ola ot lie - DEPARTMENT OF HEALTH, STATE OF FLORIDA DEPARTMENT OF HEALTH Petitioner, - i vs. : KATHLEENA.DIFIORE ss =ss—i(ié‘é#CO#CCASE NO 972IITE Respondent. . : / ADMINISTRATIVE COMPLAIN rT "Petitioner, DEPARTMENT OF HEALTH, hereinafter referred to as s “Petitioner,” files this Administrative Complaint before the Board of Nursing against KATHLEEN A. DIFIORE hereinafter referred to as “Respondent,” and alleges: 1. Effective July 1, 1997, Petitioner is the state agency charged with regulating the practice of nursing pursuant to Section 20.43, Florida Statutes (Supp. 1996); Chapter 455, Florida Statutes; and Chapter 464, Florida Statutes. 2. Pursuant to the authority of Section 20.43(3)(f), Florida Statutes (Supp. 1996), the Petitioner has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative, and prosecutorial services required by the Division of Medical Quality Assurance, councils, or boards, as appropriate, including the issuance of emergency orders of suspension or restriction. 3. Respondent is, and has been at all times material hereto, a REGISTERED NURSE, having been issued license number RN 2656982. i ah a a aa _ Services. 4. . Respondent’s last known address is 3302 Bo Jeremy Drive, Orlando, Florida 32822 5. On or about May 5, 1997, Respondent was employed by Olsten Health 6 On or about May 5, 1997, , Respondent hooked PCA pump 1 to administer Morphine automatically. 7. On or about May 6, 1997, Patient CH. was found dead. : 8. On or r about May 6, 1997, the Medical Examiners office determined that Patient C.H. had died from “Morphine Intoxication.” 9. A review of the manual for the CADD PCA pump indicates that if the Morphine cassette is not locked into place, a free flow of medicine could occur causing a patients death. . 10. Akey is required to properly i insert and lock the aforementioned cassette, a) Respondent indicated that she had read the manual for the CADD PCA pump but did not have a key or like mechanism to properly lock the cassette into place. (2) Dr. Blue has indicated that the cassette was not locked into place when it was removed from the pump. (By Based on the foregoing, the Respondent’s license to practice nursing in the State of Florida is subject to discipline pursuant to Section 464.018(1)(h), Florida Statutes, by unprofessional conduct, by violating Rule 64B9-8.005(1)(e)2, Florida Administrative Code, by administering medications or treatments in a negligent manner. ’ WHEREFORE, Petitioner respectfully Tequests the Board of Nursing enter an Order i imposing one or more of the following penalties: uspension of license, imposition te cc aa ne Maes a 1 of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, and/or any other relief that the Board deems appropriate. | Signed this\ May of 19% , Douglas M. Cook Director BY: !Nancy Snurkowsk® Chief Atior On Behalf of the Agency for Health Care Administration ewe pes mc REN FILED COUNSEL FOR/THE PETITIONER: DEPARTMENT OF Reginald D. Dieg, Senior Attorney DEPUTY CuenetTh FBN: 011292 CLERK ¢ MM. Agency for Health Care Administration ) Allied Health Section Post Office Box 14229 Tallahassee, Florida 32317-4229 DATE —Yaol (850) 414 - 8576 . . RDD/rd PCP: Baker & Woolfork DOM: 4-27-98

Docket for Case No: 00-000393