STATE OF FLORIDA DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH, Petitioner, Case No. 2008-14146 Vv. LYNDA DIANE COLEMAN, R.N., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW, Petitioner, Department of Health, by and through its undersigned counsel, and files this Administrative Complaint before the Board of Nursing against Respondent, Lynda Diane Coleman, R.N., and in support thereof alleges: 1. Petitioner is the state department charged with regulating the practice of nursing pursuant to Section 20.43, Florida Statutes; Chapter 456, Florida Statutes; and Chapter 464, Florida Statutes. 2. At all times material to this Complaint, Respondent was a registered nurse (R.N.) within the state of Florida, having been issued license number RN 1076851. £A"d HOH SA:9T BHBe-A8-W Se:ST 600¢ 2 [ne 3. Respondent's address of record is 21020 Riddle Ave., Port Charlotte, FL 33954. 4, Respondent is licensed pursuant to Chapter 464, Florida Statutes, and is a health care practitioner as defined in Section 456.001(4), Florida Statutes, 2. At all times material to this Complaint, Respondent worked as a R.N. at Douglas T. Jacobson State Veteran’s Nursing Home (Veteran’s Home) located in Port Charlotte, Florida. 6. At Veteran’s Home, a Controlled Substance Record of Use (controlled drug sheets) is delivered from the pharmacy with each controlled prescription for a patient in order to track the removal and administration of the controlled substances. These sheets are used to keep a running total of what drugs remain for each patient by listing the amount given, the amount on hand, the date, and the time administered. 7. The number of controlled drug sheets is monitored and maintained on a narcotic log in order to track what how many different medications are on the floor ready for patient administration. If a new prescription is received, the number of controlled drug sheets received is Department of Health v Lynda Coleman 2 Case Number: 2008-14146 J:\PSU\Nursirig\Brown-Blake,K\AC\Unprofessional\Coleman, Lynda,RN, inacc rec.doc Fad HOH SA:9T BHBe-A8-W Se:ST 600¢ 2 [ne recorded in the “additions” section and the sheet is added to the total on - the Narcotics Log. - 8. When a prescription is completed, the completed controlled drug sheet is returned to the pharmacy along with labels that are removed from the medications and any refill request forms if necessary. The controlled drug sheets are placed in the pharmacy bin to be delivered to the pharmacy for correct documentation. 9. The number of controlled drug sheets being sent to the pharmacy is recorded in the “subtractions” section of the Narcotics Log. This number is then subtracted from the total amount of medications available on the narcotics log. At the end of each shift, the nurse holds an “end count” in which she records the number of controlled drug sheets remaining on the floor. 10. On or about May 24, 2008, Respondent worked the 3:00 p.m. to 11:00 p.m. shift at Veteran’s home. ) 11. On or about May 24, 2008, the narcotics log indicates that at the start of the 7:00 a.m. to 3:00 p.m. shift there were fourteen (14) controlled drug sheets, and thirteen (13) narcotics sheets at the end of the shift due to the return of one controlled drug sheet to the pharmacy. Department of Health v Lynda Coleman ‘ 3 Case Number: 2008-14146 J:\PSU\Nursing\Brown-Blake,K\AC\Unprofessional\Colaman, Lynda,RN, inace rec.doc S@"d HOH [8:97 6eBe-Ae-We Sé:9T 600¢ 4 [Nf 12. On or about May 24, 2008, the narcotics log indicates that at the start and end of the 3:00p.m. to 11:00 p.m. shift there were twelve (12) controlled substances sheets. Respondent recorded the number in blue ink. 13. Respondent, using blue ink, wrote over the number thirteen (13), which was recorded in black ink-at the end of the 7:00 a.m. to 3:00 p.m. shift, marking a number twelve (12). 14. Respondent received another control drug sheet and medication for a patient at the beginning of her shift. 15. At the completion of the 3:00 p.m. to 11:00 p.m. shift, the Narcotics log should have reflected fourteen (14) controlled drug sheets. 16. After Respondent left her shift, the nurse who worked the 11:00 p.m. to 7:00 a.m. shift found two medication labels attached to the side of the pharmacy bin in the medication room, with no corresponding controlled drug sheets to indicate what happened to the medications. 17. One of the labels was for Patient E.H.’s Vicodin which was originally delivered on May 7, 2008. 18. Vicodin contains hydrocodone and is prescribed to treat pain. According to Section 893.03(3), Florida Statutes, hydrocodone, in the Department of Health v Lynda Coleman 4 Case Number: 2008-14146 :\PSU\Nursing\Brown-Blake, K\AC\Unprofessional\Coleman, Lynda,RN, inacc rec.doc 98° HOH [8:97 6eBe-Ae-We Se:ST 600¢ 2 [ne dosages found in Vicodin, is a Schedule III controlled substances that has a potential for abuse less than the substances in Schedule I and JI and has a currently accepted medical use in treatment in the United States, and abuse of the substance may lead to moderate or low physical dependence or high psychological dependence. 19. Based on Patient E.H.’s Medication Administration Records (MAR), Patient E.H. should have had seventeen (17) tablets of Vicodin remaining in his prescription 20. The other label was for Patient C.M.’s Percocet which was delivered on March 3, 2008. 21. Percocet is the brand name for a drug that contains oxycodone and is prescribed to treat pain. According to Section 893.03(2), Florida statutes, oxycodone is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States, and abuse of oxycodone may lead to severe psychological or physical dependence. 22. On or about May 25, 2008, the day shift nurse was unable to locate the missing controlled drug sheets for these two prescriptions, and reported the drugs as missing. Department of Health v Lynda Coleman 5 Case Number: 2008-14146 3:\PSU\Nursing\Brown-Blake, K\AC\Unprofessional\Coleman, Lynda,RN, inacc rec.doc 28"d YOHY 98:97 68Be-48-TWNLe Pe:ST 600¢ 42 [Nf 23. When asked about the missing sheets and medications, Respondent indicated that she administered the final tablet of Vicodin to Patient E.H., and the final Percocet to Patient C.M. 24. Respondent indicated that she placed the labels on the pharmacy bin and turned the controlled drug sheets over in the narcotic book, assuming that the drugs would be re-ordered without verifying that they were re-ordered. 25. Respondent failed to record the administration of Vicodin to Patient E.H. in his MAR on or about May 24, 2008. 26. Respondent failed to record the administration of Percocet to Patient C.M. in his MAR on or about May 24, 2008. 27. Section 464.018(1)(h), Florida Statutes (2007), provides that unprofessional conduct, as defined by board rule, constitutes grounds for discipline. 28. Rule 64B9-8.005(1)(a), Florida Administrative Code, provides that unprofessional conduct includes inaccurate recording. 29. Respondent engaged in unprofessional conduct to include inaccurate recording in one or more of the following ways: Department of Health v Lynda Coleman 6 Case Number: 2008-14146 ):\PSU\Nursing\Brown-Blake, K\AC\Unprofessional\Coleman, Lynda,RN, inacc rec.doc 8@"d HOH 46:97 6eBe-A8-We Pe:ST 600¢ 42 [Nf a. Respondent failed to properly document the administration of Vicodin to Patient E.H. on or about May 24, 2008; b. Respondent failed to properly document the administration of Percocet to Patient C.M. on or about May 24, 2008; 30. Based on the foregoing, Respondent violated Section 464.018(1)(h), Florida Statutes (2007), by engaging in unprofessional conduct, as defined by Rule 64B9-8.005(1)(a), Florida Administrative Code, to include inaccurate recording. Department of Health v Lynda Coleman 7 Case Number: 2008-14146 J:\PSU\Nursing\Brown-Blake,K\AC\Unprofessional\Coleman, Lynda,RN, inacc rec.doc 64"d HOH 46:97 6eBe-A8-We Pe:ST 600¢ 42 [Nf WHEREFORE, the Petitioner respectfully requests that the Board of Nursing enter an order imposing one or more of the following penalties: permanent revocation or suspension of Respondent's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, placement of the Respondent on probation, corrective action, refund of fees billed or collected, remedial education and/or any other relief that the Board deems appropriate. SIGNED this Ow day a Decuuben 2008. Ana M. Viamonte Ros, M.D., M.P.H. State Surgeon General Curnexs Anntionette Smith Assistant General Counsel DEPAR IMENT ¢ of HEALTH DOH Prosecution Services Unit DEPUTY CLEP 4052 Bald Cypress Way, Bin C-65 CLERK ate Tallahassee, Florida 32399-3265 DATE Florida bar Number 0615951 (850) 245 - 4640 Telephone (850) 245 — 4683 Facsimile PCP: To¥ PCP Ment 8: Cy Honea ep Dmg Department of Health v Lynda Coleman & Case Number: 2008-14146 J:\PSU\Nursing\Brown-Blake, K\AC\Unprofessional\Coleman, Lynda,RN, inace rec.doc Ald HOH 46:97 6eBe-A8-We Se:9T 6O00¢ 2 [NC TE'd TWHLOL NOTICE OF RIGHTS Respondent has the right to request a hearing to be conducted in accordance with Section 120.569 and 120.57, Florida Statutes, to be represented by counsel or other qualified representative, to — present evidence and argument, to call and cross-examine witnesses and to have subpoena and subpoena duces tecum issued on his or her behalf if a hearing is requested. NOTICE REGARDING ASSESSMENT OF COSTS Respondent is placed on notice that Petitioner has incurred costs related to the investigation and prosecution of this matter. Pursuant to Section 456.072(4), Florida Statutes, the Board shall assess costs related to the investigation and prosecution of a disciplinary matter, which may include attorney hours and costs, on the Respondent in addition to any other discipline imposed. Department of Health v Lynda Coleman 9 Case Number: 2008-14146 ; J:\PSU\Nursing\Brown-Blake, K\AC\Unprofessional\Coleman, Lynda,RN, inacc rec.doc thd YOHY 46:97 68@2-48-TWNLe S2:9T 600¢ 42 [Nf

Docket for Case No: 09-005630PL