vs. ) CASE NO. 79-770
Respondent. )
Pursuant to notice, the Division of Administrative Hearing, by its duly designated Hearing Officer, James E. Bradwell, held a public hearing in this case on August 14, 1979, in Jacksonville, Florida. 1/
For Respondent: Christopher A. White, Esquire
The issue posed for decision herein is whether or not the Respondent's license to practice nursing should be suspended, revoked, or otherwise disciplined based on conduct which will be set forth hereinafter in detail as outlined by the Administrative Complaint filed herein on or about March 5, 1979.
Karyn Elaine Houghton Ruen, Respondent, is a licensed Registered Nurse who holds license No. 0942442. On March 5, 1979, the Florida State Board of Nursing, Petitioner, filed a five-count Administrative Complaint against the Respondent alleging that during the period February 4, 1978, through April 6, 1978, the Respondent engaged in unprofessional conduct in violation of Subsection 464.21(1)(b), Florida Statutes, in that on approximately five occasions, Respondent signed out on the hospital's narcotic control records on various occasions for a controlled substance and failed to chart the same on patients' medication administration records. Additionally, it is alleged that the Respondent failed to follow effective doctors' orders in the administering
of prescribed drugs and that the Respondent failed to follow establish "wastage" procedures as required by her employer, St. Luke's Hospital, Jacksonville, Florida. 2/
Elmer H. Schorer, R.Ph., is the Chief Pharmacist (Director of Pharmacy) for St. Luke's Hospital, Jacksonville, Florida, and has been registered to practice pharmacy in the State of Florida for approximately twenty years. Pharmacist Schorer is the custodian of controlled substances records for St. Luke's Hospital and tendered copies of those records during the course of the hearing. He testified that all written doctors' orders automatically terminate after forty-eight hours unless renewed by a written prescription. (Petitioner's Composite Exhibit 1.)
Donald J. Smith, the Director of Medical Records for St. Luke's Hospital since January 18, 1978, appeared and testified that he is custodian of patients' medical treatment records and tendered such records during the course of the hearing. (Petitioner's Composite Exhibit 2.)
Juanita B. Gold, a Registered Nurse licensed to practice in this state for approximately thirty-three years, is the Head Nurse for the Orthopedic Floor for St. Luke's Hospital. She has been so employed for the past eight years.
Ms. Gold testified that she knew Respondent as a staff nurse on her floor during times material to the complaint allegations filed herein.
Count 1 of the Administrative Complaint alleges that on or about February 4, 1978, while employed as a Registered Nurse at St. Luke's Hospital, Respondent signed out on the narcotic control record on three occasions for a controlled substance, to-wit: Demerol (Mepheridine), for a patient, Margery E. Murrhee, and charted same on the patient's medication administration record. It is alleged that on said date and time, there was no doctor's order for said drug for said patient. Respecting the Compliant allegations, the evidence showed that the last written doctor's orders for the administration of Demerol to Patient Murrhee was written on the physician's direction on February 1, 1978, and according to the testimony of Juanita Gold, R.N., there was an automatic termination of said doctor's orders forty-eight hours after it was given, unless renewed by a physician. An examination of the medication administration record revealed that the Respondent administered Demerol on three occasions on February 4, 1978, to said patient. As an aside, it was also noted that the same medication was also administered by nurses on other shifts on the same date also subsequent to and in violation of the doctor's orders which had terminated.
In Count 2 of the Administrative Complaint, it is alleged that on February 5, 1978, at approximately 7:30 p.m., Respondent signed out on the narcotic control record for Demerol, a controlled substance, for Patient Murrhee when there was no doctor's order in force on said date and time and she (Respondent) charted the administration of same on the patient's administration record, but failed to chart same on the patient's nurses' notes. The same facts were offered to establish the allegations in Count 2 of the patient, Margery E. Murrhee, on the date and time alleged in Count 2. Much like the evidence offered in support of Count 1, evidence also showed that Demerol had been given to Patient Murrhee by other nurses on the prior shift contrary to doctor's orders and the automatic termination procedures in effect at the hospital. However, contrary to the Complaint allegations, the evidence revealed that the Respondent charted the administration of Demerol on the patient's nurses' notes which, according to the notes, revealed that the Demerol was administered to Patient Murrhee for pain.
Count 3 of the Administrative Complaint alleges that on February 9, 1978, Respondent, while employed as a Registered Nurse at St. Luke's Hospital, signed out on the narcotic control record for Demerol 75 mg., a controlled substance, for Patient David Demick, at 7:30 p.m., 1:30 p.m. and 11:00 p.m. The patient's doctor's orders called for Demerol 75 mg. every three to four hours for severe pain. It is thus alleged that the time interval was incorrect and contrary to the doctor's orders called for Demerol 75 mg. every three to four hours for severe pain. It is thus alleged that the time interval was incorrect and contrary to the doctor's orders. Additionally, it is alleged that the Respondent indicated that the 11:00 p.m. dosage was "wasted", but (Respondent) failed to have the wastage witnessed and signed as required. The evidence revealed that the Respondent did not administer any medication to Patient David Demick contrary to the doctor's orders. What the evidence shows is that Demerol, as prescribed by the treating physician, was administered to Patient Demick at 7:30 p.m. and 10:30 p.m. on February 9, 1978, which administrations complied with the doctor's orders for the administration of Demerol every three to four hours.
Respecting the allegations that the Respondent failed to follow the established wastage procedure at 11:00 p.m. on February 9, 1978, the evidence shows that the Respondent stated that the 11:00 p.m. dosage was taken from the narcotic cabinet in error and as such had to be wasted. The wastage policy of St. Luke's Hospital is that any wastage of drugs must be witnessed and signed by a nurse other than the nurse wasting the medication. In this regard, the evidence showed that this wastage in question was witnessed only by the Respondent, although Respondent testified that to her best recollection, she was unable to find another nurse to witness the wastage at that particular time, 11:00 p.m., which was the time when the nurses changed shifts. Respondent offered that she felt it improper to leave an open narcotic vial in the narcotics cabinet in order that she summon another nurse to witness the wastage. Additionally, she testified that she did not feel she could properly take an open narcotic vial with her in the hallway in order to find a person who could witness the wastage. Therefore, she considered the safest alternative was to waste the narcotic on her own since obtaining a witness was impractical under the circumstances.
In this regard, the evidence does establish that during shift changes, the nurses stations are fairly busy and that it would not be unusual for an employee to encounter difficulty obtaining a witness to a wastage of a drug in conformance with established policy.
Count 4 of the Administrative Complaint alleges that on or about April 6, 1978, Respondent signed out for Demerol 75 mg. at 7:15 p.m. and 10:20 p.m. for a patient, Mildred Blake, and charted it as having been administered at 7:45
p.m. and 10:45 p.m., a three-hour interval, contrary to the patient's doctor's orders which called for the administration of said drug every four hours. The evidence in this regard revealed that through the Respondent's own admission, Demerol was administered to Patient Blake at three-hour intervals contrary to the doctor's orders. An examination of the medication administration records revealed that there were no subsequent doses of Demerol administered to Patient Blake.
Count 5 of the Administrative Complaint alleges that on or about April 6, 1978, Respondent signed out on the narcotic control record for Demerol 75 mg. for a patient, Bruce Hanks, at 5:15 p.m. and 10:00 p.m., and failed to chart the administration of the 5:15 p.m. dose on the patient's medication administration record. It is also alleged that Respondent incorrectly charted Percodan, a
controlled substance, as having been administered at 10:30 p.m. instead of 8:15 p.m., the time Respondent signed out for it on the narcotic control record. It is alleged that Respondent charted Demerol as having been given at 8:15 p.m. when no Demerol was signed out at that hour by the Respondent on the narcotic control record. (The remaining allegations of Count 5 were withdrawn.)
An examination of the narcotic control record and the medication administration chart reveals that the Respondent properly administered the dosage of Demerol to Patient Hanks at 5:15 p.m. and 10:30 p.m. on April 6, 1978, and such was properly noted on the narcotic control record and medication administration chart. Evidence also reveals, as reflected on the narcotic control record and the medication administration chart, that the Respondent properly administered the dosage of Percodan at 8:15 p.m. and properly charted same on the medication chart. Additionally, the testimony of Respondent's supervisor, Juanita Gold, establishes that the administration of the Demerol at 5:15 p.m., the Percodan at 8:15 p.m. and the Demerol at 10:30 p.m. was in compliance with the treating physician's orders.
The Respondent's nurses' notes revealed that she failed to chart the 5:15 p.m. administration of Demerol on the nurses' notes. The evidence also reveals that the nurses' notes also reflect that the Respondent improperly noted the administration of Demerol at 8:15 p.m. instead of Percodan and that the Respondent further improperly noted the administration of Percodan at 10:30 p.m. instead of Demerol. However, the nurses' notes showed that the Respondent realized her mistake and made a notation on the nurses' notes in an attempt to correct the proper administration of Percodan at 8:15 p.m. and the administration of Demerol at 10:30 p.m. In this regard, the testimony of Respondent's immediate supervisor, Juanita Gold, revealed that nurses often find it necessary to return and complete their nurses' notes after medications have been administered and sometimes after the narcotic control record and medication administration charts have been properly noted. The situations, according to Ms. Gold, occur when nurses are extremely busy. Additionally, Ms. Gold testified that occasionally nurses are allowed discretion in determining at what time certain medications should be administered to particular patients without outstanding physicians' directions.
FINDINGS AND CONCLUSIONS
The Respondent's conduct, as alleged in paragraphs 1 and 2 of the Administrative Complaint, evidences a departure from the minimal standards of acceptable and prevailing nursing standards since there were no doctor's orders in effect at the times alleged. It is thus found that the Respondent failed to properly review the physician's directions at said times. As a mitigating factor, it is found that as reflected on the administration records introduced, other nurses on the same dates, albeit different shifts, were also improperly administering the same medication to patients in questions as noted on the various medication charts. Contrary to the Complaint allegations, the Respondent in fact charted the February 5, 1978, administration on the patient's nurses' notes.
As to the allegations of paragraph 3, it is found that the Respondent did not administer any medication contrary to the doctors' orders. Although it is found that the Respondent failed to summon a witness to the wastage dosage of Demerol at 11:00 p.m., as alleged in paragraph 3, it is found that the Respondent exercised her best judgment under the circumstances and thus did not depart from the minimal standards of acceptable and prevailing nursing practices as alleged.
As to the Complaint allegations in paragraph 4, it is found that the Respondent administered the medication to Patient Mildred Blake contrary to the doctor's orders and thus Respondent departed from the minimal standards of acceptable and prevailing nursing practices.
Respecting the Complaint allegations of paragraph 5, it is found that the acceptable prevailing nursing practice is for nurses on occasion to revert back and complete their nurses' notes as the circumstances dictate. Therefore, although Respondent initially made a mistake regarding the noting of the 8:15
p.m. administration of Percodan and the 10:30 p.m. administration on the nurses' notes, she (Respondent) attempted to rectify this mistake immediately on the nurses' notes by a proper notation thereon. Therefore, Respondent did not depart from the minimal standards of acceptable and prevailing nursing practices as alleged. However, in view of the Respondent's failure to note the 5:15 p.m. administration of Demerol on the nurses' notes, although noted on the other administration narcotic control records and the medication administration charts, Respondent departed from the minimal standard of acceptable and prevailing nursing practices in failing to note the 5:15 p.m. administration of Demerol on the nurses' notes, although noted on the other administration narcotic control records and the medication administration charts, Respondent departed from the minimal standard of acceptable and prevailing nursing practices in failing to note the 5:15 p.m. administration on the nurses' notes.
It was also noted in mitigation, that although the Respondent was employed at St. Luke's Hospital for a period of more than ten months, the instances alleged occurred on only three days during that period, and further, that the Respondent has not been the subject of any other disciplinary proceedings.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter and the parties to this action. Subsection 120.57(1), Florida Statutes.
The parties were duly noticed pursuant to the notice provisions of chapter 120, Florida Statutes.
The authority of the Petitioner, Board of Nursing, is derived from Chapter 464, Florida Statutes.
As set forth in the section entitled "FINDINGS AND CONCLUSIONS," competent and substantial evidence was offered to establish that the Respondent engaged in conduct violative of Subsection 464.21(1)(b), Florida Statutes.
That the Respondent be placed on probation for a period of two (2) years.
The above recommendation is based on mitigating factors offered during the hearing, including the fact that Respondent's employment record does not reflect
that the Respondent has been the subject of any other disciplinary actions either prior to or subsequent to the instant proceedings.
DONE AND ORDERED in Tallahassee, Leon County, Florida, this 5th day of October, 1979.
JAMES E. BRADWELL
Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301
Filed with the Clerk of the Division of Administrative Hearings this 5th day of October, 1979.
1/ Pursuant to leave, the parties were granted an opportunity to submit Proposed Findings of Fact which were received on August 29, 1979. The Proposed Findings and Recommendations were considered by me in preparation of this Recommended Order.
2/ During the course of the hearing, the Petitioner's counsel withdrew the Complaint allegations that the Respondent, as alleged in paragraph 5 of its Administrative Complaint, failed to sign out for Demerol at the proper intervals in keeping with the doctor's orders.
Geraldine B. Johnson, R.N.
Suite 504, Richard P. Daniel State Office Building
Christopher A. White, Esquire Grissett and Humphries
