Judges: DON W. DAVIS
Agency: Department of Health
Latest Update: Apr. 22, 1988
Summary: Respondent nurse found to be negligent by failing to conform to minimal standards of nursing practice.
87-5633STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
DEPARTMENT OF PROFESSIONAL ) REGULATION, BOARD OF NURSING, )
)
Petitioner, )
)
vs. ) CASE NO. 87-5633
)
MCDONALD KNIGHTS, )
)
Respondent. )
)
RECOMMENDED ORDER
Pursuant to notice, the above matter was heard before the Division of Administrative Hearings by its duly designated Hearing Officer, Don W. Davis, on April 7, 1988, in Miami, Florida. The following appearances were entered:
APPEARANCES
For Petitioner: Lisa M. Bassett, Esquire
Department of Professional Regulation
130 North Monroe Street Tallahassee, Florida 32399-0750
For Respondent: William E. Hoey, Esquire
2398 South Dixie Highway Miami, Florida 33133-2399
BACKGROUND
In an administrative complaint, the Petitioner charged the Respondent with failing to conform to minimal standards of acceptable and prevailing nursing practices. The Respondent, a registered nurse licensed by the Petitioner, requested a formal administrative hearing.
At hearing, the Petitioner presented four evidentiary exhibits and the testimony of three witnesses. The Respondent presented the testimony of one witness. Proposed findings of fact submitted by the Petitioner are addressed in the appendix to this recommended order. No proposed findings were received from the Respondent within ten days of hearing as required by the Hearing Officer, nor have such findings been filed as of the time of preparation of this recommended order.
Based upon all of the evidence, the following findings of fact are determined:
FINDINGS OF FACT
The Petitioner is the Department of Professional Regulation, Board of Nursing. The Petitioner regulates the practice of nursing pursuant to section 20.30, and Chapters 455 and 464, Florida Statutes.
The Respondent, McDonald Knights, is a registered nurse and holder, at all times pertinent to these proceedings, of license number 1715572. He received his formal training in England and became licensed in the State of Florida by endorsement on or about May 5, 1986.
At all times material to these proceedings, the Respondent was employed as a registered nurse assigned to work in the surgical cardiac care unit at Cedars of Lebanon Medical Center in Miami, Florida.
Francesco Garofalo was a patient in the coronary care unit of the medical center on March 8, 1987, awaiting cardiac aortic bypass surgery the next morning as a result of acute myocardia infarction. He was being intravenously infused with two medications, lidocaine (for arrhythmia) and nitroglycerin (for pain). The medications were applied through continuous intravenous infusion at separate injection sites and through separate volumetric pumps. At approximately 7:45 p.m., the alarm sounded on the volumetric pump responsible for discharging the nitroglycerin intravenous infusion. The Respondent answered the alarm and noted the container of nitroglycerin was empty. Since the previous shift had not provided a back up container of the medication, it was necessary for Respondent to order a replacement be delivered from the unit's pharmaceutical supply. While awaiting delivery of the medication, the Respondent started a dextrose solution running into the patient to prevent the injection site from closing. At this time, the patient complained of pain at the site of his other intravenous injection for lidocaine. The Respondent determined that this injection site had been infiltrated with the lidocaine solution leaking into the subcutaneous tissue of the patient's arm, resulting in discomfort to the patient. The Respondent decided a new site should be secured.
In the process of securing a new site for the lidocaine infusion, the Respondent removed a manual plunger apparatus termed a "cassette" from the volumetric pump. This action effectively discontinued the function of the pump. After inserting the needle in the new venous site, Respondent manually operated the plunger apparatus to insure that the line was open and effectively discharging a smooth flow of lidocaine medication into the patient's body. He did not establish a rate of flow for the medication into the patient's body beyond cutting down the manual flow to an amount equal, in his opinion, to 10 to
20 drops per minute. At this point, the Respondent went to take a telephone call and left the patient's care to another nurse who had entered the room. The time was approximately 7:47 p.m.
Cordette Steer is a registered nurse with twenty years experience. When she entered the patient's room to allow the Respondent to take the telephone call, she received no instruction from the Respondent. She did not know the medication being injected was lidocaine. Due to the toxic nature of lidocaine and her observation that the volumetric pump for administering this medication had been effectively bypassed, Steer assumed the Respondent had hung a harmless saline or dextrose solution to keep the vein open for the injection. She proceeded to apply tape to secure the needle at the injection site because,
as she testified, "nobody would expect lidocaine to be infusing off of the pump, this is something that is never done." At 7:50 p.m., the patient complained of chest pain. Steer was aware of the exhaustion of the patient's nitroglycerin
and that a new bag had not yet arrived from the pharmacy. She stepped from the room and returned almost immediately with nitroglycerin tablets which she gave to the patient to relieve his chest pain. He shortly began to exhibit seizure symptoms commonly associated with lidocaine toxicity. Code Blue was sounded.
The Respondent was among those personnel responding. He disconnected the lidocaine infusion, stopping the flow of lidocaine to the patient. The time was 7:55 p.m. Resuscitation attempts failed and the patient subsequently expired at approximately 8:30 p.m.
Nancy Cox is a critical care educator employed with the Miami Children's Hospital. She is an expert in the fields of surgical and cardiac critical care. She reviewed the medical records pertinent to this proceeding and her expert testimony establishes that:
Lidocaine is an extremely toxic medication which can be fatal if the volume administered to a patient is not closely controlled.
The dosage the patient should have been receiving was 15 cubic centimeters per hour or approximately three teaspoons per hour.
The volumetric pump sets the rate of delivery of an intravenous drug with a finite, or high, decree of accuracy. When the pump is turned off, with the cassette in place, the flow of medication is stopped. When the cassette is removed from the pump device, an open flow is established and the pump fails to act as a regulator.
Finite control of drug administration is not possible manually, as was attempted by the Respondent in this case, without taking considerable time to adjust the rate of flow in concert with timed intervals. Even when this is done, the plunger may spring open and allow a greater than desired drug flow. The Respondent should not have established a smooth flow of lidocaine, but rather a dripping or slow rate of infusion.
The Respondent deviated from accepted minimal standards of cardiac or critical care nursing when he used the lidocaine solution to initially infuse at an open, unregulated rate in order to determine if the new injection site was functioning as opposed to establishing a patent intravenous route by either injecting saline via a syringe into the catheter, or connecting a bag of a saline or dextrose solution to the catheter for this purpose and then allowing it to infuse, prior to re-connecting the lidocaine.
The Respondent also deviated from accepted minimal standards of acceptable and prevailing nursing practice by not informing Cordette
Steer that lidocaine was being administered intravenously to the patient without the use of the volumetric pump.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter of this proceeding, and the parties thereto, pursuant to Subsection 120.57(1), Florida Statutes.
The evidence presented by Petitioner is clear and convincing. As a result of the Respondent's unprofessional conduct in failing to ensure that the flow of lidocaine being administered to the patient was regulated in accordance with the doctor's orders or informing Nurse Steer that the intravenous line contained lidocaine, the Respondent failed to conform to minimal standards of acceptable and prevailing nursing practice. His unprofessional conduct is further evidenced by the fact that he permitted a telephone call a higher priority than the uninterrupted completion of a medical procedure. Such conduct is a violation of section 464.018(1)(f), Florida Statutes.
This failure by the Respondent to conform to the minimal standards of acceptable prevailing nursing practice also constitutes a sufficient basis for the imposition of disciplinary penalties by Petitioner pursuant to provisions of section 21O-10.005, Florida Administrative Code. This same provision of the Florida Administrative Code also permits the Petitioner to impose discipline for acts of negligence, or gross negligence, occasioned by an offender's action or failure to act. The action of the Respondent was certainly sufficient to justify discipline on this basis as well.
RECOMMENDATION
Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Board of Nursing enter a final order finding the
Respondent guilty of the offense charged in the administrative complaint, suspending his license for a minimum period of one year with probationary reinstatement thereafter conditioned upon 1) a showing by the Respondent that he has enrolled and completed continuing education courses, as deemed appropriate by the Board, in the area of cardiac critical care with an emphasis on intravenous medication applications, and 2) he agrees to comply with reasonable terms and conditions of the Board for a subsequent probationary period of two years.
DONE AND RECOMMENDED this 22nd day of April, 1988, in Tallahassee, Leon County, Florida.
DON W. DAVIS
Hearing Officer
Division of Administrative Hearings The Oakland Building
2009 Apalachee Parkway
Tallahassee, Florida 32399-1550
(904) 488-9675
Filed with the Clerk of the Division of Administrative Hearings this 22nd day of April, 1988.
APPENDIX TO RECOMMENDED ORDER, CASE NO. 87-5633
The following constitutes my specific rulings, in accordance with requirements of section 120.59 Florida Statutes, on proposed findings of fact submitted by the parties.
PETITIONER'S PROPOSED FINDINGS
Included in finding number 2.
Included in finding number 2
Rejected as unnecessary.
Including in finding number 2.
Included in finding number 3.
Included in finding number 4.
Rejected as unnecessary.
Included in finding number 4.
Included in finding number 7.
Rejected as unnecessary.
Rejected as unnecessary.
Included in finding number 4.
Included in finding number 4.
Rejected as unnecessary.
Rejected as unnecessary.
Rejected as unnecessary.
Rejected as unnecessary.
Included in finding number 6.
Included in finding number 6.
Included in finding number 5.
Included in finding number 6.
Included in finding number 6.
Included in finding number 6.
Included in finding number 6.
Included in finding number 6.
Patient was pronounced officially dead at 8:52 p.m., but Respondent testified that death occurred earlier.
Included in finding number 7.
Included in finding number 7.
Included in finding number 5.
Included in finding number 7.
Rejected as unnecessary.
Rejected as unnecessary.
Rejected as unnecessary.
Included in finding number 7.
Included in finding number 7.
Included in finding number 5.
Included in finding number 7.
Rejected, not supported by the evidence.
Included in finding number 7.
Rejected as unnecessary.
Included in finding number 7.
Included in finding number 6.
Rejected as a conclusion of law.
COPIES FURNISHED:
Lisa M. Bassett, Esquire Department of Professional
Regulation
130 North Monroe Street Tallahassee, Florida 32399-0750
William E. Hoey, Esquire 2398 South Dixie Highway Miami, Florida 33133-2399
William O'Neill, Esquire Department of Professional
Regulation
130 North Monroe Street Tallahassee, Florida 32399-0750
Judie Ritter Executive Director
Department of Professional Regulation
Room 504, East Coastline Drive Jacksonville, Florida 32201
Docket for Case No: 87-005633
Orders for Case No: 87-005633
| Issue Date |
Document |
Summary |
|
Jul. 21, 1988 |
Agency Final Order
|
|
|
Apr. 22, 1988 |
Recommended Order
|
Respondent nurse found to be negligent by failing to conform to minimal standards of nursing practice.
|
