STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF PROFESSIONAL ) REGULATION, BOARD OF NURSING, )

)

Petitioner, )

)

vs. ) CASE NO. 81-2222

)

BEVERLY GIBSON, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice the Division of Administrative Hearings, by its duly designated Hearing Officer, K. N. Ayers, held a public hearing in the above- styled case on 2 March 1982 at St. Augustine, Florida.

APPEARANCES

For Petitioner: W. Douglas Moody, Jr., Esquire

Department of Professional Regulation

119 North Monroe Street Tallahassee, Florida 32301

For Respondent: Geoffrey B. Dobson, Esquire

Post Office Box 1957

St. Augustine, Florida 32084

By Administrative Complaint dated 19 August 1981 the Department of Professional Regulation, Board of Nursing, Petitioner, seeks to revoke, suspend or otherwise discipline the license of Beverly Gibson, R.N., Respondent. As grounds therefor it is alleged that Respondent was guilty of unprofessional conduct in failing to conform to minimally accepted standards of nursing practices in the treatment of patients, Alice Nettles and Peggy Logan. At the conclusion of Petitioner's case Respondent moved to dismiss the complaint respecting Peggy Logan due to insufficient evidence and Petitioner, by and through its attorney, concurred with this motion. Accordingly, this charge is dismissed. With respect to Alice Nettles, the complaint alleges that Respondent, on 25 March 1981, improperly inserted a nasogastric tube, through which the semi-comatose patient, Alice Nettles, was fed, into the lungs of the patient rather than the stomach.

At the hearing the parties stipulated that Respondent is a registered nurse as alleged and was so registered at all times here relevant, and that the cause of death of Alice Nettles was cardiogenic shock, brought about by aspiration of feeding material. Thereafter, nine witnesses were called by Petitioner, Respondent testified in her own behalf, and four exhibits were admitted into evidence. The description of a nasogastric tube was inserted in the record in lieu of the admission into evidence of the tube itself.

Proposed findings submitted by Petitioner and not included herein were not supported by the evidence or were deemed immaterial to the results reached.

FINDINGS OF FACT

1. Beverly Gibson, Respondent, is licensed by the Florida Board of Nursing as a registered nurse and was so licensed at all times relevant hereto. In March, 1980, she was employed at Putnam Memorial Nursing Home, Palatka, Florida. During her tour at Putnam Memorial Nursing Home, Respondent served as Nurse Supervisor, Acting Director of Nurses, then Director of Nurses until she left in September, 1980.

   
   

2. Alice Nettles was admitted to Putnam Memorial Nursing Home sometime prior to March 20, 1980, following a cardiovascular accident (throat) which rendered her practically helpless and semi-comatose. She was unable to perform many necessary functions and required total nursing care. This included feeding through a nasogastric tube. Mrs. Nettles was described as being in poor condition upon arrival and so remained until her death on 26 March 1980.

   
   

3. Nurse's Notes (Exhibit 1) show that on 21 March 1980 Alice Nettles pulled the nasogastric tube out at approximately 8:00 p.m. This tube was reinserted around midnight on March 23 by Audrey Wright, R.N., and patient was fed 300 cc. of juice. During the 7-3 shift her intake was 800 cc. On 24 March an entry on the 7-3 shift shows "n.g. tube out." Although the date of 24 March does not appear on Exhibit 1, the last entry on Exhibit 1 for March 23 is the 3-

   11 p.m. shift, which is followed by an entry for the 7-3 shift where the entry respecting the n.g. tube is contained. The initial entry on 25 March shows "n.g. tube out." For 25 March Exhibit 1 shows a 12:00 temperature taken and thereafter an entry shows "n.g. tube passed by Mrs. Gibson, R.N." Thereafter, Exhibit 1 shows intake of 400 cc. signed by Bivins and on the 3-11 shift the patient was fed two times with intake of 600 cc. and Exhibit 1 states patient tolerated the feeding well and "thick white mucous returned."

   
   

4. During the early hours of March 26, beginning with a midnight entry that "pt sounds congested. Mucous deep and thick unable to suction much out. Resp. labored," Alice Nettles' condition became serious. By 2:00 a.m. she became cyanotic and was administered oxygen, following which her color improved and her respiration was less labored. Her intake was 600 cc. during this first shift on 26 March. On the 7-3 shift she was fed an unrecorded amount one time and was very unresponsive. By mid-morning her condition had worsened and the patient was transferred to the emergency room at Putnam Community Hospital in Palatka.

   
   

5. Upon her arrival at the emergency room, Nettles was in cardiopulmonary arrest and attempts were made to get more oxygen into her lungs. These attempts included mechanically induced chest compressions which resulted in copious amounts of white material coming out of her nose and mouth with each compression. Some 1500 cc. of such material was suctioned from patient.

   
   

6. Attempts to intubate the patient to force more oxygen into the lungs were hampered by the large amounts of milky material coming from the lungs into the mouth and throat. While attempting to insert a tube into the patient's trachea, the nasogastric tube which had been inserted on 25 March was observed to be in the trachea of Alice Nettles. At 10:45 a.m. Alice Nettles was pronounced dead (Exhibit 3).

7. There are three recognized methods for nurses to check to see that a nasogastric tube is inserted into the stomach and not into the lungs of a patient. These are aspiration through the tube of the stomach contents; injection of air through the tube and listening with a stethoscope over the stomach to hear the air exit from the tube; and placing the end of the tube in a glass of water and watching for bubbles. If bubbles appear the tube is in the lung. A positive method of checking the position of the tube is by x-ray. Unfortunately for Mrs. Nettles, this method was not available to Respondent.

   
   

8. The physical evidence observed by the various witnesses during the last hours of Alice Nettles' life establishes that subsequent to the insertion of the nasogastric tube on 25 March 1980 approximately the same amount of liquid was passed into Nettles' body through this tube as was removed from her lungs upon her arrival at the hospital. The only way for this quantity of fluid to get into Mrs. Nettles' lungs was for the tube to have been inserted through the trachea into the lungs instead of through the intended passage to the stomach.

   
   

9. Respondent testified that when she inserted the tube in Nettles she performed the three tests noted in Finding 7 above and that all of these tests showed the tube to be placed in the stomach. She testified that she aspirated milky substance from the stomach of Mrs. Nettles although Exhibit 1 showed that the tube had been removed from Mrs. Nettles for at least 24 hours before being reinserted by Respondent on 25 March. While the tube was removed, no food entered Alice Nettles' stomach. Feeding fluids would not remain in the stomach to be aspirated for that long a period of time.

   
   

10. The glass of water test is the least satisfactory of the methods noted in Finding 7, especially on a comatose patient. While the presence of bubbles would definitely indicate that the tube was in the lungs, the absence of bubbles in the glass of water would not be conclusive that the tube was not in the lungs.

    
    

11. Following the insertion of the nasogastric tube on 25 March, Alice Nettles was fed 400 cc. by Respondent and/or Ruth Bivins, L.P.N., who was present when the tube was inserted. Ms. Bivins was a reluctant witness, who recalled only that she held Mrs. Nettles' hands while the tube was being inserted and that the tube was securely taped to Alice Nettles' nose.

    
    

12. Susan Myers, L.P.N., relieved Respondent and Bivins for the 3-11 shift on 25 March. Before each of the two feedings she administered to Nettles on this shift, she testified she performed the glass of water test and the ausculation (of air into stomach) test and listened with a stethoscope. Both tests indicated the tube was in the stomach. The ausculation test requires both knowledge and discretion on the part of the person making the test. Not only does the stethoscope have to be properly placed, but also it is necessary for the tester to know the sound to be expected. Although an L.P.N. should, if properly trained, be able to perform this test as efficiently as could a registered nurse, it is apparent either that Myers did not perform the test or was not adequately trained.

13. The early shift on 26 March was manned by Audrey Wright, R.N., who testified that she customarily uses two tests before injecting liquid into a nasogastric tube. The tests she uses are the glass of water test and the aspiration from the end of the tube test. Had the tube not been securely taped to the patient, she would have noticed. Undoubtedly, she aspirated a milky substance from the nasogastric tube; however, unless she carefully observed this material for signs of digestion, she could have easily concluded the material came from the stomach rather than from the lungs.

    
    

14. Liquid can be passed into the lungs of comatose patients without a noticeable reaction from the patient. While conscious patients are likely to cough or evidence signs of distress if liquid is fed to their lungs, comatose patients may not show the same symptoms. Accordingly, it is especially important that extra care be taken to ensure the nasogastric tube is properly inserted to the stomach of a comatose or semi-comatose patient. The improper placing of the nasogastric tube by Respondent so as to allow liquid to enter Alice Nettles' lungs when she was fed contributed to the cardiac shock, which resulted in Alice Nettles' death.

    
    

15. The attending nurses on 25 and 26 March after feeding was started noted thick white mucous in Alice Nettles' mouth which was difficult to suction. This was described as thick white mucous, mucous deep and thick, and thick tenacious mucous. Apparently this phenomenon led none of them to conclude that this was feeding material coming from Alice Nettles' lungs.

    
    

    CONCLUSIONS OF LAW

    
    

16. The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of these proceedings.

    
    

17. Inserting a nasogastric tube through the trachea into the lungs of a patient constitutes unprofessional conduct, in that it fails to conform to the minimal standards of acceptable and prevailing nursing practices.

    
    

18. Although Respondent testified that she performed all the tests available to her to check the position of the nasogastric tube when inserted, her testimony that she aspirated feeding material from the patient's stomach is not credible. No such feeding material would have remained in the stomach more than 24 hours after Alice Nettles received her last feeding and, therefore, she could not have aspirated such material.

    
    

19. All witnesses were in agreement that the nasogastric tube was securely taped to Alice Nettles' nose and no evidence was presented that anyone had the opportunity or motive to move this tube. Even if the patient had been able to dislodge the tube, it is highly unlikely that she could have moved it from her stomach and led it to her lungs.

    
    

20. The correlation between the quantity of fluids passed through this tube into the body of Alice Nettles on 25 and 26 March after the tube was inserted and the quantity of fluids removed from her lungs in the hospital emergency room near the time of her death on 26 March is too close to support any conclusion except the nasogastric tube inserted by Respondent on 25 March 1980 led to the lungs of Alice Nettles and not to her stomach.

21. Despite the testimony of those witnesses who provided liquids to Alice Nettles through the nasogastric tube on 25 and 26 March 1980 that they checked the tube before each feeding to ensure it was leading to the stomach rather than to the lungs, all of these witnesses had a motive for saying they always performed such tests before feeding a patient. Without specific recall of each feeding, these witnesses would be expected to say they normally (always) performed the required tests before feeding a patient through a nasogastric tube. To admit otherwise would admit unprofessional conduct, which could lead to disciplinary action against their licenses.

    
    

22. Any finding of fact herein made which also constitutes a conclusion of law is adopted as a conclusion of law. Any conclusion of law herein made which also constitutes a finding of fact is adopted as a finding of fact.

    
    

23. From the foregoing it is concluded that Beverly Gibson, R.N., on 25 March 1980 while inserting a nasogastric tube in Alice Nettles failed to conform to accepted and prevailing practices in adequately testing to be certain that the nasogastric tube was properly inserted; and, in failing to so conform, was guilty of unprofessional conduct. It is further concluded that had those nurses feeding Alice Nettles through this nasogastric tube during the afternoon and evening of March 25 and the morning hours of March 26, 1980, properly performed the tests prescribed for checking the position of the nasogastric tube, this incorrect position would have been discovered. The thick white mucous observed should also have put them on notice that all may not be right. It is, therefore,

RECOMMENDED that the license of Beverly Gibson be suspended for a period of six (6) months.

ENTERED this 19th day of April, 1982, at Tallahassee, Florida.

K. N. AYERS, Hearing Officer Division of Administrative Hearings The Oakland Building

2009 Apalachee Parkway

Tallahassee, Florida 32301

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 19th day of April, 1982.

COPIES FURNISHED:

W. Douglas Moody, Jr., Esquire Department of Professional

Regulation

119 North Monroe Street Tallahassee, Florida 32301

Geoffrey B. Dobson, Esquire Meredith, Dobson & Cushman Post Office Drawer 1957

St. Augustine, Florida 32084

Helen P. Keefe, Executive Director Board of Nursing

Room 504, 111 East Coastline Drive

Jacksonville, Florida 32202

Samuel R. Shorstein, Secretary Department of Professional

Regulation

130 North Monroe Street Tallahassee, Florida 32301

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

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

STATE OF FLORIDA DEPARTMENT OF PROFESSIONAL REGULATION

BOARD OF NURSING

IN RE:

BEVERLY ANN JONES GIBSON, R.N., CASE NO. 0011982 License No. 0995722. DOAH NO. 81-2222

/

ORDER

As the result of an Administrative Complaint filed against the Respondent On August 19, 1981, this cause came before the Florida Board of Nursing of the Department of Professional Regulation pursuant to s. 120.57(1)(b)9, F.S., on June 3, 1982, in Jacksonville, Florida. Pursuant to the Respondent's request, a formal hearing was held before K. N. Ayers, a designated hearing officer from the Division of Administrative Hearings, on March 2, 1982.

APPEARANCES

For Petitioner: W. Douglas Moody, Esquire For Respondent: Geoffrey B. Dobson, Esquire

FINDINGS OF FACT

Having reviewed the entire record in this matter, it is the opinion of the Board that the hearing officer's findings of fact are supported by competent substantial evidence in the record and the Board hereby adopts those findings as its own.

CONCLUSIONS OF LAW

The Board hereby adopts the hearing officer's conclusion of law that the findings of fact constitute a violation of the Nurse Practice Act, specifically

s. 464.018(1)(f), F.S., in that the Respondant was guilty of unprofessional conduct.

The Board specifically rejects, however, the hearing officer's recommended penalty. A review of the entire record demonstrates to the Board that a six (6) month suspension is not adequate in view of the results of the Respondent's unprofessional conduct.

Therefore, it is ORDERED AND ADJUDGED that the license of Beverly Ann Jones Gibson be and is hereby REVOKED.

Done and Ordered this 15th day of June, 1982.

Mary F. Henry, Chairman Florida Board of Nursing

cc: W. Douglas Moody, Esquire Geoffery B. Dobson, Esquire

K. N. Ayers

Beverly Ann Gibson U1 5 982

85 Park Place

St. Augustine, Florida 32084

Docket for Case No: 81-002222

Orders for Case No: 81-002222