STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

BOARD OF NURSING, )

)

Petitioner, )

)

vs. ) CASE NO. 76-1914

)

MARION SANDERS, R. N., )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice the Division of Administrative Hearings by its duly designated Hearing Officer, James E. Bradwell, held a hearing in the above cause on November 19, 1976 in Jacksonville, Florida.

APPEARANCES

For Petitioner: Julius Finegold, Esquire

1130 American Heritage Life Building Jacksonville, Florida 32202

For Respondent: Reese Marshall, Esquire

201 West Union Street Jacksonville, Florida

The Florida State Board of Nursing, hereinafter sometimes called the Board and/or the Petitioner, filed an administrative complaint against the Respondent (licensee) Marion Sanders, R.N. who, based on a stipulation, holds license no. 21383-4. The Board seeks to suspend the referenced license and the licensee's right to practice thereunder based on the following allegations:

1. On or about January 22, 1976 1/ while employed as a registered nurse by the Jacksonville Drug Abuse Program, licensee was instructed by her immediate supervisor to go to the Duval County Jail to pick-up and return to the Methadone Clinic for destruction a bottle of methadone, a narcotic that had been given to Jerald Cole, a client, the previous day as a take-out dose; which dosage had been confiscated by Duval County Jail officials when he was booked into the jail. It is alleged that instead of returning and destroying the methadone as instructed licensee without authorization medicated one Emmett Brown, another client, with its contents. Additionally, it is alleged that licensee failed to properly chart the administration of same on the narcotics disposition sheet.

   2/

   
   

2. The administrative complaint also alleges that on or about January 29, while employed as above, licensee discontinued the voluntary detoxification schedule of a client contrary to the written orders of the medical director. It is averred that in a February 5, incident report respecting this matter, licensee admitted being in error in terminating the detoxification process without doctor's order. Based on these allegations, licensee was suspended

without pay for a period of 30 days by her employer and the Board concludes that the above allegations constitute unprofessional conduct by Petitioner in violation of Florida Statutes, Section 464.21(b) and that her license as a registered nurse should be suspended based thereon.

Based upon my observation of the witnesses and their demeanor while testifying I make the following:

FINDINGS OF FACT

1. Respondent, Marion Sanders, is a registered nurse who holds license no. RN21383-4. Marion Sanders has been registered with the Board since approximately 1959 or 1960. Other than the two incidents set forth in the subject administrative complaint, the licensee had not been subjected to any disciplinary action. On January 22, she was employed with the Jacksonville Drug Abuse Program where her principal duties consisted of making "jail runs" to administer methadone medications to jail clients that had been incarcerated and treated by the Jacksonville Drug Abuse Program. On January 22, while making a "jail run" she saw a client who had been picked up by the police on January 21, and at that time had in his possession a bottle of methadone. While accompanied by a guard and correctional officers, she visited the client who was being held in the "court chute" where she medicated the patients that were being held in the presence of correctional officers, a nurse and an officer that works in the clinic. The Respondent licensee medicated client Jerald Cole with the bottle that she received from the nurse that had been picked up earlier. According to her testimony, that dosage was lower than the bottle that she had brought there from the clinic inasmuch as it contained 45 mg whereas the bottle that she brought from the clinic contained 50 mg. In the next cell she approached Emmett Brown and she asked him if he had called the clinic. Sanders testified that she recalled Emmett Brown since her earlier days of employment with the Drug Abuse Program sometime in September of 1975. When Messenger Brown replied that he had called the clinic, she administered to him the dose that she had picked up from the jail. She testified that this was done because she was aware that he was on a 70 mg dosage in September and that she felt that it was a "humanitarian thing to do at the time". As revealed by the factual stipulation, licensee Sanders did not chart the administration of the methadone dosage to Emmett Brown on the narcotics disposition sheet.

   
   

2. Victor A. Pena, M.D., was called and testified that he was presently employed by the City of Jacksonville Drug Abuse Program since January of 1976. According to Dr. Pena, there are two kinds of 21 day detoxifications i.e., administrative and voluntary. He expressed the opinion that the voluntary detoxification is the better method since a client can go the regular procedure of 21 days and restart in the program again whereas with the administrative detoxification method, the patient has to wait a fixed number of days after he finishes the 21 day program before he can re-enter the program. He testified that the detoxification program can only be stopped by doctor's orders which, as his testimony reveals, was based on his common judgement and the patient's medical record. Dr. Pena was shown a carbon copy of an exhibit captioned City of Jacksonville Drug Abuse Program client I.D. no. 2481 bearing the name Mark Znidorka. He indicated that the document reflected the voluntary detoxification of client Znidorka which was a voluntary detoxification procedure starting at 5:00 p.m. with a decrease of the present methadone dosage. He testified further that Mark Znidorka was a client who had been placed on voluntary detoxification and he had not been discontinued on January 29, 1976. According to the incident report submitted by Respondent Sanders, she discontinued the voluntary detox program which according to Dr. Pena was contrary to his orders.

3. On cross examination, Dr. Pena testified that nurses are advised as to whether a client was on administrative or voluntary detox during medical staff meetings held approximately biweekly whereas standing orders and instructions were outstanding to the nurses to discontinue the detox program only pursuant to doctors' orders. Dr. Pena could not recall that Mrs. Sanders was instructed whether patient Znidorka was on administrative or voluntary detox. He again re- emphasized his opinion that the voluntary method was better inasmuch as a patient could be continued in excess of the 21 days if withdrawal signs persisted or the client showed signs of becoming ill, a flexibility not available in the administrative detoxification program. When questioned on whether he had issued written orders to Respondent Sanders for client Znidorka, Dr. Pena could only reply that he delivered the orders to the nurses' station or the nurse in charge. He testified however that it is the nurses' responsibility to check the dosage for all clients which is available to them on a cardex file. He testified that the instructions are transmitted to a cardex by whoever takes the doctors' orders and that generally would be the head nurse or any RN. When shown the transmittal order for patient Znidorka, Dr. Pena failed to recognize the signature of the staff person who received the order and transferred it to the cardex.

   
   

4. Joan Knox, a registered nurse since approximately 1946, testified that during January 1976 she was employed by the City of Jacksonville Drug Abuse Clinic. Mrs. Knox worked with Respondent Sanders in the drug abuse program for approximately 9 months. She testified that as doctors' orders were transmitted from the doctors offices, they were placed on the nurses desk and any available staff nurse would transpose that order onto the cardex file sheet. She transferred the doctor's order information regarding Mark Znidorka stating that he was a voluntary detox client and that such information was present on the cardex system on January 26. She testified that nurses were explained the difference between voluntary and administrative detoxification, a procedure explained, according to her, at a staff meeting.

   
   

5. Wally Campbell who is presently employed as the program psychologist at the Jacksonville Drug Abuse Program, testified that he has been employed with the program since December, 1974. He testified that the topic of voluntary detoxification and withdrawal was a topic frequently discussed at staff meetings but he could not specifically recall whether Respondent Sanders was present when this difference was discussed. In fact, he testified that there was a time when voluntary detoxification meant something different from the procedure presently utilized. He testified that this difference existed under a program called the Life Drug Program which was an adjunct of the Northeast Florida Comprehensive Drug Control Program.

   
   

6. Patricia J. Monsour, a registered nurse who worked with the City of Jacksonville Drug Abuse Program from April, 1975 through February 13, 1976, testified that she recalled staff meetings being held from time to time prior to January 29, 1976, wherein the difference between voluntary detoxification and voluntary withdrawal was discussed. She testified that she recalled the difference being discussed twice because she was instrumental in drafting the procedural manual for the nursing staff before it was handed in and during staff meeting she went over the various procedures with the nursing staff. She considered it important that all staff nurses understood the procedures that she had written in the procedures manual and that if there were any differences or other questions, she wanted to correct them before they were turned in and made part of the manual given to nurses to control procedures. During this period of time, she was the head nurse and drafted the manual information concerning

   voluntary detoxification and voluntary withdrawal. She testified that she completed her portion of the manual dealing with voluntary detoxification and voluntary withdrawal during late November or early December, 1975, but that to her knowledge the manual was never completed. She testified that when she learned of the discontinuation of the treatment to client Znidorka, she approached Respondent Sanders, who admitted to terminating the voluntary detox program and that when she ordered Sanders to submit an incident report, Sanders admitted to having terminated the program based on the client's request and suggestions from Znidorka's counselor. She testified that to the best of her knowledge, counselors or medication nurses did not possess the authority to terminate the detox program without a doctor's orders. On cross examination, she testified that she did not recall Dr. Campbell ever explaining in December, 1975, or any other time the difference between administrative and voluntary detox. When questioned whether Respondent Sanders was present during the various staff meetings, she could not specifically recall whether she was present or not. She further testified that after the January 26 incident, Dr. Pena called a staff meeting three days later, on January 29, to explain the difference between voluntary detoxification and withdrawal and administrative detox. The special meeting was called to explain the difference because there was obviously a misunderstanding that had to be clarified to prevent it from recurring. She testified further that after the incident and subsequent to the January 29 staff meeting, a written communique was issued to all staff personnel explaining to them the difference between the various detoxification processes. She could not recall whether or not such a written directive or instructions were present in the nurses' station.

   
   

7. It thus appears that the person in charge of drafting the procedures manual was not certain that the difference between the two detoxification methods were ever explained to Respondent Sanders and she further expressed her opinion that the detoxification was discontinued based on a general lack of understanding among the nursing staff personnel. This becomes more evident when reflection is given to the fact that a special staff meeting was called a few days after the January 29 incident and a special staff meeting was called to explain the differences in the two methods. Thereafter written directives were given to the nurses at the various medication stations. As an aside, there is further evidence that there is some basis in fact for a misunderstanding by nurses of the two methods in view of differences that had existed under the prior drug abuse program. Based on these facts and conclusions, it is therefore concluded that the licensee's conduct involved herein is not of the type in which she can be charged with having erroneously stopped the detoxification of patient Znidorka here without an order contrary to outstanding regulations.

   
   

   CONCLUSIONS OF LAW

   
   

8. The Division of Administrative Hearings has jurisdiction over the parties to this proceeding.

   
   

9. The parties were properly noticed pursuant to the notice provisions of Chapter 120 Florida Statutes.

   
   

10. By failing to destruct a bottle of methadone that the licensee received and which had been confiscated by the Duval County jail officials and by administering the same to client Emmett Brown, licensee failed to follow the instructions of her supervisor on January 22, 1976, and in addition failed to properly chart the administration of the same on the narcotics disposition sheet as, stipulated.

11. The Board failed to establish by competent and substantial evidence that the licensee, while employed above on January 29, 1976, discontinued the voluntary detoxification schedule of a client contrary to the medical director's written orders as charged in Count Two of the Administrative Complaint.

RECOMMENDATION

Based on the above facts and conclusions including the stipulations based on the allegations contained in count one of the administrative complaint filed herein, it is hereby recommended that the licensee's earlier suspension for a 30 day period without pay by her employer as set forth in paragraph three of the administrative complaint is just and sufficient penalty for her action as found herein and that no additional penalty be subjected to her based on such conduct.

DONE and ENTERED this 6th day of January, 1977, in Tallahassee Florida.

JAMES E. BRADWELL, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304

(904) 488-9675

ENDNOTES

1/ Unless otherwise noted all dates are in 1976.

2/ At the outset of the hearing, counsels stipulated to the factual allegations contained in the first count of the administrative complaint filed herein.

COPIES FURNISHED:

Julius Finegold Esquire

1130 American Heritage Life Building Jacksonville, Florida 32202

Reese Marshall Esquire

201 West Union Street Jacksonville, Florida

Docket for Case No: 76-001914

Orders for Case No: 76-001914