vs. ) CASE NO. 84-1421
DEBORAH K. GROVE, )
Respondent. )
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 March 5, 1985, at Lakeland, Florida.
For Petitioner: Julia P. Forrester, Esquire
For Respondent: Rodney W. Smith, Esquire
By Administrative Complaint filed March 28, 1984, the Department of Professional Regulation, Petitioner, seeks to revoke, suspend, or otherwise discipline the license of Deborah K. Grove, as a registered nurse. As grounds therefor it is alleged that on or about August 21, 1983, Respondent failed to provide or assist in providing care to a critically ill newborn infant admitted to Polk General Hospital; that she failed and refused to assist the attending physician in providing needed care to this infant; that she improperly placed this infant in an incubator in an isolation room when its condition required its placement in an isolette in an observation nursery; that she improperly interrupted emergency life support being given to the newborn in order to weight the infant; that she failed to accurately report the condition of the infant to the hospital duty obstetrician; and thereby failed to conform to the minimal standards of acceptable and prevailing nursing practices.
At the hearing Petitioner called 11 witnesses and the deposition of the principal complaining witness was admitted as Exhibit 1, Respondent called 3 witnesses and 8 exhibits were admitted into evidence.
Proposed findings submitted by Respondent have been considered. To the extent those proposed findings are included herein they are adopted; otherwise, they are rejected as not supported by the evidence, consist of the recitation of the testimony of witnesses, are cumulative, or are unnecessary to the conclusions reached.
In August 1983 Deborah K. Grove, Respondent, was employed by Polk General Hospital as a registered nurse. On August 21, 1983, Respondent was the charge nurse in the nursery at Polk General Hospital. During the mid-morning of August 21, Polk General received a report that a premature baby had been born in the women's toilet at the jail in Bartow and mother and child were enroute to the hospital by emergency vehicle. Preliminary report was that the infant was having difficulty breathing, was somewhat cyanotic, but had a good pulse. This information was passed to the nursery to enable them to prepare to receive this infant. Respondent telephoned the duty pediatrician, Dr. Pilapil, who was in charge of the pediatric section that day to inform him of the pending arrival and to get instructions. For a baby born outside the hospital the general practice is to place the baby in isolation to guard against infecting other babies in the nursery. Dr. Pilapil told Respondent to place the baby in an incubator in isolation and that he would come to the nursery shortly. At the time this call was received Dr. Pilapil was standing by in surgery to receive a baby to be delivered by Caesarean section. At this time that patient had not been anesthesized.
Dr. Rahn Shaw was a resident at Polk General Hospital in Family Practice Residency Program and was assigned to pediatrics. Shaw had graduated from medical school some two months before and had been at Polk General for approximately two weeks on August 21, 1983, when he was advised of the expected arrival. Shaw was described by other doctors as a very good resident, but he had never before faced a crisis situation unsupervised. In the meantime Respondent had directed the incubator be connected to heat and oxygen and prepared for the baby's arrival. Upon receipt of the initial report Respondent believed the baby would be dead on arrival or expire shortly thereafter.
Some ten minutes later the ambulance arrived with the mother and child. When wheeled in the hospital the baby was lying on its mother's abdomen and the umbilical cord had not been cut. Dr. Shaw severed the umbilical cord and proceeded toward the nursery with the baby. At this time the baby was gasping for breath, was cyanotic but had a strong heart beat. Shaw was led to the isolation section by Respondent who took the infant from Shaw, put her in the incubator and closed the top of the incubator.
There was a great amount of dispute at this point in time regarding the infant's continued need for suction. The paramedics who accompanied the infant in the ambulance had suctioned the baby's mouth and nose and had given the infant oxygen enroute to the hospital. Upon arrival of the infant at the hospital, after the cord had been severed, Shaw was given an OB pack which contained a suction bulb he used to suction the infant. Before the infant arrived at the incubator the suction bulb had been dropped on the floor and was no longer available for use. Shaw testified the baby needed continued suction, the paramedics testified additional suctioning was not needed when they arrived at the hospital, and other witnesses testified on both sides of this issue. The most accurate condition is believed to be that additional suctioning was indicated but was not essential.
Partly as a result of a provision in Polk General Hospital's policy manual regarding premature infants (Exhibit 2), several nurses were under the distinct impression that only pediatricians could give orders in the nursery. Since residents could practice only under the supervision of a licensed doctor, the authority of a resident to give orders in the nursery was even more suspect. When news of the imminent arrival of the baby born in the jail toilet was announced, and Shaw was the doctor in charge, Respondent told another nurse that she would not take orders from Shaw.
Enroute to the pediatric isolation section with the infant in his hands, Shaw attempted to help the infant's breathing by holding its head down slightly to help remove mucus and to resuscitate the infant by pressing on the rib cage. When he handed the infant to Respondent, saw the infant placed in the incubator with no further attempt to help the baby deemed to be in critical condition, Shaw opened the incubator and recommenced resuscitation. When he felt what he thought to be a slowing of the heartbeat, he started chest massage to increase the heartbeat. At this time Shaw was a very concerned and frightened young doctor who wasn't getting the help he expected and needed from the Respondent. Respondent was disturbed that Shaw was interfering with her duties to care for the infant as she had been directed by Dr. Pilapil. Respondent believed the infant would be all right if left in the warm incubator with adequate oxygen and that chest massage was not necessary or indicated on such a small baby. She also feared that Dr. Shaw would attempt to intubate the infant and she did not believe he had sufficient experience to do so on a premature infant. Shaw, on the other hand, believed the infant would die if left to its own resources in the incubator.
All witnesses agree that the choice of an incubator in which to place the infant was a poor one and that the infant could have been better cared for had an isolette been used. The latter would allow the infant to be handled through the ports of the side of the isolette and not disturb the warmth and oxygen supply to the infant which results when the incubator is used and the top is lifted to work on the infant.
Shortly after Shaw removed the infant from the incubator he asked Respondent what the gestational age of the infant was. Respondent didn't know, but, to provide information needed for future procedures, placed the baby on the scales and recorded a weight of 1 lb. 14 ozs. This procedure should have been delayed until the infant had passed the critical phase.
After Shaw commenced working the infant in the incubator Respondent again telephone Dr. Pilapil, who advised her he would be there shortly. Again there was conflicting testimony as to events immediately following. Shaw testified he was left alone with the infant for ten minutes, that he became so concerned and frustrated that he began to cry; that his request to Respondent for help was rebuffed, and that when she did return he told her "If you're not going to help me, get the hell out of the room." Shaw also thought of intubating the infant. Respondent testified that when she left the isolation room to get supplies or call Dr. Pilapil she always ensured someone else was present with Shaw, that she complied with all of Shaw's orders to get necessary equipment, that she provided a bubble blanket, ambu bag and oxyhood for the baby, and that Shaw had worked on the baby for ten minutes before she realized that he was not going to let her do her job. Other witnesses affirmed that Shaw was crying and that he was left alone only for a very brief period, if at all.
When the baby was first taken to the isolation section and the top of the incubator was lifted by Shaw, he and Respondent started arguing about the proper care for the infant. Respondent testified that she didn't need orders to provide oxygen and warmth to the infant and that she did provide both. She also told Shaw that she would not obey his orders. At the hearing Respondent testified that she did obey the orders she received from Shaw relating to getting equipment for the infant.
Nursing procedures require nurses to follow doctors' orders. If the order is patently erroneous, or if the nurse believes the order to be wrong, it is appropriate for the nurse to delay carrying out the order while a supervisor is called to the scene. The evidence was unrebutted that orders given by a doctor not on the scene may be modified by the nurse when a crisis situation, not anticipated by the off-scene doctor, arises. Pursuant to this principle, when the infant arrived in a crisis condition the infant should have been placed in that part of the nursery providing all the equipment needed rather than in an incubator in isolation. Had an isolette been taken to the isolation section, better care could have been provided for the infant, or the infant could have been placed in an isolette in the observation part of the nursery. On the other hand, isolettes are in a limited supply and, if the infant had died in the isolette (as Respondent apparently thought might happen), the isolette would have to be "sunned" which consists of placing the isolette in the "sun" for three days after cleaning it before it is again used.
When Dr. Pilapil finally arrived and relieved Shaw, he had the infant placed in an isolette. The infant survived without apparent further difficulty. It is evident that had Dr. Pilapil been at the nursery when the premature infant arrived the events leading to the charges here being considered would not have occurred. When the infant did arrive Respondent accurately relayed the infant's symptoms to Dr. Pilapil. Had he come to the nursery then, this hearing would not have been necessary.
Shaw reported the incident to Dr. Caltenco, an obstetrician on the staff at Polk General, who told Shaw to write down the events as he recalled them. Caltenco advised the hospital authorities of the incident. Respondent called Juanita Lott, R.N., assistant director of nursing at Polk General, at her home to tell her of the incident and that she (Respondent) might be in trouble, but did not advise Frances Bass, R.N., the head nurse at obstetrics at Polk General, who was Respondent's supervisor on duty at the time the incident occurred. Ms. Bass learned of the incident while on duty that day and called the Director of Nursing, Laurie McCranie. Ms. McCranie told Ms. Bass to submit what she knew in writing, have Respondent do the same thing and present these statements to her when she arrived at the hospital on Monday. At a meeting among Respondent, Ms. McCranie, and others involved in the incident of August 21, 1983, Respondent admitted to Ms. McCranie that she had told Shaw she would not follow his orders and that she would not follow the orders of anyone in the pediatrics ward who was not a pediatrician. When Respondent persisted in her position that she had done nothing wrong and would do the same thing again in similar circumstances, despite being warned that such persistence would result in her discharge from employment at Polk General Hospital, Respondent's employment was terminated.
Respondent is an excellent clinical nurse, well versed in nursing practices and procedure and was considered to be an excellent member of Polk General Hospital's nursing staff before the August 21, 1983, incident. In her exit evaluation (Exhibit 6) Respondent received the highest mark on the form (Excellent) but for block 5 -- ability to get along with others -- in which she was marked "good."
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties to, and the subject matter of, these proceedings.
Each of the counts of the Administrative Complaints charge Respondent with unprofessional conduct in violation of Section 464.018(1)(f), Florida Statutes, which provides:
Unprofessional conduct, which shall include, but not be limited to, any departure from, or the failure to conform to, the minimal standards of acceptable and prevailing nursing practice, in which case actual injury need not be established.
Here, the burden is upon Petitioner to prove the charges alleged. Balino v. Department of Health and Rehabilitative Services, 348 So.2d 349 (Fla. 1st DCA 1977). The quality of the evidence required to sustain this burden has been variously described before and after the present Administrative Procedure Act was passed. In Reid v. Florida Real Estate Commission, 188 So.2d 846 (Fla. 2d DCA 1966) the court concluded that an action to revoke a license was penal in nature and that penal sanctions should be directed only towards those who by their conduct have forfeited their right to the privilege [of licensure] and then only upon clear and convincing proof of substantial causes justifying the forfeiture of license. Accord, Lewis v. Planned Financial Services, 340 So.2d 941 (Fla. 4th DCA 1976).
In Florida Department of Health and Rehabilitative Services v. Career Service System, 289 So.2d 412 (Fla. 4th DCA 1974), the court held that an administrative tribunal measures proof presented to it by the preponderance of the evidence standard. That case involved the quantum of evidence required to discharge an employee for cause. This case and others of similar input seriously undercut Reid, supra.
Florida Department of Transportation v. JWC Corporation and Department of Environmental Regulation, 396 So.2d 778 (Fla. 1st DCA 1981) involved the burden of proof in a petition by the Department of Transportation for a permit from DER to construct a complex source of air pollution. In this case the court upheld the standards established by Rule 17-1.59, Florida Administrative Code, for permit proceedings involving DER which provides "The person requesting the hearing, variance, license, or other relief, shall have the burden of proof to establish, by a preponderance of the evidence, entitlement to the requested license, variance, or other relief."
Bowling v. Department of Insurance, 394 So.2d 165 (Fla. 1st DCA 1981) involved a proceeding to revoke the license of an insurance agent. In retreating from the preponderance of the evidence standard without adopting the clear and convincing evidence standard, the court stated at p. 171-2:
Although the APA does not in terms descend to such particulars, we have recognized the Act's implication that evidence 'appropriate in form' may differ from one proceeding to another depending on the 'nature of the issues involved.' Now we recognize also that in both form and persuasiveness evidence may 'substantially' support some types of agency action, yet be wanting as a record foundation for critical findings in a license revocation. So holding, we need not attempt to resurrect the pre-APA 'clear and convincing proof' standard for license revocation proceedings. Rather, we glean a requirement for more substantial evidence from the very nature of the license discipline proceedings: when the standards of conduct to be enforced are not explicitly fixed by a statute or rule, but depend upon such debatable expressions as 'in the applicable regular course of business'; when the conduct to be assessed is past, beyond the actor's power to conform it to agency standards announced prospectively; and when the proceedings may result in the loss of a valuable business or professional license, the critical matters in issue must be shown by evidence which is indubitably as 'substantial' as the consequences.
The United States Supreme Court has approached the burden of proof standards as a constitutional due process issue.
Addington v. Texas, 441 U.S. 426, 99 S.Ct. 1804 (1979), involved the standard of proof required to commit an individual involuntarily for an indefinite period to a state mental hospital. The court stated at p. 1308:
The function of standard of proof, as that concept is embodied in the Due Process Clause and in the realm of fact finding, is to 'instruct the fact-finder concerning the degree of confidence our society thinks it should have in the correctness of factual conclusions for a particular type of adjudication.' In re Winship, 397 U.S. 358, 370, 90 S.Ct. 1068, 1076, 25 L.Ed. 2d 368
(1970) (J. Harlan concurring). The standards serve to allocate the risk of error between the litigants and to indicate the relative importance attached to the ultimate decision.
Generally speaking, the evolution of this area of law has produced across a continuum three standards or levels of proof for different types of cases. At one end of the spectrum is the typical civil case involving a monetary dispute between private parties.
Since society has a minimum concern with the outcome of such private suits, plaintiff's burden of proof is a mere preponderance of the evidence. The litigants thus share the risk of error in roughly equal fashion.
In a criminal case, on the other hand, the interests of the defendant are of such magnitude that historically and without any explicit constitutional requirement they have been protected by standards of proof designed to exclude as nearly as possible the likelihood of an erroneous judgment. In the administration of criminal justice, our society imposes almost the entire risk of error upon itself. This is accomplished by requiring under the Due Process Clause that the state prove the guilt of an accused beyond a reasonable doubt. In re Winship, supra.
The intermediate standard, which usually employs some combination of the words 'clear,' 'cogent,' 'unequivocal,' and 'convincing,' is less commonly used, but nonetheless is 'no stranger to the civil law.' Woodby v. INS, 385 U.S. 276, 285, 37
S.Ct. 483, 488, 17 L.Ed 362 (1966). See
also, McCormick, Evidence Section 320 (1954);
9 J. Wigmore, Evidence Section 2498 (3rd ed. 1940). One typical use of the standard is in civil cases involving allegations of fraud or some other quasi-criminal wrongdoing by the defendant. The interests at stake in those cases are deemed to be more substantial than mere loss of money and some jurisdictions accordingly reduce the risk to the defendant of having reputation tarnished erroneously by increasing the plaintiff's burden of proof. Similarly, this Court has used the 'clear, unequivocal and convincing' standard of proof to protect particularly important individual interests in various civil cases. See e.g. Woodby v. INS, supra, at 285, 37 S.Ct. at 487 (deportation); Chaunt v. United States, 364 U.S. 350, 353, 31 S.Ct. 147, 149, 6 L.Ed. 2d
120 (1960) (denaturalization); Schneiderman v. United States, 320 U.S. 118, 125, 159, 63 S.Ct. 1333, 1336, 1357, 87 L.Ed. 1796 (1943) (denaturalization).
After noticing the function of the legal process is to minimize the risk of erroneous decisions; that commitment for any purpose constitutes a significant deprivation that requires due process protection; that the state has a legitimate interest in providing care to its citizens unable because of emotional disorders to care for themselves; and that the state also has the authority under its police powers to protect the community from dangerous
tendencies of the mentally ill, the court in Addington v. Texas, supra, concluded the middle ground between preponderance of the evidence and beyond a reasonable doubt, viz, "clear and convincing" evidence was required to meet the due process guarantees. Similarly, in Williams v. Williams, 424 So.2d 159 (Fla. 1st DCA 1983), the court held the standard of proof in proceedings for noncriminal involuntary confinement is clear and convincing evidence.
Santosky v. Kramer, 102 S.Ct. 1383 (1982) involved severing the rights of parents to their children upon a finding of permanent neglect. While holding that, before the state may sever completely and irrevocably rights of parents in their natural child, due process requires that the state support its allegation by at least clear and convincing evidence, the court stated at p. 1397:
The extent to which procedural due process must be afforded the recipient is influenced by the extent to which he may be 'condemned to suffer previous loss.' Goldberg v. Kelly,
397 U.S. 254, 262-263, quoting Joint Anti- Facist Committee v. McGrath, 341 U.S. 123, 163, (Frankfurter, J. concurring). Whether the loss threatened by a particular type of proceeding is sufficiently grave to warrant more than average certainty on the part of the fact-finder turns on both the nature of the private interest threatened and the permanency of the threatened loss.
License revocation cases are clearly penal in nature. Vining v. Florida Real Estate Commission, 281 So.2d 437 (Fla. 1973). Furthermore, the consequences of these proceedings can result in the loss of an occupational or professional license for which the licensee has devoted many years to acquire. This is much more than a "money judgment." In an action to revoke a professional license the risk of error from using the preponderance standard is substantial; and the contervailing state interest favoring that standard is comparatively slight. The language in Bowling, supra, above-quoted, that "when the proceeding may result in the loss of a valuable business or professional license, the critical matter in issue must be shown by evidence which is indubitably as 'substantial' as the consequences" is another way of saying what was earlier stated in Matthews v. Eldridge, 424 U.S. 319, 96 S.Ct. 893, 47 L.Ed. 2d 18 (1976), that both the risk of erroneous deprivation of private interests resulting from use of a "fair preponderance" standard and the likelihood that a higher evidentiary standard would reduce the risk must be considered, and, when so considered, the standard of proof that by its very terms demands consideration of the quantity, rather than the quality, of the evidence, may misdirect the fact finder in the marginal case. Santosky v. Kramer, supra.
The reviewing court measures the correctness of the administrative orders under review by competent and substantial evidence standard. Florida Department of Health and Rehabilitative Services v. Career Service System, supra. While that appellate standard does not change, the court in Bowling, supra, has raised the evidentiary standard at the trial level in license revocation proceedings by saying competent and substantial evidence in license revocation proceedings requires more than a preponderance of the evidence.
Weighing the evidence presented by the above standards will not support a finding that Respondent improperly failed to provide emergency life support to the infant or to assist in providing emergency life support. It is
clear that use of an isolette was preferred to the incubator used and Respondent could have had the infant placed in an isolette despite having been old by Dr.
Pilapil to place the infant in an incubator; nevertheless, Dr. Pilapil had directed the baby be placed in an incubator and told Respondent that he would arrive shortly. Respondent should be able to rely on Pilapil's announced early arrival and the fact that she expected such early arrival is supported by the third telephone call she made to him while Shaw was giving the baby cardiac massage. Several expert witnesses testified that two people should be present while cardiac message is being given and it was unprofessional for Respondent to leave Shaw during this period. On the other hand, Respondent testified that she never left Shaw alone, that when she went out for supplies or to call Pilapil she directed someone to remain in the room with Shaw. While it is easy to visualize how a second person can be of assistance while an adult is given CPR, it is a little more difficult to visualize where a third hand can be placed on a
1 lb. 14 ox. premature infant. The evidence is not clear and convincing that Respondent failed to provide or assist in providing life support to the infant.
Applying the same standard of proof to Charge II, the evidence will support a finding that Respondent failed to assist Shaw as much as she should have and that she refused to follow his orders. Respondent acknowledged that she told Shaw she would not follow his orders as he had no authority to give orders in the nursery. This is in the nature of a preemptive strike to eliminate the issuance of orders by declaring they will not be followed if issued. By arguing with Shaw while he was attempting to improve the infant's breathing constitutes a failure to assist.
Count III contains several charges. While the evidence is clear that the infant would have been better off if placed in an isolette in an observation nursery than in an incubator in isolation, it cannot be found to be unprofessional conduct to place the infant where directed by Dr. Pilapil. After placing the infant in the incubator, Respondent called Pilapil and accurately reported the baby's condition upon arrival. If an incubator was not appropriate for such a patient, Dr. Pilapil should have so advised Respondent when this call was made to him.
With respect to the charge of interrupting life support being given in order to weight the infant, Shaw's testimony is that weighing the baby did not interrupt any care he was giving (Exhibit 1, pp 40-41). Respondent testified she weigh the baby to help obtain the gestational age when Shaw requested the gestational age; and when she returned the baby to the incubator, Shaw resumed chest compressions. This indicates life support was interrupted, albeit at the instigation of Dr. Shaw. This evidence will not support a finding of unprofessional conduct of this charge.
Finally under Charge III is the allegation that Respondent failed to accurately report the condition of the infant to Dr. Pilapil. The evidence, to the contrary, clearly shows that the condition of the infant was correctly reported to Dr. Pilapil by Respondent.
From the foregoing it is concluded that Respondent refused to follow Dr. Shaw's orders on August 21, 1983, and that this constituted unprofessional conduct in violation of Section 464.018(1)(f), Florida Statutes, as alleged and that she is not guilty of all other charges.
It is noted that Respondent was considered to be an excellent nurse by all of her supervisors at Polk General Hospital before the incident of August 21, 1983, and that, had she acknowledged error, she would not have been terminated. Had she not been terminated, presumably the charges here considered would not have been proffered.
The evidence was clear that there was more than a little doubt among the nursing staff at Polk General Hospital regarding the authority of any doctor, other than a pediatrician, to give orders in the nursery. This concept was sufficiently pervasive to cause the hospital administrators to promptly promulgate two directives immediately after August 21, 1983, (Exhibits 3 and 4) to correct this misconception. If a full-fledged member of the staff didn't have authority to give orders in the nursery, what authority could a resident, two months out of medical school, have? With this background the offense is not as heinous as it might otherwise be. It is therefore
RECOMMENDED that the license of Deborah K. Grove be suspended for a period of 60 days and that she be placed on probation for two years.
ENTERED this 23rd day of April 1985 in Tallahassee, Florida.
K. N. AYERS Hearing Officer
Filed with the Clerk of the Division of Administrative Hearings this 23rd day of April 1985.
Julia P. Forrester, Esquire Department of Professional Regulation
Rodney W. Smith, Esquire Post Office Box 628 Alachua, Florida 32615
DPR Case No. 0040067
vs. DOAH Case No. 84-1421
DEBORAH K. GROVE, R.N.,
Respondent.
Respondent, DEBORAH K. GROVE, holds Florida License Number 1230282 as a registered nurse. Petitioner filed an Administrative Complaint seeking suspension, revocation, or other disciplinary action against the license.
Respondent requested an informal hearing, which was terminated upon agreement of the parties that disputed facts were material. The cause was remanded for formal hearing, which was duly held before the Division of Administrative Hearings. A Recommended Order has been forwarded to the Board pursuant to Section 120.57(1), Florida Statutes; it is attached to and made a part of this Order.
The Board of Nursing met on May 30, 1985, in Jacksonville, Florida, to take final agency action. The Petitioner was represented by William Furlow, Esquire. The Respondent was present and represented by Rodney W. Smith, Esquire. The Board has reviewed the record in the case, including the transcript and exhibits.
The Board accepts and adopts the Findings of Fact contained in the Recommended Order.
The Board accepts and adopts the Conclusions of Law contained in the Recommended Order except for the Hearing Officer's conclusion that Respondent violated Section 464.018(1)(f), Florida Statutes, for unprofessional conduct based on Respondent's refusal to follow resident Dr. Shaw's orders. The Board's rejection of this conclusion is based upon: The evidence of the hospital policy that only pediatricians were authorized to give orders in the nursery; that Respondent followed the orders of Dr. Pilapil, a pediatrician; and that, as a resident, Dr. Shaw was not authorized to give orders in the nursery.
Based on the foregoing, it is hereby ORDERED that the Administrative Complaint be and the same is hereby DISMISSED.
Pursuant to Section 120.59, Florida Statutes, the parties are hereby notified that they may appeal this final order by filing one copy of a Notice of Appeal with the clerk of the Department of Professional Regulation, and by filing the filing fee and one copy of a Notice of Appeal with the District Court of Appeal within thirty days of the date this Order is filed.
This Order shall become effective upon filing with the clerk of the Department of Professional Regulation.
DONE AND ORDERED this 15th day of July, 1985.
Sandra S. Bauman, Chairman Florida Board of Nursing
I HEREBY CERTIFY that a true and correct copy of the foregoing Order has been sent to DEBORAH KAY GROVE, 813 Glendale Street, Lakeland, Florida 33803, at or before 5:00 p.m., this 15th day of July, 1985, by U.S. Mail.
