STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF PROFESSIONAL ) REGULATION, BOARD OF NURSING, )

)

Petitioner, )

)

vs. ) CASE NO. 91-4825

)

PAIGE CHRISTOPHER, )

)

Respondent. )

)

RECOMMENDED ORDER

Pursuant to notice, a formal hearing was conducted in this case on April 10, 1992, in Key West, Florida, before J. Stephen Menton, a duly designated Hearing Officer of the Division of Administrative Hearings.

APPEARANCES

For Petitioner: Roberta L. Fenner, Esquire

Department of Professional Regulation 1940 North Monroe Street

Tallahassee, Florida 32399-0792

For Respondent: Lynn Hankins-Fielder, Esquire

Browning, Guller and Associates, P.A.

402 Applerouth Lane, Suite 10 Key West, Florida 33040

STATEMENT OF THE ISSUE

The issue in this case is whether the nursing license of Respondent, Paige Christopher, should be revoked or otherwise penalized based on the acts alleged in the Administrative Complaint.

PRELIMINARY STATEMENT

On May 24, 1991, the Department of Professional Regulation (the "Department") issued a two-count Administrative Complaint against Respondent. The allegations of the Administrative Complaint focus on the Respondent's treatment of a patient hereinafter referred to as H.S. or the "Patient". The Department alleged that Respondent was guilty of unprofessional conduct in her treatment of H.S. in violation of Rule 21 O-10.005(1)(e)(1), Florida Administrative Code, and Section 464.018(1)(h), Florida Statutes. Specifically, the Department charged that (1) Respondent failed to keep accurate patient records for H.S. and (2) Respondent's treatment of H.S. was below minimally acceptable standards and prevailing nursing practices. Respondent disputed the factual allegations set forth in the Administrative Complaint and requested a formal administrative hearing. The case was referred to the Division of

Administrative Hearings which noticed and conducted a hearing pursuant to Section 120.57, Florida Statutes.

The case was scheduled for hearing on April 10, 1992 in Key West, Florida.

On March 30, 1992, Petitioner filed a Motion to Abate and a Motion to Amend. Attached to the Motion to Amend was a proposed Second Amended Administrative Complaint. A telephone conference hearing was held in connection with both motions on April 1, 1992. As set forth in an Order entered on April 1, 1992, the Motion to Abate was denied, the Motion to Amend was granted and the Second Amended Administrative Complaint was accepted. The Second Amended Administrative Complaint alleged violations of the same statutory and rule provisions that were set forth in the initial Administrative Complaint, but modified somewhat the factual allegations that were the basis for the charges. Respondent did not seek a continuance of the April 10 hearing as a result of the filing of the Second Administrative Complaint and, in fact, Respondent opposed Petitioner's request to place the case in abeyance pending further review of the matter by the Probable Cause Panel.

At the hearing, Petitioner presented the testimony of five witnesses: Douglas Brown, the Administrator of the Key West Convalescent Center (the "KWCC"); Joan Slack, R.N., the Director of Nursing at the KWCC; Martin Elliot, R.N., currently employed as Assistant Vice President for Patient Care Services at Health Systems of Key West and formerly the temporary Director of Nursing at KWCC; Terry Trent, R.N., formerly the Assistant Director of Nursing at KWCC; and Stephanie Beckrow, L.P.N., formerly employed as a Supervisor of Nursing at KWCC.

Petitioner offered six (6) exhibits into evidence at the hearing, all of which were accepted into evidence during the hearing except Petitioner's Exhibit

5 which is discussed below. Petitioner's Exhibit 7 is the deposition testimony of Nancy Cox who was an expert witness retained by Petitioner. Petitioner submitted this deposition as a late-filed exhibit. It is accepted into evidence in accordance with a ruling made during the hearing.

Petitioner's Exhibit 1 was a copy of the medical records for the Patient from Florida Keys Memorial Hospital from January 21, 1990 through February 5, 1990. Petitioner's Exhibit 2 was a copy of the records from the hospitalization of the Patient at DePoo Memorial Hospital from December 29, 1989 through January 10, 1990. Petitioner's Exhibit 3 was a copy of the Patient's records from KWCC. Portions of these records were admitted as Respondent's Exhibits. At the hearing, Respondent did not object to the introduction of all of the Patient's records, but expressed a desire to confirm whether the records were accurate and/or complete. The documents were made available to Respondent for comparison. No objection to the accuracy or completeness of the documents has been raised.

Petitioner's Exhibit 5 is a curriculum vitae for Nancy Cox, an expert witness whose deposition was offered by Petitioner. Respondent objected to the introduction of this resume because it was apparently an updated version of a resume previously provided to Respondent. Respondent claims that this updated version was not provided to her prior to the time of the deposition testimony of the witness. A review of the transcript of the testimony of the witness indicates some confusion as to whether the updated version had been provided to Respondent. Petitioner agreed to furnish a copy of the "updated" resume to Respondent. However, it does not appear that a copy of the "updated" resume was provided to counsel for Respondent until the commencement of the hearing.

Respondent did not have an opportunity to cross-examine the witness regarding the "updated" resume. Accordingly, Petitioner's Exhibit 5 is hereby rejected.

Petitioner's Exhibit 6 was a copy of medical records for the Patient at Florida Keys Memorial Hospital from April 3, 1984 through April 9, 1984. These documents were reviewed by Petitioner's expert and considered in the formulation of her expert testimony. Respondent objected to the introduction of these documents into evidence on the grounds that they had not previously been disclosed by Petitioner. Petitioner contends that these records were provided by Respondent. However, Respondent denied ever seeing the records let alone providing them to Petitioner. The documents were marked for the purpose of establishing the documents relied upon by Petitioner's expert. The parties were granted the opportunity to present further argument regarding the admissibility of these records in their post-hearing submittals. Neither party has provided any additional information regarding these documents in their post-hearing submittals. It is noted that, prior to the hearing, the parties stipulated to the authenticity of the Patient's records from the hospital. Respondent had an opportunity to review the records and no objection has been raised as to the authenticity of the records. After consideration of all the circumstances presented, it is concluded that the prehearing stipulation should apply to Petitioner's Exhibit 6 and the documents are accepted.

At the hearing, Respondent presented the testimony of two additional witnesses: Robert D. Carraway, M.D., who testified as a fact witness and was allowed to offer opinion testimony regarding the treatment and monitoring of geriatric diabetic patients; and Louise Stewart, R.N., who was accepted as an expert in nursing care and procedures for geriatric patients. Respondent also recalled Joan Slack.

Respondent had thirty three (33) exhibits marked for identification during the course of the hearing, all of which were accepted into evidence. The deposition of Dahna Schaublin, who is employed as an investigator by Petitioner, was submitted as a late-filed exhibit and has been marked as Respondent's Exhibit 34. It is hereby accepted in accordance with a ruling made during the hearing.

A transcript of the proceeding has been filed. Both parties have submitted proposed recommended orders. On July 16, 1992, Respondent filed a Motion to Strike Petitioner's Proposed Recommended Order. Petitioner filed Petitioner's Response to Motion to Strike on July 22, 1992. After reviewing the Motion and the Response thereto, Respondent's Motion to Strike is denied and Petitioner's Proposed Recommended Order has been reviewed and considered in the preparation of this Recommended Order. A ruling on each of the parties' proposed findings of fact is included in the Appendix to this Recommended Order.

On January 29, 1993, counsel for Respondent filed a Motion to Withdraw as Respondent's Counsel. That Motion represents that irreconcilable differences have arisen between counsel and Respondent. Good cause having been shown and no opposition having been stated, the Motion to Withdraw is granted provided that counsel shall provide Respondent with a copy of this Recommended Order at her last known address.

FINDINGS OF FACT

Based upon the oral and documentary evidence adduced at the final hearing and the entire record in this proceeding, the following findings of fact are made:

1. At all times pertinent to this proceeding, the Respondent was a registered nurse in the State of Florida having been issued license number RN 1943882. Respondent has been a registered nurse since 1988. No evidence of any prior disciplinary action against Respondent was presented.

   
   

2. KWCC is a convalescent center that provides skilled nursing care for residents who can no longer live without custodial care. Most of the residents of a convalescent center such as KWCC spend the rest of their lives in the convalescent center.

   
   

3. At all times pertinent hereto, Respondent was employed at KWCC. She began working at KWCC around the beginning of 1989. She was assigned to work the 7 a.m. to 3 p.m. shift.

   
   

4. During the pertinent period, the patients at KWCC were divided into four care groups on two floors. Each group had approximately 30 patients. Typically, anywhere from 3 to 7% of the KWCC patient population during the pertinent time period were diabetic. During the 7 a.m. to 3 p.m. shift, four nurses were on duty with one assigned to each care group. There was also a nursing supervisor on each floor who oversaw two care groups. During the period from January 10-January 21, 1990, Respondent was providing nursing care at KWCC for Patient Group 4. One of the patients in this Group during this time period was H.S.

   
   

5. In January of 1990, H.S. was 83 years-old with diabetes militis. He was also diagnosed as having diabetic neuropathy, hemiparesis from a previous stroke and senile dementia.

   
   

6. H.S. was initially admitted to KWCC on April 17, 1989.

   
   

7. When the Patient was first admitted to KWCC in April of 1989, he was able to ambulate on his own, but he moved very slowly. The Patient was initially admitted to KWCC for physical therapy, gait training and rehabilitation of weakness caused by a stroke. While he was at KWCC, the Patient fell on several occasions. He progressively became more and more bedridden.

   
   

8. As part of the KWCC admission records, a physician diagnosed H.S. with "diabetes, insulin dependent" and ordered insulin and micronase.

   
   

9. Diabetes militus refers to the metabolic disorder which results from the disturbance of the body's insulin mechanism. Insulin controls and modulates the body's use of glucose. Glucose is the fuel that provides energy for the metabolic processes in the body. Glucose cannot be used in the blood stream, it can only be used in the body cells. Insulin aides in the transport of glucose into the cells. In the normal condition, a body produces sufficient amounts of insulin to control glucose metabolism. The lack of the appropriate amount of insulin and/or a resistance to the effects of insulin can create certain metabolic problems.

   
   

10. Micronase is an oral agent that prompts the body's production of insulin. Diabetics who are unable to produce sufficient amounts of insulin are sometimes treated with exogenous insulin.

    
    

11. There was conflicting and confusing evidence presented as to when an individual is appropriately referred to as an insulin dependent diabetic. The more persuasive evidence indicates that the term insulin dependent diabetic (or

    "IDDM") is sometimes loosely used by medical professionals to refer to any diabetic who is taking exogenous insulin.

    
    

12. While there is an apparent lack of conensus as to the characteristics of and/or relationship between different forms of diabetes militis, the evidence established that the disorder is often classified by medical practitioners according to type. There are essentially two types of diabetes pertinent to this case: Type I diabetes, sometimes referred to as juvenile on-set diabetes, usually refers to a condition where there is an absolute loss or complete lack of insulin. Individuals with Type I diabetes are necessarily insulin dependent diabetics who will quickly decompensate and go into diabetic ketoacidosis without insulin. Type II diabetes, sometimes called adult on-set diabetes, refers to a condition where there is a relative lack of insulin or a lack of sensitivity to the endogenous insulin that the individual has.

    
    

13. Type II diabetics do not necessarily need exogenous insulin to survive. They can sometimes be treated with oral medications that prompt or facilitate the body's production of insulin. On the other hand, exogenous insulin can sometimes be the easiest and most appropriate way to control a Type II diabetic's high blood sugars. In other words, exogenous insulin can sometimes facilitate a Type II diabetic's management and treatment. In all cases, proper control of diabetes requires a balance between the medications used, the level of activity and rest, and the amount of food ingested.

    
    

14. Some experts consider Type I and Type II to be two different diseases. In fact, there is some indication that Type II diabetics have different genetic make-ups than Type I diabetics. The two types generally appear at different times of life and have different implications as to long term survival and complications. As noted below, in several instances the Patient was referred to in various medical records as "insulin dependent" or "IDDM". Petitioner has suggested that these references establish that the Patient was a Type I diabetic who absolutely could not survive without insulin. Notwithstanding these references, the more persuasive evidence in this case established that H.S. had Type II diabetes militis because his body was producing some insulin.

    
    

15. Dr. Robert Carraway treated the Patient from approximately 1983 through 1988. At the time he first saw the Patient in 1983, H.S. had already experienced 3 to 4 years of elevated blood sugar levels without treatment. Dr. Carraway diagnosed the Patient as a non-insulin dependent diabetic.

    
    

16. From 1983 through 1988, Dr. Carraway saw the Patient an additional 10 to 12 times and treated him for diabetes and for a hospital admission in 1984 related to a stroke.

    
    

17. Initially, Dr. Carraway treated the Patient's diabetes with a non- medicinal therapy of diet and exercise. Shortly after he began seeing the Patient, Dr. Carraway started H.S. on a small dose of insulin (10 units per day compared to the normal pancreas output of 35 to 40 units per day.) According to Dr. Carraway, even though the Patient was receiving insulin, he was not insulin dependent. The Patient could have been and was taken off insulin by his physicians when they deemed it appropriate. For example, on one occasion in 1988, Dr. Carraway discontinued insulin for the Patient for approximately three weeks and ordered an oral diabetic agent instead.

    
    

18. For most of the time H.S. was treated by Dr. Carraway, he was treated with small, supplementary doses of insulin. The Patient continued on low doses of insulin off and on until his death. On various occasions, the Patient

    demonstrated a sensitivity to exogenous insulin which caused him to become hypoglycemic.

    
    

19. Hypoglycemia refers to a condition of low blood sugar. Usually this term is used in connection with a blood sugar level that is low enough to result in mental or neurological symptoms when the brain is deprived of a glucose load or a glucose level. An episode of hypoglycemia can result in permanent brain damage and/or could cause a person to pass out and injure himself. A hypoglycemic episode can ultimately progress to the point where the person becomes comatose because there is not enough glucose for brain metabolism.

    
    

20. Hyperglycemia refers to a condition of excessively high blood sugars. The warning signs for hyperglycemia include dehydration as the elevated blood glucose pulls fluid out of the cells. Hyperglycemia can result in severe derangement of mental and neurological functions when the brain becomes dehydrated. Other complications of hyperglycemia are blindness, neuropathy, atherosclerosis and kidney disease.

    
    

21. Hypoglycemia is usually a more immediate medical emergency than hyperglycemia. Hyperglycemia usually develops over a longer period of time as dehydration with its resulting problems sets in.

    
    

22. A brittle or labile diabetic is one whose blood glucose level fluctuates widely and drastically between hypo and hyperglycemia without cause. This fluctuation can occur even when the diabetic is receiving proper treatment. Consequently, a brittle or labile diabetic's blood glucose level is usually difficult to control. Brittle or labile diabetics are more susceptible to insulin shock, a situation where even small doses of insulin can cause the blood sugar to drop to a level that is not sufficient to carry on normal and appropriate body metabolism.

    
    

23. In a normal situation, an individual's blood sugar level should range between 65 to 110. For an elderly patient who is a brittle or labile diabetic, higher blood sugar levels are acceptable because attempts to tightly control blood sugar levels within a lower range can result in hypoglycemic episodes which can be far more dangerous and/or injurious. This is especially true for a patient, such as the one in this case, who is sensitive to insulin.

    
    

24. The evidence did not conclusively establish the extent to which Respondent was involved with the care of the Patient prior to January 10, 1990. The nursing notes do reflect some entries by Respondent during the period from April through December, 1989. Respondent attended at least one intradisciplinary care plan conference for H.S. at KWCC on November 27, 1989 where the possibility of diabetes complications and problems related to the high risk for blood sugar complications for the Patient were identified. The nursing approaches and actions discussed included monitoring for signs and symptoms of hypoglycemia.

    
    

25. On December 29, 1989, H.S. was transferred from KWCC to DePoo Hospital with respiratory distress, bilateral edema and fever.

    
    

26. The Patient was hospitalized at DePoo from December 29, 1989 until January 10, 1990. He was described by his physician on admission to DePoo as a "brittle diabetic", which, as indicated above, means that he fluctuated between hypo and hyperglycemia.

27. The Patient's final diagnosis on discharge from DePoo was "septicemia, pneumonia, labile diabetes-insulin dependent with hypoglycemia, stroke with left hemiparesis, and urinary retention."

    
    

28. During the Patient's hospitalization at DePoo from December 29, 1989 through January 10, 1990, he was treated for pneumonia which was apparently resolved prior to his discharge.

    
    

29. During this hospital stay, the Patient's blood glucose levels were frequently tested and the Patient demonstrated a very labile course. The Patient had at least two occasions of marked hypoglycemia. The hypoglycemic episodes occurred even though his blood sugar level was being monitored frequently. The wide fluctuations in the Patient's blood sugar levels during this hospitalization appeared to be due to his condition as opposed to any errors in his treatment.

    
    

30. Prior to his hospitalization on December 29, 1989, H.S. had been receiving insulin. Because of the hypoglycemic episodes that H.S. experienced during his hospital stay, his attending physicians reduced the amount of insulin given to the Patient. On January 7, 1990, Dr. Calleja 1/ noted "will discontinue insulin temporarily." Although the doctor's notation indicated that the insulin was being discontinued "temporarily", there is no evidence that it was ever reinstated by Dr. Calleja or any other physician treating the Patient.

    
    

31. Because of the hypoglycemic episodes that occurred while the Patient was hospitalized at DePoo, it was medically acceptable to discontinue the Patient from insulin and start him on an oral hypoglycemic agent, Micronase.

    
    

32. On several occasions in the hospital records and in the physician's notes, the Patient was referred to as "IDDM", which, as noted above, stands for insulin dependent diabetes militis. Some of these entries were made by the physicians even after insulin had been discontinued. This reference was apparently premised on the Patient's prior history of taking insulin. The Patient was actually suffering from Type II diabetes militis and did not necessarily need insulin even though he had been taking insulin in the past.

    
    

33. As noted above, the evidence presented in this case suggests that there is no conclusive standard for using the terms "IDDM" or "insulin dependent diabetes". Generally, the terms are used with respect to an individual diabetic who is currently on insulin.

    
    

34. Even before the Patient was admitted to DePoo on December 31, 1989, he was suffering from some neurological impairment. He had a stroke in 1984, his medical records reflect some left facial weakness from at least 1988 and a CAT scan in 1989 showed evidence of a possible prior stroke and dilation of the ventricles which would be consistent with the chronic process of multiple small strokes or degeneration of the central nervous system to the point where the brain matter was slowly wasting and was slowly contracting and deteriorating. The hypoglycemic shock episodes the Patient experienced during his hospitalization at DePoo may also have contributed to the neurological damage that was evidenced on his later admission to Florida Keys Memorial on January 21, 1990.

    
    

35. On January 10, 1990, H.S. was discharged from DePoo and readmitted to KWCC. Shortly before the Patient's discharge, his blood sugar level was 207.

36. Upon his readmission to KWCC, the Patient was placed in Care Group 4 to which Respondent was assigned. As discussed in more detail below, he remained in Care Group 4 until January 21, 1990.

    
    

37. Respondent worked on January 10 through 12, she was off January 13 through 15, returned to work on January 16 through 18, was off on January 19 and worked on January 20 through 21. No evidence was presented to establish that Respondent should have questioned the care or monitoring of the Patient during the times that she was not working.

    
    

38. The physician's orders that accompanied the Patient upon his discharge from DePoo Hospital and his readmittance to KWCC specifically provided "d- c[discontinue] all previous medication orders see new med orders as follows:. .

    ." Those orders set forth several medications to be given to the Patient including micronase. The new orders did not include insulin. Respondent signed the form that contained the physician's orders on January 10, 1990. She noted the physician's orders and recorded them in the Patient's records. She wrote "DC 1/10/90" next to the Patient's prior medication orders including the prior order for insulin to be given every morning. During the course of Petitioner's investigation and at the hearing in this case, it was suggested that the deletion of an order for insulin for the Patient upon his return to KWCC on January 10, 1990 was an oversight which should have been detected by Respondent. The evidence did not support this conclusion. The evidence established that there was a deliberate decision by the Patient's physician to discontinue insulin which was properly noted by Respondent. Whether and/or when insulin should have been reinstated was not clearly established.

    
    

39. All of the nurses who were caring for H.S. at KWCC were aware that, upon his return on January 10, 1990, his insulin orders had been discontinued.

    
    

40. Upon the Patient's return to KWCC on January 10, 1990, Respondent documented his condition and noted that he had a decubitis and alerted her supervisor of this condition.

    
    

41. Respondent contends that the blood sugar level of a diabetic, even a non-insulin dependent diabetic, should be checked at least four times a day with either a glucometer or a urine dipstick. The more persuasive evidence established that, while monitoring of diabetic patients is essential, glucometer testing and urine dipsticks do not always give accurate readings. When a glucometer or urine dipstick is not used, nurses must be particularly cognizant of changes in a diabetic's condition. Close monitoring of a diabetic is especially necessary if the patient's blood sugar level has been unstable. If a diabetic patient quits eating or his food intake changes significantly, his activity level changes, his vision becomes impaired, he becomes confused or dizzy or he has a fever, the need to monitor the patient becomes greater.

    
    

42. From January 10, 1990 through January 21, 1990, neither Respondent nor any of the other nurses at KWCC used a glucometer or a urine dipstick to monitor the Patient's glucose level.

    
    

43. Previously, for approximately one month in June of 1989, a glucometer was used by the staff at KWCC pursuant to a physician's orders to monitor the Patient's blood sugar levels. These glucometer tests were discontinued in June of 1989, apparently because the fasting blood sugar tests, which are considered more accurate, reflected different results than the glucometer tests.

44. There were no physician orders for glucometer testing of the Patient other than as noted above. After the glucometer test order was discontinued in June of 1989, the Patient's physician ordered monthly fasting blood sugar tests.

    
    

45. It appears that on at least one subsequent occasion, a KWCC nurse used a glucometer without a physician's order to test the Patient's blood sugar level. The glucometer result was compared with a fasting blood sugar test and a discrepancy was found thereby indicating that the glucometer was not giving an accurate reading for this Patient.

    
    

46. During January of 1990, KWCC had a glucometer available for use by the nurses to check the glucose level of patients. While glucometers are often used by diabetics in their homes to test their blood sugar levels, glucometer results are not always dependable and a glucometer should not be used in place of more accurate fasting blood sugar tests.

    
    

47. Respondent was never given any training on how to use a glucometer. The KWCC personnel manual required a nurse to be trained in the use of the glucometer before using the instrument. Notwithstanding this requirement, the evidence established that some of the nurses at KWCC used the glucometer without any formal training. They simply read the directions.

    
    

48. In January of 1990, KWCC had urine dipsticks available to test urine glucose and urine ketones. A urine dipstick is a chemical strip that is dipped in the urine to determine the amount of either sugar or ketone bodies in the urine. This test is very useful for monitoring the condition of a diabetic. When the blood glucose level exceeds the threshold of the kidneys, glucose is spilled into the urine indicating a hyperglycemic state. Similarly, ketones in a patient's urine can confirm that the body is breaking down fats as opposed to glucose. Upon his return to KWCC, the Patient had an indwelling Foley catheter. Thus, it would have been very easy to monitor the Patient's blood sugar levels with a urine dipstick. The evidence did not clearly establish why urine dipsticks were not used to monitor the Patient's blood sugar levels. There are some indications that the Patient had a high renal threshold. Therefore, a urine dipstick would not have always detected a moderately high blood sugar level for this Patient. Nevertheless, this condition did not render the urine dipstick useless as a monitoring tool for this Patient. The test could still reflect extremely high blood sugar levels and/or ketones.

    
    

49. When the Patient returned to KWCC from DePoo on January 10, 1990, the physician orders provided "continue all other orders" except where specifically noted. The physician's orders did not require periodic glucometer testing or any other specific blood sugar monitoring. The nurses properly interpreted this order to require a continuation of the monthly fasting blood sugar tests.

    
    

50. Even though there was no physician's order in January, 1990 for glucometer or urine dipstick testing of the Patient, the use of these monitoring tools is a nursing prerogative which does not necessarily require a physician's order.

    
    

51. After his return to KWCC on January 10, the Patient was often lethargic and usually did not eat well.

    
    

52. Theresa Trent was the Assistant Director of Nursing at KWCC. She was also the floor supervisor for the second floor where Care Group 4 was located. Ms. Trent was on vacation from January 9 through January 17, 1990. She returned to work on January 19, 1990. She did not work on Saturday, January 20 or

    Sunday, January 21. Thus, Respondent's usual supervisor was only on duty one day (January 19) during the pertinent time period (January 10-21.)

    
    

53. On January 12, 1990, Respondent noted that H.S. had "fruity" smelling breath. Fruity smelling breath can be a sign of ketoacidosis (also referred to as ketotic acidosis), which is the breakdown of fats as opposed to glucose by the body. Ketones are symptomatic of severe hyperglycemia. Generally, a patient would need a blood glucose level of 500 or 600 before he would be in ketoacidosis. The patient would usually not live more than twelve to twenty four hours after being in full bloom ketoacidosis unless he was specifically treated. Fruity smelling breath does not necessarily mean that a patient is in ketoacidosis. The evidence in this case did not establish that the Patient's "fruity" smelling breath had any direct relationship to his diabetic condition.

    
    

54. Respondent notified her supervisor and the Patient's physician of the fruity smelling breath she observed on January 12 and she also alerted them that the Patient was lethargic and eating very little. As a result of Respondent's observations, the physician ordered that the Patient be started on tube feedings of Jevity. A naso-gastric ("NG") tube was inserted during the afternoon shift of January 12 and the tube feedings were started at 75 cc per hour on a continuous pump. The tube feedings continued throughout the Patient's stay at KWCC.

    
    

55. Jevity is a strong glucose solution. When given to a diabetic, it can cause a rapid rise in the blood sugar which can result in hyperglycemia in the absence of insulin and, sometimes, even when insulin is present. As a result of the tube feedings, the Patient's intake of glucose, which had been low because he was not eating, suddenly increased significantly. In such circumstances, close monitoring of a patient's blood sugar level for possible hyperglycemia was essential.

    
    

56. As a result of Respondent's observations on January 12, the physician also ordered a fasting blood sugar test for January 13, 1990. This test reported the Patient's blood sugar at 188, an acceptable level for an elderly, labile diabetic such as this Patient. No new orders were given by the physician as a result of the fasting blood sugar test. No further blood sugar tests were taken from January 13 until the Patient was admitted to the hospital on January 21.

    
    

57. This January 13 fasting blood sugar test was approximately five days after the Patient had been discontinued from insulin. The results of the test support Respondent's contention that the Patient was not an insulin dependent diabetic. The test results also indicate that the oral medication prescribed for the Patient was working.

    
    

58. The only evidence presented of changes in the Patient's condition from January 13 until January 20 were the nurses' notes and other KWCC records.

    Those notes reflect that on the late evening shift of January 13, 1990, the Patient was talkative and responsive. Subsequent to January 13, the Patient was usually lethargic and subdued.

    
    

59. The nurses' notes indicate that the Patient was running a temperature of 101 on the evening of January 15, 1990. Respondent was not on duty when the Patient's fever was noted, however, the fever was noted in the records and the notation should have alerted Respondent to be especially observant of the Patient's condition.

60. An infection or fever can make a diabetic patient very labile and can alter the patient's insulin need. Consequently, a diabetic patient with a fever must be followed very closely.

    
    

61. When Respondent returned to work on January 16, 1990, she noted the new orders for the Patient including the initiation of tube feedings. She also noted that the Patient's feeding tube was coiled in the back of his throat. She removed it, initiated suction, reinserted the tube and assessed his condition. Petitioner has not alleged that Respondent's actions in this regard were in anyway deficient.

    
    

62. It is possible that when the NG tube was coiled in the back of his throat, the Patient aspirated some of the tube feeding that was infusing at 75 cc's an hour. The evidence on this point was inconclusive. There was no persuasive evidence of any resultant respiratory distress. The Patient was diagnosed with pneumonia at the time of his admission on January 21. However, insufficient evidence was presented to conclude that the pneumonia was in any way related to his treatment at KWCC and/or any actions of the Respondent.

    
    

63. While Respondent sunctioned a large amount of thick sputum from the Patient on January 16, it does not appear that she checked the Patient's temperature. During the evening shift of January 16, the Patient was noted to be running a fever of approximately 101.6. The Patient was also found to have diminished breath sounds in the left lung. The Patient's treating physician, Dr. Swords (incorrectly referred to as "Dr. Sorrens" in the transcript) saw the Patient at KWCC on January 17, 1990. He did not issue any new orders for the Patient on that date. The Patient was still verbally responsive according to the nurses' notes on January 17.

    
    

64. On January 19, 1990, it was noted again that the Patient was running a fever. As noted above, Respondent was not working on this date. Beginning at 1

    a.m. on January 19, the Patient showed very high temperatures. He still responded to verbal stimuli, but was not as responsive as he had been in the past. In other words, his level of consciousness was deteriorating which can be a sign of hyperglycemia. By 9 a.m., he was not verbally responsive at all. By 2:30 in the afternoon, he was showing signs of decreased breath sounds in the right lower lobe. He continued to become more lethargic and nonresponsive. At that time, his temperature was 102.4 rectally. The nurses on duty phoned the Patient's physician and advised him of the Patient's condition. The physician did not order any blood sugar tests. The physician did order Augmentin, an oral antibiotic, for the Patient as a result of the information conveyed to him.

    
    

65. After midnight on the morning of January 20th, his temperature was still up and he was not verbally responsive.

    
    

66. Even though the Patient had been running a fever of 103.6 at midnight, there is no indication of the Patient's temperature during Respondent's morning shift on January 20. Furthermore, the KWCC records indicate that on January 20 the Patient's urine output was 1000 cc's during the 7 a.m. to 3 p.m. shift. However, the Respondent's entry in the nursing notes from that day only noted an output of 100 cc. No explanation was provided for this discrepancy. Decreased urine output can be a sign that the kidneys are failing due to hyperglycemia.

    
    

67. Respondent's nursing notes for January 20 were late entries that were not recorded until after the January 21 notes. The January 20 notes indicate that the Patient opened his eyes when his name was called, but could not verbally respond.

68. By 4 a.m. on January 21, the Patient was showing signs of tachycardia, which means a fast heartbeat, and tachypnea, which means he was breathing too quickly.

    
    

69. At 5 a.m. on January 21, the Patient was still non-verbal and lethargic, and his urine output was minimal. As noted above, the decrease in urine output is a possible sign that his kidneys were failing which may have been related to hyperglycemia.

    
    

70. When Respondent came on duty on the morning of January 21, the nurse's notes from the preceding evening reflected concern regarding the Patient's condition. The Patient's urine output was only 100 cc, he showed only minimal non-verbal responsiveness and his temperature was elevated throughout the night. At 7:30 a.m. on January 21, the Patient's blood pressure was way down and his heart rate and respiratory rate were up as was his temperature. His urinary output was still very low. Respondent notified the Patient's physician and obtained an order to transfer the Patient to Florida Keys Memorial Hospital.

    
    

71. The Patient's condition indicated that he was experiencing complications and warranted his admission to the hospital.

    
    

72. On the transfer form to Florida Keys Memorial Hospital, Respondent noted in the "Diagnosis" section that the Patient was diabetic, had mononeuropathy with left arm weakness and that he had suffered a prior stroke. In the "Comments" section of the form, Respondent noted that the Patient was "NIDDM" [which means non-insulin dependent diabetes militis] does take Micronase, has not rec'd A.M. dose."

    
    

73. Upon admission to Florida Keys Memorial Hospital, H.S.'s blood sugar was 1,420. H.S. was diagnosed as being in a diabetic coma and as having "poorly controlled diabetes, insulin dependent" and pneumonia. At the time of his admission, he was only responding to painful stimuli. He was immediately given insulin.

    
    

74. When the Patient was admitted to the hospital, he had decubitis ulcers, which indicate that he had been relatively immobile for some period of time.

    
    

75. During the Patient's hospitalization at Florida Keys Memorial which began on January 21, 1990, his pneumonia was resolving and his blood sugar was brought to within an acceptable range. However, the Patient's neurological condition never improved due to a combination of neurological impairment and deterioration and his physicians determined that aggressive medical care was no longer appropriate. On or about January 30, 1990, an agreement for withdrawal of life support regarding the Patient was obtained and, on or about February 5, 1990, the Patient expired. The final diagnosis was "hyperosmolar coma, diabetes (poorly controlled) pneumonia, multiple cerebral infracts, hydrocephalus."

    
    

76. The Patient's hyperosmolar coma was thought to have been initiated by his high blood sugar. Petitioner has suggested that the Patient's extremely high blood glucose level was the result of the erroneous discontinuance of insulin for the Patient. No evidence was presented to substantiate this contention. There was some evidence presented to suggest that the Patient's high blood sugar level on January 21 may have been in reaction to or a secondary condition of the infection he was fighting and/or pneumonia. However, this evidence was not conclusive. Similarly, while the evidence established that the

    Patient's blood sugar level was probably rising for at least a couple of days before his admission to the hospital on January 21, no conclusive evidence was presented as to the rate at which the blood sugar level would have gone up.

    
    

77. In sum, although the Patient had a blood sugar level of 1420 upon his admission to the hospital on January 21, 1990, the evidence was insufficient to establish that this elevated blood sugar level was directly related to any actions or inactions by Respondent and/or the improper monitoring of his blood sugar levels or some other deficiency in his nursing care.

    
    

78. There is no medical evidence that the Patient's hyperosmolar coma was associated with ketotic acidosis. Ketotic acidosis is a condition usually associated with severe or total insulin absence so that the body is unable to metabolize glucose leading to fat metabolism which can cause a patient to become acidotic. In this case, although the Patient's glucose levels were very high, it appears there was sufficient insulin present to avoid ketotic acidosis. Indeed, the Patient's treating physician at Florida Keys Memorial noted on his discharge summary that the Patient presented with "hyperosmolar coma and nonketotic acidosis."

    
    

79. As noted above, there were some questions regarding the usefulness of a glucometer for this Patient because of indications that it was not providing accurate readings when compared to fasting blood sugar tests. In addition, there were some indications that the Patient had a high renal threshold and, therefore, urine dipsticks did not always provide an adequate reading of his blood sugar levels. Nonetheless, it is clear that by at least January 16, 1990, the Patient began running persistent fevers. A fever is especially dangerous to a brittle diabetic such as the Patient. Some special efforts to monitor his condition were essential. It does not appear that such steps were taken during the Respondent's shifts on January 16 through 18 and on January 20. In mitigation, the Patient was seen by a physician on January 17, 1990 and Respondent knew that the Patient's physician was notified of his condition on January 19, 1990. The only change ordered as a result of these consultations was the administration of an antibiotic.

    
    

80. Except as noted above, there is no evidence that Respondent ignored any changes in the Patient's condition or symptoms from January 10 through January 21. Likewise, there was no evidence presented of any other specific changes or situations which Respondent should have noted regarding the Patient from January 10 through January 20.

    
    

    CONCLUSIONS OF LAW

    
    

81. The Division of Administrative Hearings has jurisdiction over the parties to and the subject matter of this proceeding pursuant to Section 120.57, Florida Statutes.

    
    

82. Pursuant to Section 464.018(2), Florida Statutes, the Board of Nursing is empowered to revoke, suspend or otherwise discipline the license of a registered nurse who is found guilty of any of the grounds enumerated in Section 464.018(1), Florida Statutes.

    
    

83. Petitioner has the burden of proof in this license discipline case and must prove the allegations set forth in the Administrative Complaint by clear and convincing evidence. Ferris v. Turlington, 510 So.2d 292 (Fla. 1987).

    Evans Packing Company v. Department of Agriculture and Consumer Services, 550 So.2d 112, 116 (Fla. 1st DCA 1989); Pascale v. Department of Insurance, 525

    So.2d 922 (Fla. 1st DCA 1988). The evidence must be of such weight that it produces in the mind of the trier of fact a firm belief or conviction, without hesitancy, as to the truth of the allegations sought to be established." Slomowitz v. Walker, 429 So.2d 797, 800 (Fla. 4th DCA 1983). Furthermore, the disciplinary action taken may be based only upon the offenses specifically alleged in the Administrative Complaint. See, Sternberg v. Department of Professional Regulation, Board of Medical Examiners, 465 So.2d 1324, 1325 (Fla. 1st DCA 1985); Kinney v. Department of State, 501 So.2d 129, 133 (Fla. 5th DCA 1987); Hunter v. Department of Professional Regulation, 458 So.2d 842, 844 (Fla.

    2d DCA 1984).

    
    

84. The Administrative Complaint issued in the instant case alleges that the Board of Nursing has grounds to discipline Respondent pursuant to Section 464.018(1)(h), Florida Statutes. That subsection authorizes the Board to take disciplinary action against a licensed registered nurse for "[u]nprofessional 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."

    
    

85. In determining whether the licensee has violated Section 464.018, Florida Statutes, as charged in the Administrative Complaint, one "must bear in mind that it is, in effect, a penal statute...this being true the statute must be strictly construed and no conduct is to be regarded as included within it that is not reasonably proscribed by it. Furthermore, if there are any ambiguities included such must be construed in favor of the...licensee." Lester

    v. Department of Professional and Occupational Regulations, 348 So.2d 923, 925 (Fla. 1st DCA 1977).

    
    

86. Florida Administrative Code Rule 21O-10.005(1)(e) enumerates various acts that constitute "unprofessional conduct," within the meaning of Section 464.018(1)(h), Florida Statutes. Among these acts is "inaccurate recording, falsifying or altering of patient records." Florida Administrative Code Rule 21O-10.005(1)(e).

    
    

87. Petitioner has charged Respondent with inaccurate record keeping in connection with the entry she made on the transfer form for the Patient from KWCC to the hospital on January 21, 1990 where she noted that the Patient was "NIDDM does take Micronase, has not rec'd AM dose." The Administrative Complaint does not allege any other instance of inaccurate record keeping by Respondent. In the Prehearing Stipulation and at the hearing in this case, Petitioner conceded that it was not charging Respondent with any other record keeping violation other than the charges levied with respect to the January 21, 1990 transfer form.

    
    

88. The "minimum standards of acceptable and prevailing nursing practice" in Florida for nursing documentation and charting are fairly general. The documentation must include accurate, significant information regarding a patient's condition and it must be descriptive.

    
    

89. The evidence in this case indicates that the terms "IDDM" and "NIDDM" are sometimes loosely used. Respondent was using the acronym "NIDDM" as a descriptive term relating to whether or not the Patient was receiving insulin. It was not intended as a medical diagnosis.

    
    

90. The notation cited by Petitioner to support its charges was made in the "Comments" section of the transfer form. In the "Diagnosis" section of the form, Respondent accurately described the Patient as a "diabetic" who suffered

    from "mononeuropathy with left arm weakness" and Respondent also noted that the Patient had previously been diagnosed as having suffered from a stroke. While there were several references in the medical records that the Patient was "IDDM", such an entry on the transfer sheet would have been incorrect in this case since the Patient had not been receiving insulin for approximately two weeks. In sum, Respondent correctly noted that the Patient had diabetes but was not taking insulin at the time of his transfer. This situation was consistent with the outstanding orders for the Patient at the time of his transfer.

    
    

91. Respondent's notations on the January 21, 1990 transfer sheet meet the minimum standards of acceptable, prevailing and professional nursing care in Florida pursuant to Section 464.018(1)(h), Florida Statutes and Rule 21O- 10.005(1)(e)(1), Florida Administrative Code.

    
    

92. Petitioner has also charged Respondent with unprofessional conduct for failure to initiate and obtain the necessary nursing and medical intervention for the Patient. The Second Amended Administrative Complaint charges "[s]pecifically, Respondent failed to intervene where appropriate and follow the chain of command to insure that patient H.S.'s glucose level was closely monitored and that insulin was administered pursuant to a physician's order."

    
    

93. It appears that Petitioner originally brought this case under the assumption that Respondent and others at KWCC had failed to note that the physician had "mistakenly" deleted an order for insulin for the Patient who was presumed to be an insulin dependent diabetic. However, the evidence established that insulin was deliberately discontinued for the Patient by his physician and this order was properly noted by Respondent. Whether this medical decision was appropriate is not clear and is beyond the scope of this case. The Patient was seen by a physician on at least two occasions subsequent to his transfer from the hospital on January 10, 1990. Neither physician reinstituted the order for insulin. The evidence was insufficient to establish that the discontinuance of insulin was erroneous and/or that the Respondent should have questioned whether the orders were appropriate. Nonetheless, the evidence did establish that the Patient's condition, including his history of wild fluctuations in blood sugar levels, his persistent fever from January 16 through January 21, the discontinuance of insulin and the tube feedings with a high glucose content, mandated very strict and close monitoring. While a glucometer or urine dipstick may not have been completely accurate for this particular patient, Respondent should have sought some intervention to guard against hyperglycemia in view of the Patient's deteriorating condition. The evidence established that Respondent failed to appropriately recognize and respond as the Patient quit eating, began running a fever and started exhibiting signs and symptoms of confusion deteriorating consciousness. The evidence did not establish when the Patient's hyperglycemia should have been noted if proper care had been provided.

    
    

94. No conclusive evidence was presented to establish that an earlier or different intervention by the Respondent would have in any way altered or changed the Patient's prognosis and/or results.

    
    

95. The penalties for a violation of the statute or rule are found in Rule 21O-10.005(2) and Rule 21O-10.011, Florida Administrative Code. Under those guidelines, a violation of Section 464.018(1)(h) may result in a penalty ranging from reprimand to suspension, probation and fine. No aggravating circumstances were offered at the hearing.

RECOMMENDATION

Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Nursing enter a Final Order finding

Respondent not guilty of Count I of the Second Amended Administrative Complaint, but finding her guilty of Count II for violating Section 458.464.018(h), Florida Statutes. As punishment therefore, Respondent should be (1) reprimanded, (2) fined $250 and (3) placed on probation for a period of 1 year, the terms and conditions of which should be set by the Board of Nursing.

DONE AND ENTERED this 12th day of March, 1993, at Tallahassee, Florida.

J. STEPHEN MENTON Hearing Officer

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-1550

(904) 488-9675

Filed with the Clerk of the Division of Administrative Hearings this 12th day of March, 1993.

ENDNOTE

1/ Dr. Calleja was one of the Patient's treating physicians during his hospitalization at DePoo from December 29, 1989 through January 10, 1990.

APPENDIX

Both parties have submitted Proposed Recommended Orders. The following constitutes my rulings on the proposed findings of fact submitted by the parties.

The Petitioner's Proposed Findings of Fact

Proposed Finding Paragraph Number in the Findings of Fact of Fact Number in the Recommended Order Where Accepted or

Reason for Rejection.

1. Subordinate to Findings of Fact 16-18.

2. Rejected as vague and unlimited as to time. As set forth in Findings of Fact 29, the Patient fluctuated between hyperglycemia and hypoglycemia during his hospital stay from December 29, 1989 and January 10, 1990.

3.-9. Subordinate to Findings of Fact 11-14 and 32.

1. Rejected as vague and confusing. As set forth in Findings of Fact 20, hyperglycemia can cause serious health consequences.

2. Adopted in substance in Findings of Fact 20.

3. Rejected as not supported by the weight of the evidence.

4. Adopted in substance in Findings of Fact 20.

5. Adopted in substance in Findings of Fact 19.

6. Adopted in substance in Findings of Fact 20.

7. Adopted in substance in Findings of Fact 13.

8. Adopted in substance in Findings of Fact 9.

9. Adopted in pertinent part in Findings of Fact 53 and 78.

10. Adopted in substance in Findings of Fact 48.

11. Adopted in substance in Findings of Fact

    13 and 60.

12. Adopted in substance in Findings of Fact 60.

13. Adopted in substance in Findings of Fact 13.

14. Adopted in substance in Findings of Fact

    13 and 60.

15. Rejected as vague, ambiguous and unnecessary.

16. Rejected as vague, overly broad and ambiguous. This subject matter is addressed in Findings of Fact 54 and 55.

26.-27. Rejected as overly broad. This subject

matter is addressed in Findings of Fact 53.

1. Rejected as vague and unnecessary.

2. Adopted in substance in Findings of Fact

   19 and 20.

3. Rejected as vague, ambiguous and overly broad.

4. Adopted in substance in Findings of Fact 6-8.

5. Adopted in substance in Findings of Fact 1.

6. Subordinate to Findings of Fact 3 and 24.

7. Adopted in pertinent part in Findings of Fact 24.

8. Adopted in substance in Findings of Fact 25-27.

9. Adopted in substance in Findings of Fact 29-30.

10. Adopted in substance in Findings of Fact

    26 and 29.

11. Adopted in substance in Findings of Fact 29.

12. Rejected as unnecessary. This subject matter is addressed in Findings of Fact 29.

13. Rejected as unnecessary and as constituting argument rather than a finding of fact.

14. Adopted in pertinent part in Findings of Fact 29.

15. The first sentence is adopted in substance in Findings of Fact 38. The footnote is adopted in substance in Findings of Fact

    10. The second sentence is subordinate to Findings of Fact 38.

16. Subordinate to Findings of Fact 32.

44.-50. Subordinate to Findings of Fact 41, 50 and

79 and Conclusions of Law 93.

1. Rejected as overly broad. This subject matter is addressed in Findings of Fact 40, 51 and 58-70.

2. Rejected as vague and unnecessary.

3. The first sentence is rejected as vague and unnecessary. The second sentence is adopted in substance in Findings of Fact 48.

4. Rejected as vague, overly broad and unnecessary.

5. Subordinate to Findings of Fact 79 and Conclusions of Law 93.

6. Rejected as unnecessary. This subject matter is addressed in Findings of Fact 51.

7. Rejected as vague, speculative and unnecessary. This subject matter is addressed in part in Findings of Fact 42.

8. Adopted in substance in Findings of Fact 41.

9. Adopted in substance in Findings of Fact 53.

10. Subordinate to Findings of Fact 53.

11. The first three sentences are adopted in substance in Findings of Fact 54 and 56. The last sentence is rejected as vague, overly broad and contrary to the weight of the evidence.

12. Subordinate to Findings of Fact 55.

13. Subordinate to Findings of Fact 55 and 56.

14. Rejected as not supported by the weight of the evidence.

15. Rejected as vague, ambiguous and unnecessary.

16. Adopted in substance in Findings of Fact

    61 and 62.

17. Rejected as speculative and unnecessary. This subject matter is addressed in Findings of Fact 62.

18. Adopted in substance in Findings of Fact 63.

19. Adopted in substance in Findings of Fact 60.

20. Adopted in pertinent part in Findings of Fact 63.

21. Adopted in substance in Findings of Fact 64.

22. Adopted in substance in Findings of Fact 64.

23. Rejected as unnecessary.

24. Adopted in substance in Findings of Fact 64.

25. Subordinate to Findings of Fact 42.

26. Adopted in substance in Findings of Fact 65.

27. Adopted in substance in Findings of Fact 68.

28. Subordinate to Findings of Fact 67.

29. Adopted in substance in Findings of Fact

    68 and 69.

30. Subordinate to Findings of Fact 66.

31. Subordinate to Findings of Fact 70.

32. Rejected as vague and overly broad. This subject matter is addressed in Findings of Fact 80.

33. Subordinate to Findings of Fact 79 and Conclusions of Law 93.

34. Adopted in substance in Findings of Fact

    42 and 56.

35. Subordinate to Findings of Fact 76.

36. Rejected as vague, ambiguous and overly broad as to time.

37. Subordinate to Findings of Fact 79.

38. Subordinate to Findings of Fact 79 and Conclusions of Law 93.

39. Adopted in substance in Findings of Fact 50.

40. Rejected as vague and ambiguous. This subject matter is addressed in Findings of Fact 24.

41. Subordinate to Findings of Fact 79 and Conclusions of Law 93.

42. Rejected as vague and ambiguous. This subject matter is addressed in Findings of Fact 42 and 79.

43. Rejected as vague and ambiguous.

44. Adopted in substance in Findings of Fact 50.

45. Subordinate to Findings of Fact 43-46.

46. Rejected as vague and unnecessary.

47. Subordinate to Findings of Fact 47.

48. Subordinate to Findings of Fact 47.

49. Rejected as unnecessary. This subject matter is addressed in Findings of Fact 47.

50. Adopted in substance in Findings of Fact 73-75.

51. Rejected as constituting argument. This subject matter is addressed in Findings of Fact 72 and Conclusions of Law 87-91.

52. Rejected as irrelevant.

53. Subordinate to Findings of Fact 11, 14 and 33.

54. Subordinate to Findings of Fact 11, 14, 33, 72 and Conclusions of Law 89-91.

55. Rejected as unnecessary.

56. Rejected as unnecessary.

57. Rejected as unnecessary.

The Respondent's Proposed Findings of Fact

Proposed Finding Paragraph Number in the Findings of Fact of Fact Number in the Recommended Order Where Accepted or

Reason for Rejection.

1. Addressed in the Preliminary Statement.

2. Adopted in substance in Findings of Fact

   1 and 3.

3. Adopted in substance in Findings of Fact 4 and 36.

4. Adopted in substance in Findings of Fact 4.

5. Subordinate to Findings of Fact 5, 6 and 14.

6. Adopted in substance in Findings of Fact 2.

7. Subordinate to Findings of Fact 14-18.

8. Rejected as constituting argument. This subject matter is addressed in the Preliminary Statement and in Findings of Fact 15-18.

9. Rejected as constituting argument.

10. Rejected as constituting argument.

11. This proposed finding of fact includes sixteen definitions which were set forth in Appendix C to Respondent's Proposed Recommended Order. Except for numbers 10, 14 and 15 which are deemed

    unnecessary, these definitions have been incorporated in the following Findings of Fact: 9-14, 19-22, 33, 44, 46, 48, 53 and

    72.

12. Adopted in substance in Findings of Fact 15.

13. Adopted in substance in Findings of Fact 17.

14. Adopted in substance in Findings of Fact 16.

15. Adopted in substance in Findings of Fact

    17 and 18.

16. Adopted in substance in Findings of Fact 17.

17. Adopted in substance in Findings of Fact 17.

18. Adopted in substance in Findings of Fact 17.

19. Subordinate to Findings of Fact 23.

20. The first sentence is subordinate to Findings of Fact 24. The remainder of this proposal is rejected as unnecessary.

21. Adopted in substance in Findings of Fact 42-45 and 49.

22. Rejected as unnecessary.

23. Subordinate to Findings of Fact 47.

24. Adopted in substance in Findings of Fact 26-28.

25. Subordinate to Findings of Fact 29-31.

26. Adopted in substance in Findings of Fact 29.

27. Adopted in substance in Findings of Fact 29.

28. Rejected as unnecessary and speculative.

29. Subordinate to Findings of Fact 79.

30. Rejected as unnecessary and not established by competent substantial evidence.

31. Rejected as unnecessary.

32. Subordinate to Findings of Fact 48.

33. Rejected as unnecessary and not established by competent substantial evidence.

34. Adopted in substance in Findings of Fact

    38 and 49.

35. Rejected as vague, ambiguous and unnecessary.

36. Adopted in substance in Findings of Fact 38.

37. Adopted in substance in Findings of Fact 40.

38. Subordinate to Findings of Fact 38.

39. Subordinate to Findings of Fact 53-57.

40. Subordinate to Findings of Fact 63.

41. Adopted in substance in Findings of Fact 37.

42. Subordinate to Findings of Fact 37.

43. Adopted in substance in Findings of Fact 61.

44. Adopted in substance in Findings of Fact 37 and 63-67.

45. Adopted in substance in Findings of Fact 64.

46. Subordinate to Findings of Fact 66-67.

47. Subordinate to Findings of Fact 64-67 and 79.

48. Subordinate to Findings of Fact 64-67.

49. Subordinate to Findings of Fact 70 and 71.

50. Adopted in substance in Findings of Fact 72.

51. Adopted in substance in Findings of Fact

    72 and Conclusions of Law 89-91.

52. Adopted in substance in Findings of Fact 11, 14 and 33.

53. Subordinate to Findings of Fact 73-78.

54. Adopted in substance in Findings of Fact 75.

55. Adopted in substance in Findings of Fact 75.

56. Adopted in substance in Findings of Fact 14, 32 and 33.

COPIES FURNISHED:

Jack McRay, General Counsel Department of Professional Regulation 1940 North Monroe Street

Northwood Centre, Suite 60 Tallahassee, Florida 32399-0792

Anna Polk, Executive Director Department of Professional Regulation/

Board of Nursing

1940 North Monroe Street Northwood Centre, Suite 60 Tallahassee, Florida 32399-0792

Roberta L. Fenner, Esquire

Department of Professional Regulation 1940 North Monroe Street

Northwood Centre, Suite 60 Tallahassee, Florida 32399-0792

Lynn Hankins-Fielder, Esquire Browning, Guller and Associates, P.A.

402 Applerouth Lane, Suite 10 Key West, Florida 33040

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions to this Recommended Order. All agencies allow each party at least 10 days in which to submit written exceptions. Some agencies allow a larger period within which to submit written exceptions. You should contact the agency that will issue the final order in this case concerning agency rules on the deadline for filing exceptions to this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.

Docket for Case No: 91-004825

Orders for Case No: 91-004825