pressure was taken or pupils checked, the board determined. No 911 call was made and “her employer had an employee policy stating ‘only time 911 is called without the Chief Medical Officer’s approval is [a cardiac arrest or hanging.’”

The nurse then called another nurse for more medical information on the inmate. She was told to take a blood pressure and call the on-call medical provider, the report read. A call was made, and a correctional officer said the inmate no longer had a pulse.

According to the order, Ms. Peace rushed back to the chow hall and began CPR as someone retrieved AED equipment.

Eventually, the report found, a correctional officer directed someone to call 911. The inmate was transported to the hospital and pronounced dead at 7:36 a.m.

‘Failure to conform’

The board concluded that the nurse’s behavior “failed to conform to legal and acceptable standards for the nursing profession,” among other shortcomings.

“Overall, the board found Ms. Peace’s conduct particularly egregious when she failed to further assess the inmate by not taking his blood pressure, and leaving him multiple times while he was in clear distress,” the order concluded.

“As such, the board voted to increase the discipline to a year of suspension stayed immediately for probation concurrent with employment with no option to have the probation lifted after six months.”

Ms. Peace was also ordered to complete 12 contact hours of continuing education including:

• Six hours in assessing and treating the unresponsive patient in emergency situation.

• Three hours in critical thinking/decision making skills.

• Three hours in nursing ethics or professional accountability.

• These credits shall be in addition to, and not in lieu of, the continuing education contact hours required for renewal.

A failure to comply could result in further discipline.

Also during probation, among other terms, Ms. Peace “shall inform all nursing employers that the board has placed her license on probation and shall provide all of her employers with a copy of (the) order, …”

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