vs. ) CASE NO. 76-1243
Respondent. )
A hearing in the above styled cause was held pursuant to notice in the Conference Room, St. Augustine General Hospital, St. Augustine, Florida, on September 9, 1976 before Stephen F. Dean, assigned Hearing Officer of the Division of Administrative Hearings. This matter came on to be heard on the Administrative Complaint filed against Sandra Ann Pomar by the Florida State Board of Nursing alleging that she had failed to properly chart narcotic drugs on the patients' medication record and nurses' notes which constitutes unprofessional conduct in violation of Section 464.21(1)(b), Florida Statutes.
For Respondent: George M. McClure, Esquire
St. Augustine, Florida FINDINGS OF FACT
Sandra Ann Pomar is a licensed practical nurse holding license number 38952-1 issued by the Florida State Board of Nursing.
Sandra Ann Pomar was employed as a graduate practical nurse by St. Augustine General Hospital from October 1975 until November 1975, and as a licensed practical nurse from that date until February 1976.
In February and March 1976 Sandra Ann Pomar was assigned duties as a medication nurse on the 11:00 p.m. to 7:00 a.m. shift at said hospital.
Night nurse staffing for the four wings of the 120 bed facility was one Night Supervisor who was a Registered Nurse, one Medication Nurse for each wing who was a Licensed Practical Nurse, and two Nurse's Aides to service the four wings.
On or about February 9, 1976 irregularities in the accountability for narcotic drugs came to the attention of the the Director of Nursing, Frances F. Sellers, R.N.
Sellers together with the hospital pharmacist instituted a detailed examination of the narcotic sign-out sheets and comparison of these documents with patient chartings.
This examination revealed various errors by the nursing staff in charting administration of drugs and recording of nurses' observations in nurses' notes. However, the major discrepancies were errors in charting of narcotic drugs. Such errors are more clearly evident because of the detailed records of their withdrawal from Medical Stores.
The errors discovered in the charting of narcotic drugs were made by the Respondent.
The errors noted began on February 8, 1976 when Respondent signed out
75 mg of Demerol at 12:00 midnight from stores to administer to a patient, Harrison. Harrison's doctor had prescribed 75 mg of Demerol every 4 to 6 hours PRN for pain at 12:45 p.m. on February 7, 1976 and cancelled the order at 10:25
a.m. on February 8, 1976. The patient's medication record indicates the drug was not administered; however, no wastage report was entered on the narcotic sign-out sheet.
On February 17, 1976 the Respondent signed out 75 mg of Demerol from Medical Stores at 12:00 midnight and again at 4:00 a.m. for administration to a patient, Hutton. The patient's medical records and the nurses' notes do not reflect administration of the drug. Wastage of the drug was not recorded.
On March 2 and 3, 1976, the Respondent signed out 25 mg of Leritine from Medical Stores at 11:30 p.m., March 2, 1976 and again at 3:00 a.m., March 3, 1976 for administration to a patient, McCelland. Although the patient's medication record reflected administration of her 11:30 p.m. medication, it did not reflect administration of the drug at 3:00 a.m. The administration of the drug was not charted by Respondent or by other attending nurses who had administered the drug in nurses' notes. Wastage of the drug was not recorded.
On the following night, March 3 and 4, 1976, the Respondent signed out from Medical Stores 100 mg of Demerol at 11:30 p.m., 3:30 a.m. and 7:00 a.m.
for administration to a patient, Pacetti. Neither nurses' notes nor the patient's medication record show that the drug was administered. Wastage was not recorded.
On March 4 and 5, 1976 the Respondent signed out from Medical Stores
50 mg of Demerol at 11:30 p.m. and 4:00 a.m. for a patient, Stevens. Neither the nurses' notes nor patients' medication record indicate administration of the drug. Wastage was not recorded.
On March 4 and 5, 1976 the Respondent signed out from Medical Stores 1 mg of Dilaudid at 2:00 a.m. and 5:00 a.m. for a patient, Bennett. The drug was shown as having been administered on the patient's medication record at 2:00
a.m. but not at 5:00 a.m. The Respondent's nurse's notes indicate, however, that a drug was administered twice during that shift for the relief of pain.
On March 5, 6 and 7, 1976, the Respondent signed out for patient Moyers from Medical Stores; 75 mg of Demerol at 1:00 a.m. on March 5, 1976 and
on her next shift signed out the same quantity of Demerol at 3:30 a.m. on March 6, 1976 and on the following shift signed out for the same quantity of Demerol at 11:50 p.m., March 5, 1976 and at 3:30 a.m. on March 7, 1976. The patients' medication record indicates that the drug was administered at 12:00 midnight and 4:00 a.m., March 5, 1976. The nurses' notes indicate one administration, March 6, 1976, administration on March 6 and 7, 1976 at 11:30 p.m. and 3:30 a.m. The patient's medication records for March 7, 1976 were not introduced, and the Respondent's nurses' notes for March 5 and 6, 1976 were not introduced. The Respondent failed to enter the 1:00 dosage and placed the entries for March 6, 1976 in the March 5, 1976 column.
The Respondent signed out from Medical Stores 75 mg of Demerol for a patient, Gerald Combs, at 11:30 p.m. on March 4, 1976; at 3:50 a.m. on March 5, 1976; and at 12:00 midnight, March 6, 1976. The patient's medication record shows that the drug was administered at 11:50 p.m. and 3:50 a.m. on March 5, 1976. No record was made of administration of the drug at 12:00 midnight, March 6, 1976 on the nurses' medication record. Nurses notes indicate that he received pain medication I.M. two times on March 5, 1976 and one time on March 6, 1976 at 1:00 a.m.
The Respondent signed out from Medical Stores for 75 mg of Demerol for a patient, John Combs, at 11:30 p.m., March 4, 1976; 3:30 a.m., March 5, 1976; and 2:30 a.m. on March 6, 1976. She also withdrew 50 mg of Demerol for this patient at 11:30 p.m. or 12:30 a.m. on March 6, 1976. The patient's medication records reflect that he received the medication at 11:15 p.m., March 4, 1976; 3:00 a.m., March 4, 1976; and 12:00 midnight, March 5, 1976. Nurses' notes do not cover March 4 or 5, 1976, but reflect I.M. medication for pain with relief at 12:15 a.m. on March 6, 1976.
The Respondent signed out for 50 mg of Demerol at 2:00 a.m. on March 6, 1976 for a patient, Redmond. No entry indicating administration of the drug was made on the patient's medication record; however, the nurses' notes offer some explanation in that the patient slept for long intervals on the night in question. Wastage of the drug was not recorded.
The errors committed by the Respondent were not brought to her attention because the administration was concerned about possible misuse of narcotics by a staff member. Therefore, the errors in charting were not corrected and other nursing staff and treating physicians were not advised although the investigation became centered on the Respondent very shortly after February 9, 1976.
Respondent's physician was called and testified that he had prescribed various narcotic and less powerful drugs for the Respondent over a period of years for various ailments. Most recently he had prescribed Talwin, a pain reliever stronger than codine to which the Respondent was allergic and weaker than Demerol or Morphine, for the Respondent. The Respondent had vomited when given Demerol, but he could not say whether it was from the drug or as a result of the pain she was experiencing from migrain headaches. The Doctor had observed no indication of drug use or habituation during his treatment of Respondent although the Doctor saw and treated the Respondent on February 20, and March 1, 1976. On February 20, 1976 the Doctor saw her for a skin rash and prescribed Librium for her nerves, and a medicated lotion. On March 1, 1976, the Doctor saw the Respondent again, at which time her previous condition was controlled, but she complained of a urinary infection and was treated for this. On at least the first occasion, the Doctor observed the Respondent's arms and saw no indication of injections.
Sellers eventually confronted the Respondent following her regular shift the night of March 13, 1976, regarding the results of the investigation. Sellers advised the Respondent of the errors in narcotics accountability Respondent had made. The Respondent acknowledged the errors and admitted having taken drugs while on duty; however, the Respondent specifically refused to sign a written statement to be submitted to the Florida State Board of Nursing that said she was taking drugs signed out for patients.
The statements of the Respondent to Sellers regarding the use of drugs was not an admission of theft and unauthorized use, but are solely admission of using prescribed drugs while on duty which could have affected her performance.
Due to her relative inexperience in recording the administration of narcotic drugs and her limited supervision and assistance in providing patient care, the Respondent made obvious recording errors; however, in the majority of instances some recording of the drugs had occurred either in the wrong column of the patient's medication form or in nurses notes. A review of the records indicates that the Respondent did not follow the sequence of signing out drugs, administration, and charting. This resulted in the confusion in times of administration, together with the confusion resulting from charting on the morning after the shift began after the date changed.
Although the hospital had in effect a program for correcting and counseling employees who made errors in drug administration and charting, no action under this program was initiated. Sellers stated that her review of the records revealed errors by other nurses in the administration or charting of drugs.
The real seriousness of Respondent's errors was the recurrence of these errors. However, this must be considered in, light of the fact that no corrective action was taken to point out the errors and require conformity with the the appropriate procedures. Although the hospital's administrators were apparently justified in not confronting the Respondent, this failure to correct and counsel her must be considered in mitigation relative to the number of mistakes which the Respondent made.
CONCLUSIONS OF LAW
The burden of proof rests with the Board to prove the allegations against the Respondent. The Board has shown that the Respondent made charting errors of an obvious nature, which, when discovered, were allowed to go uncorrected for over one month during which time errors of a similar nature occurred. Such errors are not professionally acceptable; however, Respondent's relative inexperience, lack of counseling, and the understaffed shift must be considered in mitigation when considering a penalty for a violation of Section 464.21(1)(b).
Based upon the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer recommends the license of the Respondent be suspended for sixty
(60) days and she be place upon probation for a period of one year.
DONE and ORDERED this 29th day of November, 1976 in Tallahassee, Florida.
STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304
George M. McClure, Esquire
St. Augustine, Florida 32084
