STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

FLORIDA STATE BOARD OF NURSING, )

)

Petitioner, )

)

vs. ) CASE NO. 78-1450

)

JANE ADELAIDE DRAKE, )

)

Respondent. )

)

RECOMMENDED ORDER

This case was heard in the Small Conference Room, Holy Cross Hospital, 4725 North Federal Highway, Fort Lauderdale, Florida, on October 18, 1978, by Stephen

1. Dean, assigned Hearing Officer of the Division of Administrative Hearings.

   
   

   This matter was presented on an Administrative Complaint filed by the Florida State Board of Nursing against Jane Adelaide Drake alleging that Drake was guilty of unprofessional conduct and that she had departed from accepted and prevailing nursing standards by failing to properly chart the administration of drugs and failing to follow appropriate narcotic inventory procedures , contrary to Section 464.21(1)(b), F.S.

   
   

   ISSUE

   
   

   Whether the Respondent failed to appropriately chart the administration of medications and make the appropriate entries in the drug inventory procedures, and whether this constituted a departure from the accepted and prevailing nursing standards.

   
   

   APPEARANCES

   
   

   For Petitioner: Julius Finegold, Esquire

   1107 Blackstone Building

   Jacksonville, Florida 32202

   
   

   For Respondent: Eugene A. Peer, Esquire

   2170 Northeast Dixie Highway Jensen Beach, Florida 33457

   
   

   FINDINGS OF FACT

   
   

   1. Jane Adelaide Drake is a registered nurse licensed by the Florida State Board of Nursing. She was employed at Holy Cross Hospital, Fort Lauderdale, Florida from approximately 1973 until March, 1978. She was the assistant head nurse on Ward 4 South on March 23, 24 and 25, 1978. Her duties included responsibility for the narcotics and other controlled substances maintained on 4 South, and the administration of controlled substances to patients.

   2. The scheme or procedure for control of narcotics and other; controlled substances called for their issuance in individual dosages daily by the hospital pharmacy to each ward, including 4 South. A Controlled Substances Disposition Record (CSDR) was used to issue controlled substances to the wards. Each ward was issued sufficient new stock daily to maintain its stockage level at the level indicated by the numbered entries on the CSDR for each drug. Additional stockage was indicated by the addition of letters following the numerical entries for a particular drug on the CSDR. Each individual drug dose was issued in an envelope which was clear on one side and had a preprinted form on the other. As drugs were administered, an entry was made by the person responsible for narcotics control on the CSDR opposite the type and strength of drug to be administered. An inventory was conducted daily from this sheet to check drugs on hand against those which had been administered.

      
      

   3. Doctor's orders for medication were transferred to an electronic data system, and daily printouts were received by each ward for each patient indicating the drugs to be administered and the times or conditions for administration. This preprinted form was referred to as the medication administration record (MAR) or patient profile. Administration of the medication was indicated by striking through the time for administration and initialing, or writing in the time of administration and initialing when it was a drug not given at a specified time. One apparent exception to the use of preprinted MARs existed when a new patient was received on a ward. In this event, hand written orders were taken prior to the preparation of the preprinted MAR.

      
      

   4. Nursing notes were maintained by each shift on each patient. Nursing notes were kept on a form which provides spaces for the patient's name and identifying data to be stamped at the top of the form, and headings for the date, time, treatment or medication administered, remarks, and signature and title of the individual making the entry.

      
      

   5. The work force on 4 South was organized into LPNs and RNs who worked directly with patients and are referred to in the record as bedside nurses. The ward supervisors, to include the Respondent, maintained the ward records, drug inventory records, doctor's orders, and administration of controlled medication. Nursing notes for the various shifts and by various RNs and LPNs reflect that only rarely did entries in nursing notes indicate that a specific drug had been administered by the bedside nurse. When recorded at all in nursing notes, generally the only remark is that the patient complained of pain and was medicated.

      
      

   6. Although acceptable nursing practice would dictate that the nurse who administers medication would sign out for a drug, administer the drug, make an entry on the MAR, and chart the drug on nurse's notes, this was not uniformly followed by the nurses on 4 South at Holy Cross Hospital. This was the result of a hospital policy that personnel not trained in the drug records system would not make entries in the drug record, complicated by a shortage of nursing staff that necessitated utilization of "pool" nurses or nurses obtained from local registries. The majority of these nurses were not trained in the hospital's drug records system. These nurses, who were used as bedside nurses, could not make entries on the drug administration records, therefore, they could not administer the drugs. This necessitated that the administration and maintenance of the drug control records be done by the regular staff. Because bedside nurses were responsible for patient charting generally, it became the prevailing practice for bedside nurses to chart the administration of medications which were administered by other staff.

   7. The specific allegations of the complaint relate to Rose Ferrara, Minnie C. Ward, and Josephine Locatelli. Regarding Locatelli, the allegation of the complaint is that the Respondent signed out for and administered Demerol (Meperidine) to the patient on March 23, 1978 but failed to properly sign out for the drug on the C8DR. Exhibit 12 is a handwritten 4AR for both March 23 and 24, 1978, on which Demerol is listed under the date March 23. Entries on this record would appear to reflect that the patient was administered Demerol by the Respondent at 1100 and 1430 on March 23, and by Ann Fosdick at 1900 on that date. The CSDR indicates that Meperidine was signed out for Locatelli at 1035 and 1435 by the Respondent and at 1900 by Ann Fosdick on March 24. The hospital records indicate that the patient was not admitted to the hospital until March

1. Obviously, neither the Respondent nor Fosdick could have administered the drug on March 23. What the records do reflect is that on March 24, the Respondent and Fosdick signed out for Demerol which was administered to the patient on March 24, but recorded on the handwritten MAR under the date of March 23, the date the doctor's order was entered. The administration of pain medication by Fosdick is reflected in the nursing notes of J. Hughes, GN, for 2000 hours March 24, 1978. No nursing notes exist in the record for the Respondent's shift. See Exhibits 2, 12 and 13. The CSDR reflects the Respondent signed out on March 25 for Meperidine at 0700. 1000, and 1430 hours for Locatelli. The nurses notes reflect no entry relating to the administration of these medications for March 25, 1978. The MAR for March 25, 1978, was not introduced. The nursing notes for March 23, 24 and 25, 1978, were maintained by persons other than the Respondent or Fosdick.

   
   

   1. Regarding Ferrara, the testimony indicates that the Respondent signed out for medications on the CSDR and made appropriate entries on the MAR except in one instance. Again, the administration was not charted in nurses notes. However, the MAR submitted as an exhibit is for March 24, 1978, while the nurses notes cover primarily March 23, 1978. The primary failure reflected in the testimony relates to Respondent's failure to chart nurses notes. However, review of the nurses notes on this patient from February until March reveals that the only pain medication received by the patient, and that only on one occasion, was Percodan which was given several weeks after the patient's leg was amputated. Although there may be individual variations to pain, it is hardly conceivable that Ferrara could have undergone the amputation of her leg without any pain medication except Percodan which was administered one time several seeks after the operation. Presumably, the patient did receive pain medication and this was not charted in nurses notes by any of the nursing staff.

      
      

   2. Regarding Minnie Ward, the CSDR shows that the Respondent signed out for Meperidine at 12 noon on March 23, 1978. The nurses notes show no complaint of pain or administration of pain medication at 12 noon on that date. However, the CSDR reflects that "PM" signed out for 50 mg of Meperidine at 0200 hours for the same patient. The MAR for March 23 does not reflect administration of the drug by "PM'. or charting of administration in the nurses notes on March 22, 23, or 24, 1978, by "RM." See Exhibits 1, 9 and 10.

      
      

   3. Further, regarding Ward, a review of her records for other dates reflects that on March 17, the Respondent signed out for Meperidine at.1105 and 1530. The nurses notes, which on that date were kept by the Respondent, reflect administration of the drug at 1100. No entry was made regarding the 1530 administration. An entry is contained at 1900 hours on that date indicating that Ward complained of pain and was medicated; however, no corresponding entry is contained in the CSDR indicating that a controlled substance was signed out for administration to this patient. The shift on 4 South would have changed

      between 1500 and 1530 hours. The pain medication administered necessarily had to come from some source, presumably the 1530 sign-out by the Respondent.

      However, it is unclear whether it was administered at 1530 and not charted until 1900, or not administered until 1900 when it was charted.

      
      

   4. On March 18, 1978, the CSDR reflected that Ward was given 50 mgs of Meperidine at 1300 hours by the Respondent. Nurses notes for that date reflect administration of pain medication at that time. The CSDR also reflects that Ann Fosdick signed out for 50 mgs of Meperidine at 1900 hours on March 18. However, the nurses notes for Fosdick's shift do not reflect that the patient complained of pain or received pain medication. On March 19, Ann Fosdick signed out for 50 mgs of Meperidine at 1800 hours as reflected on the CSDR for that date. The nurses notes kept by M. Green, title illegible, for that date reflect that Ward was medicated for pain by the team leader at approximately 1800.

      
      

   5. On March 20, 1978, the Respondent signed out for 50 mgs of Meperidine at 0900 hours and at 1330 hours, and "REK" signed out for Mereridine at 2100 hours. The nurses notes by R. Ezly, R.N., for March 20, reflect the administration of medication at approximately 1330 and the nurses notes by an LPN whose name is illegible reflect the administration of pain medication at 2000 hours. Again, the nurses notes were kept by an individual other than the person administering the medication. The MARs on March 17, 18, 19 and 20, 1978, were properly executed by the Respondent and the other nurses referred to above.

      
      

   6. The nurses notes for Minnie Ward do not reflect any remarks between 1400 hours on March 23, 1978 and 1530 hours on March 24, 1978, and two separate sets of entries for March 25, 1978.

      
      

   7. A supervisor was called to testify to what constituted acceptable and prevailing nursing practices at Holy Cross Hospital. She had been a nursing supervisor since 1976, and was supervisor on the 3 to 11 shift in March, 1978. In addition, she stated that she had only administered medication four times in the approximately four years she had been at Holy Cross Hospital as a supervisor. Her testimony was based solely upon her observations on her own shift and the review of the records of her shift which she stated that she spot- checked. The supervisor's testimony revealed that she was aware of the fact that shifts on the wards were divided into those nurses giving bedside care and those nurses administering medication. Her testimony and the testimony of the director of nursing shows that the records of the shift on which the Respondent served were spot-checked. Spot-checking was reportedly the means by which the alleged discrepancies in the Respondent's charting were noted. From even cursory inspection of the records, it is evident that medication nurses were not charting the nurses notes and bedside nurses were charting the administration of medication in nurses notes. Such spot-checking also reveals the discrepancies in charting noted above. All of those discrepancies constitute a departure from minimal standards of acceptable and prevailing nursing practice.

      
      

   8. The Respondent offered the only explanation of why these practices had occurred. During the winter months of 1977-78, there had been an increase in patient census, and shortage of staff nurses which caused working conditions to deteriorate. Some regular staff members quit their jobs worsening the already bad situation. The number of Nurses on 4 South varied between three and six to treat forty-eight patients. Even with six nurses on duty, this was 1.3 nurse hours below the hospital's goal of 4.3 nurse hours per patient per twenty-four hours. An attempt was made to make up the personnel shortages by using "pool" or registry nurses; however, hospital policy prevented these nurses from making entries on the CSDRs and MARs which kept all but a very few from administering

      medication. Theme nurses were used to provide bedside care and were permitted to chart nurses notes. Because of the acute shortages, the medication nurses, to include the Respondent, executed the CSDRs and MARs, prepared medications, and administered them, but permitted the bedside nurses to chart the administration in nurses notes.

      
      

   9. The Respondent complained concerning the staffing levels to her supervisor and to the director of nursing. The director of nursing requested a written memorandum from the Respondent, which she received; however, the situation was not improved. Thereafter, the Respondent was terminated for errors in charting, although there had been no prior complaints or counseling with regard to her charting errors, and in spite of the fact that her charting was consistent with the patterns seen with other nurses on other shifts. The general practice concerning charting errors was that nurses were counseled, required to correct errors, and required to prepare incident reports where necessary.

      
      

      CONCLUSIONS OF LAW

      
      

   10. The Respondent is charged with violation of Section 464.21(1)(b), Florida Statutes, in that she was guilty of unprofessional conduct by departing from the minimal standards of acceptable prevailing nursing practice. The record shows that she did depart from acceptable prevailing nursing practice by failing to chart in nurses notes the administration of medication. However, the same evidence indicates that other members of the staff were guilty of making entries in nursing notes reflecting that they had administered medication when they had not administered the medication and had failed to chart completely and had mischarted.

       
       

   11. While the fact that others made charting errors generally would not excuse the Respondent from departing from minimal standards of nursing practice, in this instance it does support the testimony that these errors were the result of operating shorthanded and without nurses trained in the recordkeeping system of Holy Cross Hospital.

       
       

   12. The responsibility for so many gross departures from minimal standards cannot rest solely with the nurses on a ward, but extends also to the supervisory personnel, who, according to the evidence, spot-checked these records. As stated in the Findings of Fact, the errors in charting are so apparent it is impossible to conclude that they were not discovered by the nursing supervisors. However, if they were not discovered, the nursing supervisors were negligent in the performance of their duties.

       
       

   13. The failure by shift supervisors and others to take corrective action or their negligence in failing to discern these errors constitutes a departure from the minimal standards of nursing supervision. Because part of the records presented formed the basis for disciplinary action by the hospital against the Respondent and referral to the State Board of Nursing, presumably these records were subjected to closer scrutiny than they would have been on a spot-check. This raises the question why the Respondent was singled out for disciplinary action in the fact of such gross errors of commission and omission by other nursing staff.

       
       

   14. The only apparent explanation is the Respondent's testimony that she complained in writing of the situation existing in the hospital to the director of nursing.

   15. As stated above, the departure from minimal standards of nursing practice by others is not an excuse for violation of Section 464.21(1)(b) by the Respondent. However, the evidence presented clearly shows a pattern of unprofessional conduct which arose from circumstances beyond the control of the Respondent, and when she exercised her professional judgment in bringing the situation to the attention of the director of nursing, resulted in her being dismissed for errors in charting. These matters are appropriate to be considered in mitigating any penalty assessed by the Board.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer recommends that the Florida State Board of Nursing issue a letter of reprimand to the Respondent.

DONE and ORDERED this 12th day of December, 1978, in Tallahassee, Florida.

STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304

(904) 488-9675

COPIES FURNISHED:

Eugene A. Peer, Esquire 2170 NE Dixie Highway

Jenson Beach, Florida 33457

Julius Finegold, Esquire 1107 Blackstone Building

Jacksonville, Florida 32202

Geraldine Johnson, R.N. Licensing and Investigation State Board of Nursing

6501 Arlington Expressway, Bldg B Jacksonville, Florida 32211

================================================================= AGENCY FINAL ORDER

=================================================================

BEFORE THE FLORIDA STATE BOARD OF NURSING

IN THE MATTER OF:

Jane Adelaide Drake

North Western University Institute CASE NO. 78-1450 of Psychiatry

3203 E. Huron

Chicago, Illinois 60611 As a Registered Nurse License Number 76252-2

/

ORDER

This matter came on for final action by the Florida State Board of Nursing on the 20th day of February, 1979, at the Sheraton Inn-Downtown, 224 E. Garden Street, Pensacola, Florida, 32501.

The Board, having reviewed the entire record, including all pleadings, exhibits admitted into evidence, the transcript of hearing proceedings, the Findings of Fact, Conclusions of Law and Recommended Order of the Hearing Officer, adopts the Findings of Fact and Conclusions of Law of the Hearing Officer and IT IS THEREFORE:

ORDERED AND ADJUDGED that the registered nurse license number 76252-2, of the Respondent, Jane Adelaide Drake, be suspended for a period of one (1) year. However, it is ordered that said suspension be stayed after a period of one (1) month and the licensee be placed on probation for the remaining period of eleven

1. months upon the following terms and conditions:

   
   

   1. That the Respondent shall forthwith return license number 76252-2 and current annual renewal receipt issued to practice nursing as a registered nurse to the Florida State Board of Nursing. The failure to comply shall be deemed a violation of this condition of the probation.

      
      

   2. That the Respondent refrain from violation of any law, Federal, State, or Local.

      
      

   3. That the Respondent inform, in writing, the Florida State Board of Nursing immediately of any change of address or change of employment.

      
      

   4. If employed as a nurse during the period of probation, that the Respondent have her employer provide the Board with evaluations of her satisfactory performance every three (3) months during the period of this probation.

DONE AND ORDERED this 27th day of February. 1979, at Jacksonville, Florida.

FLORIDA STATE BOARD OF NURSING

By: Dorothy C. Stratton, R.N. President

BOARD SEAL

ccs: Jane Adelaide Drake

North Western University Institute of Psychiatry

3203 E. Huron

Chicago, Illinois 60611

Eugene A. Peer, Esquire 2170 N. E. Dixie Highway Jensen Beach, Florida 33457

Julius Finegold, Esquire

Docket for Case No: 78-001450

Orders for Case No: 78-001450