Read the following case scenario:

The former Sameer Shariff, a Saudi Arabian national who changed his name to “The Left Hand of God” and is known to his followers as “Hand,” is a suspected terrorist. Department of Homeland Security (DHS) agents believe that he is planning an imminent attack somewhere in Capital City. Under duress to prevent the attack, three DHS agents and three FBI agents storm into Hand’s house, burst into his bedroom, where he is in bed with a woman, and point shotguns at him. They demand to know what he is planning. No Miranda warnings are read. Hand tells them that he has hired Alex “Boom Boom” Jaxon, a known explosives expert, to plant a bomb in the Capital City Arena, with a timer to go off in three hours when the arena will be filled with over 20,000 people for a music concert.

Jaxon is known to the police and is in Central City, which is two hours away. He is arrested by Central City police and calls his lawyer in Capital City, who tells him he will meet him there and to remain silent. The lawyer then tells Central City police that they are not to question Jaxon until they arrive in Capital City and the lawyer is present.

Central City Police Officer McFadden drives Jaxon to Capital City. McFadden knows that DHS, FBI, and Capital City police are searching the arena, but McFadden is afraid they will not find the bomb in time. By the time that McFadden and Jaxon arrive in Central city, the concert hall is already full of audience members, and the show is set to begin in twenty minutes.

McFadden, who knows Jaxon’s family from previous police contacts, tells Jaxon that his mother and two brothers, who have been surveilled by the police for the last six weeks, are at the concert and will die if the bomb goes off. Jaxon leads McFadden to the bomb, which is defused. A crying Jaxon states that his purpose was to kill infidels, but he would never harm his family.

Research Fifth Amendment cases, including Miranda v. Arizona, 386 U.S. 436 (1966), which involves custodial interrogation and the right against self-incrimination.

In your paper,

• Determine whether Hand was entitled to Miranda warnings.
• Explain whether the fact that Hand was not a citizen of the United States affects his rights in relation to the Fifth Amendment right to remain silent.
• Identify whether Hand’s questioning was custodial.
• Explain whether McFadden’s statement abouthis family constitutes custodial interrogation.
• Evaluate whether Hand’s statement can be used against him in a court of law.
• Explain whether Jaxon’s statement be used against him in a court of law.
• Determine whether Jaxon can testify against Hand.

The Right to Remain Silent paper

• Must be 750 to 1,000 words in length (not including title and references pages) and formatted according to APA style as outlined in the University of Arizona Global Campus Writing Center’s APA Style (Links to an external site.)
• Must include a separate title page with the following:
  • Title of paper
  • Student’s name
  • Course name and number
  • Instructor’s name
  • Date submitted

Advocating for Proper Assessment

You are a BCBA who has recently begun working as an in-house consultant for your local public school district.  The teacher of one of the special education classrooms you oversee has reported her student engaging in high rates of tantruming.  After discussing things with the teacher and with the student’s parents, as well as after completing several observations of the student in the classroom, you’ve noticed that the tantruming actually includes several different behavior topographies that generally occur in the following hierarchy: whining, screaming, throwing/swiping/breaking materials, and finally biting his hand(though this doesn’t happen as frequently as the other topographies).  The behaviors occur multiple times almost every school day, though there doesn’t seem to be any clear correlation between time of day and the behaviors’ occurrence.  However, things have gotten to the point where the student no longer seems to be learning as the behaviors are interfering with his engagement in the instruction, as well as impacting the teacher’s ability to provide instruction to the other students.  At your recommendation, the student’s parents were able to schedule a check up with a pediatrician to rule out any medical variables relating to these behaviors, and the doctor indicated no apparent medical cause for these behaviors.

ABC data collected during your classroom observations hasn’t suggested any clear function for these behaviors.  Therefore, you as the school principal of you can conduct a functional analysis to help better identify the variables affecting the student’s behavior.  The principal, who knows a little bit about behavior analysis and who has had some rather negative experiences with previous BCBA consultants, denies your request to complete the functional analysis, even though the student’s parents have already agreed and the teacher is onboard with doing whatever is necessary to help her student.  The principal tells you that the functional analysis cannot be done as it would require the student to be removed from his educational environment for too long, and doing so would deny the student access to educational opportunities mandated by the Individuals with Disabilities Education Act (IDEA).  Furthermore, he says that because self-injury is a component of the student’s tantruming, conducting a functional analysis would cause more unnecessary harm to the student.  The principal concludes by saying she knows many BCBAs who do all their assessment using descriptive ABC data, so you should just focus on that.

How would you respond to the principal?  What recommendations would you make given her concerns?  Using what you’ve learned in this course thus far, as well as other courses you’ve completed, provide a clear, thorough argument for proper functional assessment for this student’s behavior.  Be sure to full explain your logic as well as your rationale for your arguments.  When writing your answer, remember that you are talking with a school administrator who doesn’t have a background in behavior analysis.

After completing the assessment, my Signature Theme Report produced the following results: Communication, Relator, Individualization, Consistency, and Strategic. When I first saw the themes presented, I was a little skeptical at first but after reading the detailed descriptions I felt like it made a lot of sense and mirrored a lot of what I had already thought about myself. 

A core value that I would like to continue to strengthen would be the value of acceptance. One of my top five themes was relator which explained that I have a comfortability with gravitating towards people I already know and building relationships from there. I don’t have issues with making new relationships, but I can see that sometimes I close myself off initially to embracing new ones. With acceptance, you have to understand that there are some situations you can control and some that you can’t but embracing the latter can lead to new experiences that could be beneficial (Riley, 2021). Another core value that I would like to improve upon would be calmness. This fits in well with my theme of consistency. While I am a firm believer of things being fair and consistent, I can get easily upset when things don’t balance out like they are expected to. I know that working on being calm in tense situations will help me adapt easier when things don’t always work out as they should. 

One of the strengths that I would like to embrace fully and continue to improve upon is communication. It was no surprise to me that communication was at the top of my list for my themes. When I am in a position of leadership at work, I make it a priority to keep my staff updated on everything that is going on for that night and it is something I expect from my charge nurse when I am working the floor also. A communicator is only effective when they are aware of their style of communicating and how others perceive or respond to it (Marshall & Broome, 2021). As a communicator I know that I can always work on how I communicate non-verbally and with body language especially. The other strength that I would like to continue to work on is of being strategic. The report explained that the strategic theme fit me because I am able to sort through the clutter and find the best route when I am trying to accomplish something. I really believe this about myself because when I have a task I need to accomplish, whether I am in a leader position or not, I will break everything down and reorganize it to make sure I have come up with the best solution. I feel like the best way to do something is the way that makes it concise and without a lot of excess getting in the way. 

A characteristic of mine that I would like to strengthen would be that of instinct. My theme of individualization points out that I have an instinct about others and how they work and function. I have always felt that I easily read people and can get a sense of who they truly are and for example in the workplace how they are as a staff member. Strong leaders have good instincts and know when to listen to their gut and not always rely on data and reports (Crampton, 2018). I want to continue to use as instinct as a tool when in a position of leadership. Another characteristic I would like to continue to improve is that of being a listener. With communication being my top theme, it is apparent I value open and honest communication. When being the leader this goes both ways. I would like to always strive to be just as good a listener for those who need that as I am the communicator. I want people to feel like they can always come to me with concerns and know that I hear them. 

Min. 4 pages

APA format

Answering the following:

A. Explain the general purpose of conducting a root cause analysis (RCA).

1. Explain each of the six steps used to conduct an RCA, as defined by IHI.

2. Apply the RCA process to the scenario to describe the causative and contributing factors that led to the sentinel event outcome.

B. Propose a process improvement plan that would decrease the likelihood of a reoccurrence of the scenario outcome.

1. Discuss how each phase of Lewin’s change theory on the human side of change could be applied to the proposed improvement plan.

C. Explain the general purpose of the failure mode and effects analysis (FMEA) process.

1. Describe the steps of the FMEA process as defined by IHI.

2. Complete the attached FMEA table by appropriately applying the scales of severity, occurrence, and detection to the process improvement plan proposed in part B. 

Note: You are not expected to carry out the full FMEA.

D. Explain how you would test the interventions from the process improvement plan from part B to improve care.

E. Explain how a professional nurse can competently demonstrate leadership in each of the following areas:

• promoting quality care

• improving patient outcomes

• influencing quality improvement activities

1. Discuss how the involvement of the professional nurse in the RCA and FMEA processes demonstrates leadership qualities.

Scenario

It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, arrives at the six-room emergency department (ED) of a sixty-bed rural hospital. He has been brought to the hospital by his son and neighbor. At this time, Mr. B is moaning and complaining of severe pain to his (L) leg and hip area. He states he lost his balance and fell after tripping over his dog.

Mr. B was admitted to the triage room where his vital signs were B/P 120/80, HR-88 (regular), T-98.6, and R-32, and his weight was recorded at 175 pounds. Mr. B. states that he has no known allergies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pain at 10 out of 10 on the numerical verbal pain scale. He appears to be in moderate distress. His (L) leg appears shortened with swelling (edema in the calf), ecchymosis, and limited range of motion (ROM). Mr. B’s leg is stabilized and then is further evaluated and discharged from triage to the emergency department (ED) patient room. He is admitted by Nurse J. Nurse J finds that Mr. B has a history of impaired glucose tolerance and prostate cancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pain. After Mr. B’s assessment is completed, Nurse J informs Dr. T, the ED physician, of admission findings, and Dr. T proceeds to examine Mr. B.

Staffing on this day consists of two nurses (one RN and one LPN), one secretary, and one emergency department physician. Respiratory therapy is in-house and available as needed. At the time of Mr. B’s arrival, the ED staff is caring for two other patients. One patient is a 43-year-old female complaining of a throbbing headache. The patient rates current pain at 4 out of 10 on numerical verbal pain scale. The patient states that she has a history of migraines. She received treatment, remains stable, and discharge is pending. The second patient is an eight-year-old boy being evaluated for possible appendicitis. Laboratory results are pending for this patient. Both of these patients were examined, evaluated, and cared for by Dr. T and are awaiting further treatment or orders.

After evaluation of Mr. B, Dr. T writes the order for Nurse J to administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP at 4:05 p.m. After five minutes, the diazepam appears to have had no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication hydromorphone is administered IVP at 4:15 p.m. After five minutes, Dr. T is still not satisfied with the level of sedation Mr. B has achieved and instructs Nurse J to administer another 2 mg of hydromorphone IVP and an additional 5 mg of diazepam IVP. The physician’s goal is for the patient to achieve skeletal muscle relaxation from the diazepam, which will aid in the manual manipulation, relocation, and alignment of Mr. B’s hip. The hydromorphone IVP was administered to achieve pain control and sedation. After reviewing the patient’s medical history, Dr. T notes that the patient’s weight and current regular use of oxycodone appear to be making it more difficult to sedate Mr. B.

Finally, at 4:25 p.m., the patient appears to be sedated, and the successful reduction of his (L) hip takes place. The patient appears to have tolerated the procedure and remains sedated. He is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m.,and Mr. B is resting without indications of discomfort and distress. At this time, the ED receives an emergency dispatch call alerting the emergency department that the emergency rescue unit paramedics are enroute with a 75-year-old patient in acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure machine programmed to monitor his B/P every five minutes and a pulse oximeter. At this time, Nurse J leaves Mr. B’s room. The nurse allows Mr. B’s son to sit with him as he is being monitored via the blood pressure monitor. At 4:35 p.m., Mr. B’s B/P is 110/62 and his O2 saturation is 92%. He remains without supplemental oxygen and his ECG and respirations are not monitored.

Nurse J and the LPN on duty have received the emergency transport patient. They are also in the process of discharging the other two patients. Meanwhile, the ED lobby has become congested with new incoming patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showing a saturation of 85%). The LPN enters Mr. B’s room briefly, resets the alarm, and repeats the B/P reading.

Nurse J is now fully engaged with the emergency care of the respiratory distress patient, which includes assessments, evaluation, and the ordering of respiratory treatments, CXR, labs, etc.

At 4:43 p.m., Mr. B’s son comes out of the room and informs the nurse that the “monitor is alarming.” When Nurse J enters the room, the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2 saturation is 79%. The patient is not breathing and no palpable pulse can be detected.

A STAT CODE is called and the son is escorted to the waiting room. The code team arrives and begins resuscitative efforts. When connected to the cardiac monitor, Mr. B is found to be in ventricular fibrillation. CPR begins immediately by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are administered. After 30 minutes of interventions, the ECG returns to a normal sinus rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully dependent on the ventilator. The patient’s pupils are fixed and dilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called, and upon the family’s wishes, the patient is transferred to a tertiary facility for advanced care.

Seven days later, the receiving hospital informed the rural hospital that EEG’s had determined brain death in Mr. B. The family had requested life-support be removed, and Mr. B subsequently died.

Additional information: The hospital where Mr. B. was originally seen and treated had a moderate sedation/analgesia (“conscious sedation”) policy that requires that the patient remains on continuous B/P, ECG, and pulse oximeter throughout the procedure and until the patient meets specific discharge criteria (i.e., fully awake, VSS, no N/V, and able to void). All practitioners who perform moderate sedation must first successfully complete the hospital’s moderate sedation training module. The training module includes drug selection as well as acceptable dose ranges. Additional (backup) staff was available on the day of the incident. Nurse J had completed the moderate sedation module. Nurse J had current ACLS certification and was an experienced critical care nurse. Nurse J’s prior annual clinical evaluations by the manager demonstrated that the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was available and in working order in the ED on this day.