A CRNA kills not one but two , what a sick minded AZ BON member !

Dental Deaths

Lawsuits filed against AZ nurse anesthetist after two dental deaths

Posted: 1:02 PM, Nov 05, 2021

Updated:10:27 PM, Nov 05, 2021

By:Dave Biscobing

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A nurse faces lawsuits after two people died during dental procedures, one of which included a fire inside a patient’s mouth.

An Arizona nurse anesthetist is facing multiple lawsuits after two of his patients died in separate dental procedures within a year.

Tory Richmond is accused of medical negligence in the wrongful death cases of a woman who died from a lack of oxygen to the brain and a man whose mouth caught on fire during an oral surgery.

Through an attorney, Richmond declined to comment on the lawsuits.

Recent Stories from abc15.com

How did these deaths occur and what actions have state health boards taken? Watch Dave Biscobing’s full investigation, tonight on ABC15 News at 10.

Anesthesiologists and other certified nurse anesthetists told ABC15 that two deaths stemming from elective dental procedures is a rare and concerning anomaly.

However, Arizona’s Board of Nursing essentially cleared Richmond of any wrongdoing and only filed a generic letter of concern that isn’t easily accessible to the public.

During an open hearing, one board member also expressed sympathy for Richmond and commended him for his care in a case where a patient’s mouth caught on fire.

“It’s like they don’t care,” said Teresa Rushing, who filed one of the lawsuits after the death of her mother, Sharlon Stemmons. “What bothers me most is that my mom shouldn’t be gone. She should be here.”

FIRST DEATH

On October 25, 2019, Stemmons underwent a procedure to have her teeth pulled so she could get dentures.

The dentist was Ehsan Pourshirazi.

Through a company named Lifeguard Anesthesia, Richmond was hired to provide mobile anesthesia even though Pourshirazi’s office was not properly licensed to perform sedation procedures, records show.

During the procedure, Stemmons stopped breathing, and staff began to perform CPR on her. However, records indicate that no one called 911 until 11 minutes after the medical crisis began.

“Upon information and belief, Defendant Richmond and Defendant Pourshirazi delayed in calling 911 because they did not want to draw attention to the fact that they were administering in-office sedation without proper license and outside their legal scope of practice and hoped that they could successfully care for Mrs. Stemmons without having to involve EMS or other providers,” Rushing’s lawsuit alleges. https://ewscripps.brightspotcdn.com/81/62/f80293484ef895e0b1a140b18fe1/complaint-conformed.pdf

The lawsuit also alleges that Richmond failed to properly assess Stemmons before the procedure, failed to properly administer anesthesia, and failed to properly respond when her oxygen levels dropped.

Pourshirazi is currently tangled in an ongoing battle with Arizona’s Board of Dental Examiners, which is attempting to pull his license.

He did not have the required “1304” anesthesia permit, which allows dental officers to perform sedation procedures, records show.

Stemmons, who was 71, never regained consciousness and died from a lack of oxygen to the brain 10 days after the procedure.

SECOND DEATH

Less than a year later, Ralph Chapman died.

Chapman underwent an oral laser surgery at a different dental office, AZ Perio, which also used Richmond and Lifeguard Anesthesia on August 28, 2020.

During the procedure, his mouth caught on fire.

“Ralph Chapman was transported by ambulance to the Arizona Burn Center at Valleywise Medical Center where he remained until he died on September 9, 2020 from complications resulting from the thermal and inhalation injuries sustained during the dental procedures while under the care of Defendants,” according to a lawsuit filed by Chapman’s wife.

Chapman’s wife and her attorneys declined to comment on the case. https://ewscripps.brightspotcdn.com/2d/1f/31b16009469db025a8bcfcecc922/cv2021-008063-complaint.pdf

Their lawsuit further alleges that Richmond used an unsafe amount of oxygen during the laser surgery.

BOARD ACTION

In response to the lawsuits, Richmond’s attorney, Peter Wittekind, sent ABC15 an emailed response.

“These were two cases with tragic outcomes, and our unreserved sympathy is with the families,” Wittekind wrote.

Wittekind added, “Of course, if you have reviewed the Arizona State Board of Nursing file, you know that the Board combined both cases regarding Dr. Richmond, performed multiple interviews, completed a full investigation, and conducted a public hearing. After its full investigation and public hearing, the Arizona State Board of Nursing concluded that Dr. Richmond did not commit any unprofessional conduct. I assume you will include this in your research and report.”

The nursing board discussed its review of both deaths during a May 2021 public meeting.

The board declined to issue Richmond any formal discipline but issued a letter of concern. https://ewscripps.brightspotcdn.com/ee/c1/f6bed46e4f8c978edf00564fefeb/richmond-tory-loc-2021.pdf

During the meeting, one board member, Angela Fountain, primarily discussed the cases involving Richmond.

Fountain opened her comments about the board’s finding by expressing sympathy for Richmond.

“I have to tell you Dr. Richmond, I am sorry. You have been through hell to say it bluntly,” said Fountain, who’s also a certified nurse anesthetist.

Fountain also discussed the 11-minute delay in calling 911 during the Stemmon’s procedure.

“The concern about the timeline as far as when the 911 or EMS was activated, 11 minutes goes by in like a second when you’re managing someone’s airway, when you’re trying to deal with any kind of crisis,” she said.

“So the fact that he didn’t initiate the EMS, well he’s busy taking care of an airway and controlling that. So that truly to me was not as much of a concern because the dentist could have called 911. The other staff could have called 911. That doesn’t have to be all on you.”

Fountain also praised Richmond for his level of care in the case involving the patient who died after his mouth caught fire.

“In regards to the case with the laser, job well done as far as I’m concerned,” she said. “I’m sorry for the outcome. But job well done.”

Richmond responded, “Thank you. Appreciate that. Thank you.”

In advance of this report, Fountain sent ABC15 the following written response about her comments at the board hearing.

“While I can not discuss details regarding a specific case I would like to  provide some context to my statements during the May 2021 board meeting. First, and foremost, I have the most sincere sympathy towards any family who has lost a loved one in any healthcare involved incident.

As a board member my primary job is to protect the public.  We do that in part by ensuring that licensed and unlicensed nurses practice within their scope and follow standard of care. While others may not always agree with our determinations, we make every effort to decide the matters fairly and thoughtfully.

My comments were to provide feedback about the resuscitation efforts made, despite a tragic outcome. Again, any time there are negative outcomes with a patient, I hold the most sincere sympathies for the patient, their family and all involved.”

Richmond no longer works with Lifeguard Anesthesia.

In advance of ABC15’s report, Richmond’s attorney, Peter Wittekind, emailed another statement after seeing a preview of the story on an earlier newscast.

“I was advised that you intend to air your report this evening. I am concerned that it may not be fair, balanced and informed. In fact, if the teasers already aired are reflective of the full report, it appears the report may be not only grossly inaccurate, but malicious and defamatory.

I understand media motivation to generate ratings at almost any cost, but you also have a duty to report fairly. As I previously mentioned, the Arizona State Nursing Board has investigated these cases, carefully reviewed the pertinent medical records, and conducted a public hearing. The Board concluded that Dr. Richmond did not act unprofessionally. These were two very unique cases, performed by oral surgeons (not “dentists”), with tragic outcomes. The way the facts have been aired so far, however, is staggeringly distorted, at least as I have seen them. Portraying alleged facts in a false light, simply to create a story, would be wrong, both ethically and legally.”

HOW TO RESEARCH HEALTH CARE PROVIDERS

ABC15 has spent years investigating health care providers and their state regulatory boards.

Here are some key ways the public can verify licenses and check for any disciplinary issues and lawsuits.

1. Check Arizona health board websites. Every Arizona board has a searchable directory of their healthcare providers. These directories will allow you to verify a license and check for any posted discipline. But, health boards often have hidden records that are considered public.

2. Call health boards. In Arizona, some board actions are not required to be posted online. ABC15 has done extensive reporting on similar issues in the past. In the case above, Richmond’s letter of concern is not included on his board profile. The public has to call and request any addition records that are considered public. Also, it’s important to ask for any past meeting minutes or meeting recordings that involve the health care provider your researching.

3. Google health care providers. Yes, it’s simple. But it’s also effective.

4. Check for lawsuits. Many malpractice claims get settled before a lawsuit is filed. However, it’s important to check for lawsuits like the two filed in the case above. In Maricopa County, go to this website and search for the name of your health care provider and their business name.

Contact ABC15 Investigator Dave Biscobing at Dave@ABC15.com.

Just keeping the name out there as one of the dirty board members in AZ . A horrible nasty prison nurse. She went to Deleware , and was going to get on the BON there . Uh huh, like they would take one look at you and your potty mouth and invite you to join. The Gov in AZ is the only one who allows trash on the board . “Little pretend nurse” . She went to a community school back in PA. “Workforce vs welfare”. Not sure why LPN’s allowed on a BON , they won’t even hire them in hospitals. Jana is a loser for sure. Wonder if those she caused so much pain and suffering in their careers all highlighted her for her shameful ways. Is she that stupid or just crooked politically and desperate ? “Jeffrey ” told a co worker he had to tie a 2×4 on his ass to keep from falling in . She is a BIG girl . No matter how many diet pretzels she shoves in that big mouth of hers. And her ‘fit ‘ for not getting free coffee at java was ‘over the top”. Shame on you JANA MACHESKY , you don’t remember a lot of the good nurses that you wrongly judged, but they remember your dirty looks and unprofessional behavior. We also heard your big mouth in the pool , that last summer. You belong in a prison locked up away from people.

AZ BON has done some strange investigations. Those who are victims of this over the top . deep dive into far past and personal business unrelated to nursing or anything , you are in for a strange ride with these Nursing board members , staff , and dirty director.

Nursing board’s slow pace danger to public

By: Howard Fischer, Capitol Media Services September 22, 2021

The State Board of Nursing is slow in handling complaints, according to a new state report, a practice it says that could endanger public safety. 

Auditor General Lindsey Perry said the policy of the board, which oversees everything from advanced practice registered nurses to certified nursing assistants, says complaint investigations should be completed within an overall average of 180 days from receipt. 

But Perry said of the 25 randomly selected closed complaints the board received in fiscal year 2020, 12 were not finished within that time frame. And of those, four were serious enough to result in nurses surrendering their licenses, two led to consent agreements involving probation and one ended with a letter of censure. 

Auditors also looked at 10 open complaints and found none resolved within that 180-day time frame. 

“Untimely complaint resolution may negatively impact patient safety when delays allow licensees and certificate holders alleged to have violated board statutes and rules to continue to practice while under investigation even though they may be unfit to do so,” Perry wrote. 

She specifically cited one complaint that alleged the nurse failed to recognize and manage postpartum complications, including hemorrhaging. The result was a delay in getting the patient to a higher level of care. 

That ultimately resulted in suspension of the nurse’s license until she completed required continuing education care, followed by a 24-month probation. 

Lindsey Perry

“Despite this action, the board took 301 days to resolve this complaint, during which time the nurse continued to practice without restriction,” the report states. 

Perry said the board said the investigation was delayed because the allegations required an investigator with specialized knowledge, but that the board’s investigator with this knowledge was on extended personal leave for longer than anticipated. 

The auditor general noted, however, this isn’t the first time her agency has seen this problem. 

As far back as 2001 auditors concluded the board had “excessive investigation time frames and many open investigations.” She said the board implemented some recommendations made at that time. 

Yet a decade later Perry said more than half the complaints still were taking more than 180 days to resolve. That, she said, resulted in the nursing board implementing new policies with that 180 goal, including some interim deadlines. 

Yet the new report shows problems still exist. 

In a formal response, Joey Ridenour, the board’s executive director, said she agrees with the findings of the report. 

One issue the board cited is an increase in the number of both complaints and licensure investigations opened each year, with the figure more than doubling between 2011 and 2021. And the number of people holding licenses increased by 20%, to 130,690 in 2021. 

The result was that the average caseload was 87 per investigator. That compares with what the board believes would be the ideal number of 60, a number that would allow resolution within that 180-day deadline. 

What may help is that the board did seek – and the Legislature granted – an additional 3.5 investigative positions for the current fiscal year. 

Perry said her staffers also found that the board and its staff were not good in responding to inquiries from the public. 

The staff placed three anonymous phone calls to board offices earlier this year, requesting information about licensees with varying disciplinary histories. And in all three cases, the board “provided some accurate information about the licensees.” 

But Perry said the board provided “insufficient information.” 

In two of the cases, she said the board staff did not disclose that both nurses had a dismissed complaint or inform the callers that the board could provide general information about the nurse, such as license status and any nondisciplinary actions. 

Perry said the board did refer the callers to Nursys, a national database used to verify the licensure, discipline and practice privilege for nurses for states that participate. But state law prohibits the board from including dismissed complaints on that website. 

In all three cases, Perry said board staffers referred people to Nursys when callers asked how they can obtain additional information about specific licensees. But here too, she said, they did not tell the callers that the system doesn’t include things like dismissed complaints or nondisciplinary actions. 

Perry said that while the audit was pending, the board developed new policies and procedures to address the issues. 

(They refer you to their web page because a very biased report that the BD staff writes , and gets a ALJ to sign , is there . Just picking out anyone who is willing to lie make a statement , coached by a dirty AAG Elizabeth Campbell or Sunita Krishna . Then post it , knowing it is lies and the person has no credibility and has no clue about nursing or even met the person . The corrupt board of nursing makes all of their witnesses ‘credible” . But no one else . Along with nasty comments , hand picked to make the nurse out to be either dangerous or crazy . It is old fashion ways, but they will use anything. Abuse of power is evident.

The Audit Report , is extremely limited and missed A LOT of what this corrupt AZ BON is doing , selectively . While stating over and over “we are consistent” .

NOT FOR NURSES , NOT WHEN IT COMES TO THE BON , they will side with them . Political hacks . And the legislature , wants to hear from a big group.

AZ NA , a group of nurses who are against what is right and wrong.Puppets , following the puppet master Kathy Busby , and Racketeering Ridenour. Political . They are fighting against nurses who did nothing wrong but lost everything because of a dirty board of nursing. They are so stupid they do not even know they are fighting against themselves . Look at your lobbyist . Most likely making more than you are . SAD the nurses who are a part of this and can only believe one sided stories , very sad !

Gullible , believe anything they hear.

So sickening that this is what it has come to. At least we are still who we are and they are who they are. Puppets believe one sided lies and even act on them .

Anyone who’s experienced the control and manipulation through condition based fear programming from Mormon leadership, principles and teachings, or any other cult where mass manipulation resides, knows without a doubt the following is absolutely true.

Using education to say and do what ever they want . True or not . Twins in crime , white color . Damaging .

Any nurses that are being framed by the AZ Board of Nursing , and railroaded into getting a psychological evaluations . One of the corrupt AZ BON favorite things to order on everyone , false allegations or not . IT is by their own psych, on their own ‘list” . Which turns out to be a real shit list of dirty docs. You get on the top of the list like LETT, by being the most shady character in the state. How does he get away with it. Bob Bohanske is head of psychology board. He knows like Jokey Ridenour knows she is there to make sure the order , take the license , silence this nurse who is bringing up safety issues . Dirty Directors, every Gov gets the word. Bohanske and Ridenour will be your puppets . When a sharp nurse figures out the entire process is messed up , but this time a reel of false paper work is in the works .

Brnovich’s bimbo who was told many months ago at the Board of Nursing meeting , “your aag is confused “. Yes she is , and this was verified by a Superior Court Judge recently. Discussion about her interpretation of the law , which is a few bricks short of a full load. Campbell is an officer of the court but her oath means nothing. She will ‘try’ anything. Violated a nurses Due Process rights , and she knows or should know this is a deliberate act. Nurses run out of money, they end up not being represented , and Campbell tries any kind of games she can muster up . Dirty Games, nothing legal . How many others has this out of control loose canyon done this with ? Nurses are not trained in legal, and it appears that Campbell wasn’t either. Campbell who goes by “BETH” , at times, has pulled some real stunts in the past , and now got her tit in the wringer . Lost for the board of nursing . The gullible dirty board relies on this pettifogger for any type of legal advise to protect them legally . Campbell can’t be trusted . A huge embarrassment for the s Atty Gen office and the state of Arizona . It won’t be the last time she gets caught , no one should trust her . The cases at OAH are rigged with ALJ’s who are nothing but props , not a lot of rules to follow. Nurses in a lot of cases do not show up , they know the corruption they rigged to get them to that point. IF they have an atty , Campbell does some back room antics that gets them on her side too . Nurse pays for a lawyer while they are helping the state. Get out of OAH, to get any due process in a case at all . The judges in Superior court are not 100% for the state agency. Hope you get an honest one. At least this one knows how to interpret the law, and called Campbell on her incompetence , and said that she just wanted to haul a nurse in and strip him of his career without any time to prepare.

Running a corrupt agency that has no over sight. Abuse of discretion, unable to control wrong doings, unable to move cases and is jeopardizing the public safety . Using her position to take care of friends. SHAMEFUL , public distrust is at an all time high. NURSES who are victims of this horrible director have known all along .

Give this wicked woman the BOOT !! !

Let’s GO , GET RID OF JO !!

How boards use psychology to place a stigma on a nurse , np, Dr.

There is a definite pattern . In Arizona the lawmakers passed a bill , surely thinking this would save the state money . But instead it has cost the nurse dearly . <the azna backed this new statue > Shameful but they will be the first to say , let’s work together . Right .

The AZ BON has a ‘list ‘ of docs for dollars. They either write what the board wants or they are off they list. Psych evaluations are ordered in AZ a lot. In other states a court order is needed . It is like a CYA for the BON , and the nurse pays for all of it . IF you refuse your license will be revoked . IF you do their psych evaluation , you should be able to choose a Dr that you pick , not the Nursing Board agency. The dirty board will give you a paper with the most wicked , out for money , shameful psychologists in the state. Most attorneys in the state know the dirty docs, but you have a choice do it or no license. Most nurses who are caregivers , dedicated hard workers never think for a moment a counselor would do the most evil with their pen .

The pattern is the same , the psych experiment himself Philip Lett , asks ‘why do you think your here?” No matter how you answer it is wrong. Cindy Rollins from Prescott ,tells you everything is completely normal and sending the board a good review , and your ‘good” . Then does the opposite. It does no good to repeat the evaluation they are all crooks that remain on the list. Malpractice whores , who do not operate under their license, so they have nothing to lose by being corrupt and doing harm . No matter what you say, you are ‘defensive ” . You have to be as big a liar and narcissistic as they are .

It happens to Drs as well. The pattern is the same , but the medical / nursing workers come in one at a time and get screwed over royally , careers destroyed , no income, reputation , and isolation . While the ‘tricksters ” have a good laugh and smirk know they pulled it off again. Here is how it went with another victim of the psychological scam world. By so called ‘experts’ who are only ‘expert con artists ‘ who put the $ before good patient care .

Going to a PHP anywhere is like playing with a stacked deck. They only get the info they are provided by the agency that sent you, and a review of public records. My experience, you have no way to counter any misinformation. Lawyers are not a help. The outcome is predetermined and punitive. The process is costly. You are presumed guilty and incompetent and all evaluations are biased against you. The resulting report typically requires one if not all of the following: required counseling, a re-education program for whatever you practice (like a week long board review course or repeat residency), a record keeping course, and post course monitoring of all records, and a supervising MD. They may advise you to relinquish your license, but typically they don’t want to do that, they just want to exert as much pain as they can to encourage you to give it up. All at your own expense. Again, this is from my experience and knowledge base, and I hope that I am wrong in your case. Prepare for the worst outcome. This will follow you for the rest of your career. Make peace and accept it, or look for a different career path. It is survivable, but it can be a major hit to your self image and sense of values as well as devastating to your pocketbook. I have researched most of the programs in the US. I have no reason to believe that Idaho PHP is any different, though I have no personal knowledge of that one. They are not there to help you!

How many of the ‘board attys’ tell their clients up front it’s rigged . Like taking the BON ordered skills evaluation , not one person passed and they know that but order it anyways. BTW Sucher- Scottsdale in AZ is part of PHP and BFF with the BD atty Emma Mamaluy . It raises questions who learned this pattern of deceit from whom.

Encourage anyone that has been contacted by the AZ Board of Nursing about a complaint on their license to contact this site.

NO we do not work FOR the AZ BON , NO not associated with the AZ BON. A watchdog group that has had major issues with the process and operation of the AZ BON , it’s staff and Director.

Confidential. The ones not to trust are the investigators and the BD .

You may have found this searching for an attorney to represent you . We can advise on that too.

We can tell you what we have observed and know as victims of the AZ BON agency . Many nurses will spend countless hours researching , or in disbelief the dirty schemes they will do and dream up .

First and foremost do NOT have any discussion with them on the phone or by email and try to ‘explain your situation ” . They know this is retaliation , but do not care . They will take anything you say , and twist it to make you out to be a liar, crazy , unstable, dangerous , and of course unprofessional .

P S IF anyone from the AZ BON/ or one of their minions contacts this site pretending to be a nurse with a complaint to see what we tell people you will be outed !

There is nothing short of what the out of control board won’t do !!! NOTHING! Not at all what anyone would think of an investigation .