Route 4, Box 339B, Panama City, ) CASE NO. 75-585 Florida 32401 )
A hearing was held pursuant to notice on October 3, 1975 at 10:00 a.m. in the Conference Room of the Law Office of William E. Harris, 406 Magnolia Avenue, Panama City, Florida before Stephen F. Dean, assigned Hearing Officer of the Division of Administrative Hearings.
This case arose out of the Complaint filed by the Florida State Board of Nursing against Emmaline Hutto Parrish, L.P.N., alleging that she had dispensed controlled drugs without doctor's orders and had failed to properly chart the condition or the administration of prescribed medications to patients.
For Petitioner: Julius Feingold For Respondent: William E. Harris
Mrs. M. L. Croft was called and sworn and testified that she was a R.N. and was employed from October 1974 until March 1975 at Bay Convalescent Center, Panama City, Florida as the Director of Nursing.
On or about November 1, 1974, several events came to her attention which caused her to look into the patient care rendered by Mrs. Parrish to patients and coworkers at Bay Convalescent Center.
On November 1, 1974, she received a call from the father of an employee of Bay Convalescent Center, Ruby Goodman, a nurse's aide, who advised Croft that his daughter was ill and that she had received some medical care from Mrs. Parrish. Croft determined by an examination of records and a discussion with Mrs. Parrish that Mrs. Parrish had administered penicillin, darvon, and emperin to Ruby Goodman. Mrs. Parrish admitted that she had administered these medications to Ruby Goodman but stated to Mrs. Croft that she had not known it was against the rules. with regard to Ruby Goodman, Mrs. Parrish testifying in her own behalf said that she had thought that it was the policy of the Center to treat its employees based upon a prior occurrence when an employee had reported sick and another Registered Nurse had given medications to the employee.
Ms. Croft stated that she had also examined the charts kept by Mrs. Parrish during the month of October 1974. These included the chart of Ellis Roberts for the period of October 4 until October 30, 1974, which the witness identified and was received as Exhibit 1. There is no entry contained on
Exhibit 1 for 12:00 midnight, October 12, 1974, and thereafter at 12:00 midnight
and 6:00 a.m. from October 13 until October 17, 1974, indicating whether the patient received or refused ampicillin. Because no entry was made it cannot be determined whether a charting error had occurred, or whether Roberts received or refused his medication. No entry was made in the nurses' notes (Exhibit 4) indicating a change in medication or procedure for the administration of ampicillin. Ms. Croft testified that she counted the number of pills in the ampicillin bottle assigned to Roberts on the morning of November 1, 1974, and there were two more capsules present than there should have been. Exhibit 1 would indicate that Roberts possibly did not receive ampicillin on a total of eleven occasions between October 12, 1974 and October 17, 1974, when the medication was discontinued. Based upon Exhibit 1, Ms. Croft should have discovered eleven extra capsules of ampicillin on hand in Roberts' ampicillin bottle. Neither the testimony nor Exhibit 1 indicates who was caring for the patient, Roberts, on the evening of October 12, 13, 14, and 17, 1974. Ms. Croft testified that Mrs. Parrish was on duty during the night shift, 11:00 p.m. until 7:00 a.m. on October 15 and October 16, 1974.
Mrs. Parrish testified that she could not recall the events well but that she had withheld medication from Roberts only on one occasion and that was on doctor's orders when Roberts had run a high temperature and Mrs. Majors, R.N., had taken over charting of the patient. On that occasion because of the patient's temperature all medications were discontinued and the patient packed in ice and given an alcohol rub according to Mrs. Parrish. She further explained that Mrs. Majors had handled the charting and entered the doctor's orders upon the patient's records, therefore, she did not know why the instructions to discontinue ampicillin did not appear in the doctor's order notes for October 15, 1974. Having examined the nurse's notes and doctor's orders for October 15, 1974, Mrs. Parrish in response to the Hearing Officer's inquiry, could not identify the aforementioned incident with Roberts. Exhibit 4 indicates that Roberts first had ice packs applied on the night of October 29, 1974, in response to a serious change in his condition. The charting of the patient's condition for October 29, 1974, was by Mrs. Majors, R.N.
With regard to the charges against Mrs. Parrish relative to the patient Ellis Roberts, the Hearing Officer concludes that the evidence presented does not prove that Mrs. Parrish failed to administer ampicillin as ordered by the attending physician because the records indicate eleven occasions upon which the drug was possibly not administered while Ms. Croft's pill count indicates only two extra ampicillin pills. Exhibit 4, the nurse's notes for October 10, 1974 through October 18, 1974, do not reveal any entries by Mrs. Parrish. The absence of entries on Exhibit 1 makes it impossible to determine when or if Mrs. Parrish was on duty. However, the uncontroverted testimony of Ms. Croft was that Mrs. Parrish was on duty during the period 12:00 midnight and 6:00 a.m. on the nights of October 15 and 16, 1974. Exhibit 1 clearly indicates that at error in the charting of ampicillin occurred at 12:00 midnight and 6:00 a.m. on October 15 and 16, 1974.
Ms. Croft testified further that she had examined the chart of Anita Pritchard, which she identified and which was received as Exhibit 2. This exhibit indicates that the patient did not receive a prescribed does of lanoxin by the entry having been circled for 9:00 am. and 5:00 p.m. on October 21, 1974. However, the record further indicates along side the 9:00 a.m. entry on October 21, 1974, that the medication was given. Ms. Croft was asked to examine the nurse's notes and doctor's instructions but was unable to find any basis for the change in medication schedule. A review of Exhibit 2 indicates that the patient received all of the medications to be given at 9:00 a.m. and 5:00 p.m.
on October 21, 1974. Exhibit 2 further indicates that the patient did refuse medications form other nurses on other occasions. According to the instructions on Exhibit 2, Mrs. Parrish did not properly complete the annotation of the patient's refusal to take the medication because, according to the testimony of Ms. Croft, no entry was made in nurse's notes stating the reason for not giving the medication. Mrs. Parrish, according to her testimony, had no clear recollection of the event and could not determine from an examination of Exhibit
2 if the initial and circle appearing on the exhibit were hers or whether the lanoxin was given the patient.
Ms. Croft then identified the medication chart of Lena Sparks which was received into evidence as Exhibit 3. Ms. Croft testified that Exhibit 3 revealed that the patient Lena Sparks had received on the night of October 30, 1974, a dosage of tunial prior to bedtime. Exhibit 3 further reflects that the patient was to receive a dosage of tunial "HS PRN". According to these instructions, the patient should have received tunial at bedtime as needed or required. Exhibit 3 reflects that Mrs. Parrish administered a dosage to Ms. Sparks at 3:45 a.m. on the morning of October 31, 1974. The administration of the drug tunial to Ms. Sparks by Mrs. Parrish was contrary to the instructions regarding the administration of this drug to Ms. Sparks. Ms. Croft, having examined the records, could not find any doctor's authority to repeat the dosage at any time. Ms. Parrish testified that Ms. Sparks was a noisy and loud person and that on another occasion she had given her medication to quiet her upon the instructions of another nurse. She testified that based upon the prior incident that she had felt justified in administering tunial to Ms. Sparks and the patient awoke at 3:45 am. on October 31, 1974.
Mrs. Parrish appeared to be evasive and belligerent and her testimony concerning events .were vague and she could recall very few actual facts surrounding the incidents in question. The one incident which she recalled regarding the radical change in the patient Roberts' condition did not occur on the date when, according to, the testimony of Ms. Croft, Mrs. Parrish was on duty and failed to properly administer Roberts' medication or chart the administration of his medication.
According to Ms. Croft Bay Convalescent Center is a skilled nursing facility whose patients require trained nursing care. She also testified that oral changes in doctors' instructions require entry in nurses' notes and doctors' instructions followed up by a "change order" which must be forwarded to the doctor within twenty-four (24) hours, signed by the doctor, and returned for enclosure in the file.
Mrs. Parrish has been an L.P.N. for twenty (20) years and prior to her employment by Bay Convalescent Center had been primarily a private duty nurse for the preceding ten (10) years. At the time of the incident alleged in the Complaint, Mrs. Parrish had been employed at Bay Convalescent Center for approximately three (3) weeks. Mrs. Parrish testified that she was unfamiliar with Bay Convalescent Center's medication charting procedure.
CONCLUSIONS OF LAW
The testimony of Ms. Croft and Mrs. Parrish indicated that Mrs. Parrish administered penicillin (or crysticillin) to Ruby Goodman. Although the Hearing Officer can appreciate Mrs. Parrish's desire to assist her co-worker, Ms. Goodman, the potential hazards of administering penicillin or related drugs without a prescription or pursuant to doctors' instructions or supervision are well known.
With regard to the patient Ellis Roberts, the Hearing Officer finds that the medication records relative to the drug ampicillin were not properly kept and based upon the testimony of Ms. Croft the Hearing Officer finds that Mrs. Parrish was responsible for the proper charting of the medications on October 15 and 16, 1974, and that Mrs. Parrish failed to properly chart the administration of the patient's refusal of the prescribed ampicillin.
The Hearing Officer finds that in regard to the patient, Anita Pritchard, that Mrs. Parrish failed to properly indicate in the nurse's notes the reason for the patient's refusal of the drug lanoxin at 5:00 p.m. on October 21, 1974. With regard to the patient, Lena Sparks, the Hearing Officer finds that Mrs. Parrish, contrary to the instructions relative to administration of the drug tunial gave Lena Sparks a dosage of tunial at 3:45 a.m. on October 31, 1974. The Hearing Officer notes that the incidents in question took place over approximately two (2) weeks and appears to indicate a trend or pattern of behavior relative to the administration and charting of drugs and patient care. It would appear basic to the nursing profession that medications be administered to a patient only under a doctor's specific orders and in the specific manner prescribed. Should a nurse question the advisability of following a doctor's orders regarding a specific medication, she has an obligation to call the doctor and consult with him regarding any questions which she has. The administration or non-administration of medications should be carefully charted as should changes in doctors' orders relating to the administration of drugs. In the instant case drugs have apparently been administered and withheld without appropriate entries being charted and without any explanatory nurses' notes or doctors' orders to authorize the change. To make such entries would appear elementary without regard to the specific charting system used in the institution, however, in this instance the charting system itself was self- explanatory. An L.P.N. with twenty years experience should be familiar with functions of nurses' notes and when entries should be made and what should be included therein.
Having made the aforestated findings of fact regarding the licensee, Emmaline Hutto Parrish, I find that her actions with regard to Ruby Goodman, Ellis Roberts, Anita Pritchard, and Lena Sparks to have been unprofessional and to have violated Section 464.211)(b), Florida Statutes, and I would recommend that the licensee's license be revoked.
DONE and ORDERED this 15 day of October, 1975.
STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings The Oakland Building
Filed with the Clerk of the Division of Administrative Hearings this 13th day of October, 1975.
William E. Harris, Esquire
Ms. Helen Keefe, Executive Director Fla. State Board of Nursing
