STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, )

BOARD OF NURSING, )

)

Petitioner, )

)

vs. ) Case No. 00-1006

) BILLIE MAE TWIEHAUS HOLZHAUER, )

)

Respondent. )

)

RECOMMENDED ORDER

On June 23, 2000, a formal administrative hearing in this case was conducted by videoconference in Tallahassee and Ft.

Myers, Florida, before William F. Quattlebaum, Administrative Law Judge, Division of Administrative Hearings.

APPEARANCES

For Petitioner: Reginald D. Dixon, Esquire

Agency for Health Care Administration 2727 Mahan Drive

Post Office Box 14229 Tallahassee, Florida 32317-4229

For Respondent: Harry A. Blair, Esquire

Harry A. Blair, P.A.

2180 West First Street, Suite 401 Ft. Myers, Florida 33901

STATEMENT OF THE ISSUE

The issue in the case is whether the allegations of the Administrative Complaint filed by the Petitioner are correct and, if so, what penalty should be imposed against the Respondent.

PRELIMINARY STATEMENT

By Amended Administrative Complaint dated January 24, 2000, the Department of Health (Petitioner) alleged that Billie Mae Twiehaus Holzhauer (Respondent) violated Section 464.018(1)(h), Florida Statutes. The Respondent requested a formal hearing.

The Department forwarded the request for hearing to the Division of Administrative Hearings, which scheduled and conducted the proceeding.

At the hearing, the Petitioner presented the testimony of one witness and had Exhibits numbered 1-3 admitted into evidence. The Respondent presented the testimony of one witness, testified on his own behalf and had Exhibit numbered 1 admitted into evidence. The Transcript of the hearing was filed on August 10, 2000. Both parties filed Proposed Recommended Orders.

FINDINGS OF FACT

1. The Petitioner is the state agency charged with regulation of the practice of nursing in State of Florida.

2. At all times material to this case, the Respondent has been licensed as a practical nurse in the State of Florida, holding license number PN 0741801.

3. At all times material to this case, the Respondent was employed as a practical nurse at the Harborside Health Care facility in Naples, Florida.

4. At all times material to this case, Patient F. D. was a resident of Harborside Health Care. On or about August 17, 1998,

   at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to F. D.

5. According to the medication administration record, F. D. was to receive the nutritional supplement at approximately

   2:00 p.m.

   
   

6. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to F. D.

7. At all times material to this case, Patient L. G. was a resident of Harborside Health Care. On or about August 17, 1998, at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to L. G.

8. According to the medication administration record, L. G. was to receive the nutritional supplement at approximately 2:00 p.m.

9. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to L. G.

10. At all times material to this case, Patient R. T. was a resident of Harborside Health Care. On or about August 17, 1998, at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to R. T.

11. According to the medication administration record, R.

    
    

    T. was to receive the nutritional supplement at approximately 2:00 p.m.

12. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to R. T.

13. Minimal acceptable standards of prevailing nursing practice require that nurses accurately document the provision of supplements and nourishment to nursing home patients.

14. Minimal acceptable standards of prevailing nursing practice require that documentation of care provided to patients be recorded contemporaneously with the provision of the care.

15. The Respondent's documentation of care provided to the patients identified herein fails to meet minimally acceptable standards of prevailing nursing practice.

16. The placing of a care provider's initials on a medication administration record indicates that medication has been administered to patients. "Pre-initialing" of medication administration records poses a risk of confusion to other care providers working in the facility and is not an acceptable practice.

17. The Respondent acknowledges that she initialed each medication administration record at about 11:00 a.m., several hours prior to the actual administration of the supplement's to the patients. She asserts that she did not record the amounts of

    supplement each patient consumed (100 percent in all three cases assuming the records are accurate) until after the patient had consumed the supplement.

18. The rationale for the Respondent's practice is unclear. The Respondent suggests that she had "a few moments" at about 11:00 a.m. and so she went ahead and initialed the documents, knowing that she could complete the charting at a later time.

19. The Respondent's suggestion is the intent of the practice is to save time; however, any time saved is at best minimal.

20. If the Respondent's testimony regarding post- administration record completion is credited, the practice requires that each record be handled twice to complete a single task. The Respondent suggests that she returns to each individual record after administering the supplement and charts the amount of supplement consumed by writing in a space approximately one-quarter inch beneath the "pre-initialed" space. In reality, "pre-initialization" doubles the time required to complete the documentation and increases the potential for confusing other care providers involved in patient care and charting.

21. The Respondent continues to assert that the "pre- initialization" practice is acceptable. The assertion is clearly contrary to minimally acceptable standards of nursing practice, and to common sense.

    CONCLUSIONS OF LAW

    
    

22. The Division of Administrative Hearings has jurisdiction over the parties to and subject matter of this proceeding. Section 120.57(1), Florida Statutes.

23. The Department of Health, Board of Medicine, is responsible for disciplinary proceedings against licensed practical nurses in Florida. Chapter 464, Florida Statutes.

24. The Department has the burden of proving the allegations against the Respondent by clear and convincing evidence. Ferris v. Turlington, 510 So. 2d 292 (Fla. 1987). In this case, the burden has been met.

25. Section 464.018, Florida Statutes, provides grounds for disciplinary actions against licensees. Section 464.018(1)(h), provides for the imposition of discipline 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."

26. In this case the evidence establishes that the Respondent's documentation of care as set forth herein fails to meet the minimal standards of acceptable and prevailing nursing practice.

27. Rule 64B9-8.006(3)(I), Florida Administrative Code, provides a range of disciplinary guidelines for use by the Board of Nursing in imposing discipline for violation of Section

464.018(1)(h), Florida Statutes, where the violation involves administrative duties including charting. The rule provides for a "[f]ine from $250 - $1000 plus from 6 months probation with conditions and CE courses to two years probation with conditions and CE courses."

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Petitioner enter a final order against the Respondent, imposing a fine of $500, requiring completion of appropriate continuing education in nursing records documentation in addition to any existing continuing education requirement, and placing the Respondent on probation for a period of one year under such conditions as the Board of Nursing determines are warranted.

DONE AND ENTERED this 30th day of August, 2000, in Tallahassee, Leon County, Florida.

WILLIAM F. QUATTLEBAUM

Administrative Law Judge

Division of Administrative Hearings The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

(850) 488-9675 SUNCOM 278-9675

Fax Filing (850) 921-6847 www.doah.state.fl.us

Filed with the Clerk of the Division of Administrative Hearings this 30th day of August, 2000.

COPIES FURNISHED:

Reginald D. Dixon, Esquire

Agency for Health Care Administration 2727 Mahan Drive

Post Office Box 14229 Tallahassee, Florida 32317-4229

Harry A. Blair, Esquire Harry A. Blair, P.A.

2180 West First Street, Suite 401 Ft. Myers, Florida 33901

Ruth R. Stiehl, Ph.D., R.N., Executive Director Board of Nursing

Department of Health

4080 Woodcock Drive, Suite 202

Jacksonville, Florida 32207-2714

Angela T. Hall, Agency Clerk Department of Health

4052 Bald Cypress Way Bin A02

Tallahassee, Florida 32399-1703

William W. Large, General Counsel Department of Health

4052 Bald Cypress Way Bin A02

Tallahassee, Florida 32399-1703

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within 15 days from the date of this Recommended Order. Any exceptions to this recommended order must be filed with the agency that will issue the final order in this case.

Docket for Case No: 00-001006

Orders for Case No: 00-001006