The Issue The issue in this proceeding was whether Respondent violated the Nurse Practice Act, Subsections 464.018(d) and (f), Florida Statutes, by making a false record and by abandoning the care of her patient and thereby departing from minimal standards of acceptable and prevailing nursing practice.
Findings Of Fact At all times relevant, Respondent was licensed as a practical nurse with license number 0797251. (Petitioner's Exhibit #1, T-22). Respondent, Sheri Ward, was employed by Bayshore Registry, a private-duty nursing service. (Petitioner's Exhibit #3). On August 3, 1985, Ms. Ward was assigned to Villa Maria Nursing Center, Bon Secours Hospital in Miami, to fill in for the regular LPN who was on leave. (T-26) Her only assigned patient was Estelle Crocoll. (T-10) The patient needed continual care because she remained either comatose or semi-conscious and had to be fed by a tube. She had to be watched to ensure that she didn't regurgitate the feeding. She also had bed sores and muscle contractures and had to be turned every couple of hours. (T-11, 26-28) When she checked in for her shift around 7:00 a.m., Ms. Ward learned that Cleo Bell, the nurse in charge of the unit, was the one who would sign her time sheet. She asked Ms. Bell if she could get off a little early, like around 2:00 p.m. Ms. Bell said okay and asked that she be notified when she (Ms. Ward) left. Ms. Ward's shift was supposed to end at 3:00 p.m. that day. (T-10, 42) Ms. Bell checked on the patient at 11:00 a.m. and around 12 noon but did not see Ms. Ward. (T-l1) Helen Bushey, R.N. is the head nurse on the wing where Ms. Ward was working on August 3, 1985. (T-23) She has thirty years of nursing experience and at the hearing was qualified as an expert to testify regarding nursing standards. (T-24, 26) Among her other duties, Ms. Bushey makes the rounds to check on the patients and to introduce herself to any new private duty nurse assigned to a patient. (T-29) On August 3, 1985, Ms. Bushey checked Estelle Crocoll's room at 8:30 a.m., between 11:00 and 11:30 a.m., and again around 12 noon, but at no time saw Sheri Ward. (T-29, 30) Ms. Ward failed to answer a page and members of the staff told Ms. Bushey they could not recall seeing her after 11:00 a.m. (T-31, 33) Ms. Bushey reviewed the notes on the patient's chart around 1:45 p.m., and found that notations for 3:00 p.m. had been written up already. (Petitioner's Exhibit #3, T-31) She notified Ms. Ward's employer and Ms. Ward was barred from practicing at Villa Marie. (Petitioner's Exhibit #3, T-32) Ms. Ward claimed that she left the patient's room only to help another nurse ("Virginia") move a patient and to get the nurse to come help her move Estelle Crocoll. (T-44) She claimed that the chair in which she sat was obscured from view by a person entering the room. (T-44) She admitted that she left the job no later than 1:25 p.m., and since she could not find Ms. Bell she told "Virginia" to tell Ms. Bell she was leaving. (T-51, 52) Sheri Ward also admitted that she pre-entered notes for 3:00 p.m., having learned that "little bad habit" (her characterization) from working and training in a county hospital where ". . . you are really pressed for time." (T-46, 53) The reason she left early was to go to a wedding. (T-13, 48) It is unnecessary to determine Ms. Ward's whereabouts during the day or the exact time she left her duty; clearly, by her own admissions, Sheri Ward falsified her patient's record and abandoned the care of that patient without proper notification. Ordinary common sense would conclude that, given the uncontroverted circumstances, these actions constitute extremely bad judgement. Competent expert opinion concluded that these actions constitute a departure from minimal standards of acceptable nursing practice. (T-36)
The Issue The issue in this case is whether Respondent is guilty of violating Rule 59S-8.005(1)(e)2, Florida Administrative Code, for administering medications or treatments in a negligent manner and subject to discipline for unprofessional conduct under Section 464.018(1)(h), Florida Statutes. If so, another issue is what penalty should be imposed.
Findings Of Fact In June 1994 Respondent was licensed as a registered nurse, holding license number RN 2740932. Respondent had been licensed as a registered nurse since 1993 and as a licensed practical nurse since 1987. Respondent's license as a registered nurse became inactive June 21, 1995 after she failed to renew it. In the fall of 1993 East Pointe Hospital hired Respondent as a charge nurse in the transitional care unit, which had recently been started. Although Respondent had only recently become licensed as a registered nurse, the hospital hired her based partly on her current licensing and partly on her previous experience as a licensed practical nurse and respiratory therapist. During the weekend of June 24-26, 1994 Respondent worked the 7:00 pm to 7:00 am shift. As a charge nurse Respondent supervised several other nurses, typically licensed practical nurses. The charge nurse and nurses whom the charge nurse supervised sometimes divided up the patients in the unit, but the charge nurse retained supervisory authority over the other nurses and always remained directly responsible for patients with more complex problems. Patient C. P. had recently been transferred to the transitional care unit from the acute care unit. On the evenings in question, C.P. was among the patients for whom Respondent was directly responsible. Several IVs were being administered the evening of June 24 and early morning of June 25. One patient was having problems with an IV pump and his veins. Respondent asked another nurse, who was under Respondent's supervision, to do the accuchecks on the other patients, including C. P. Accuchecks are finger stick glucose monitors. As was the case with C. P., physicians typically order accuchecks every six hours for patients receiving their total nutrition intravenously. The purpose of the accucheck is to ensure that the patient receiving all his nutrition intravenously does not develop low or high blood sugar, which could have very serious implications. The other nurse failed to perform the accuchecks for midnight at the start of June 25 and 6:00 am on June 25. Respondent failed to follow up to ensure that they were done. Respondent's failure to perform the required accuchecks or to check to make sure that the other nurse performed them constitutes the negligent treatment of a patient. A physician had also ordered that C. P. receive antibiotics intravenously every eight hours, at about 6:00 am, 2:00 pm, and 10:00 pm. Petitioner alleges that Respondent failed to administer two consecutive doses. However, nothing in the nurses' notes documents what would have been a material omission, and no one on the nursing staff bothered to contact the physician who had ordered the antibiotics. There is also a reasonable possibility that IV bags bearing dates and times were mixed up so as to preclude a determination of which registered nurse failed to administer IV medication, if in fact two doses of antibiotics were missed. Respondent later admitted not performing the accuchecks, but never admitted failing to administer the IV antibiotics. Petitioner has failed to prove that Respondent failed to administer the IV medications as ordered. The hospital terminated Respondent's employment shortly after the incidents involving C. P. Respondent has since held two temporary nursing jobs and has applied unsuccessfully for 12 other nursing jobs. She now lives with her mother in Virginia where she earns $100-$200 weekly in employment unrelated to nursing. C. P. suffered no injury as a result of the failure to conduct ordered accuchecks and the failure, if any, to administer the prescribed IV. Respondent has not previously been disciplined as a licensed practical nurse or registered nurse.
Recommendation It is RECOMMENDED that the Board of Nursing enter a final order finding Respondent guilty of violating Rule 59S-8.005(1)(e), Florida Administrative Code, and Section 464.018(1)(h), Florida Statutes, for her failure to perform two accuchecks or make sure that another nurse had performed them and issuing a reprimand to Respondent. ENTERED on December 21, 1995, in Tallahassee, Florida. ROBERT E. MEALE 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 21st day of December, 1995. APPENDIX Rulings on Petitioner's Proposed Findings 1-4: adopted or adopted in substance. 5: rejected as irrelevant. 6-12 (first sentence): adopted or adopted in substance. 12 (second sentence): rejected as subordinate and irrelevant. 13-15: rejected as subordinate. 16: rejected as subordinate and irrelevant. 17-18: adopted or adopted in substance. 19-21: rejected as subordinate and recitation of testimony. 22-23: rejected as irrelevant and subordinate. 24: rejected as subordinate. 25: rejected as subordinate and irrelevant. 26-28: adopted or adopted in substance. 29: rejected as irrelevant. Rulings on Respondent's Proposed Findings 1-3 (first sentence): adopted or adopted in substance. 3 (first sentence)-4: rejected as subordinate and irrelevant. 5-6: adopted or adopted in substance, although not as to the identify of the other nurse. 7: adopted or adopted in substance, except that the failure either to perform the accuchecks or ensure that the other nurse did is negligence. 8-14: rejected as subordinate. 15-18: adopted or adopted in substance. COPIES FURNISHED: Laura P. Gaffney, Senior Attorney Agency for Health Care Administration General Counsel's Office Department of Business and Professional Regulation 1940 North Monroe Street, Suite 60 Tallahassee, FL 32399-0792 Robert E. Tardif, Jr. Duncan & Tardif, P.A. P.O. Drawer 249 Ft. Myers, FL 33902 Linda Goodgame, General Counsel Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Judie Ritter, Executive Director Board of Nursing Daniel Building, Room 50 111 East Coastline Drive Jacksonville, FL 32202
The Issue The issue is whether respondent's license as a practical nurse should be disciplined for the reasons cited in the administrative complaint.
Findings Of Fact Based upon the entire record, the following findings of fact are determined: At all times relevant hereto, respondent, Ruthie Mae Owens Brooks (Brooks or respondent), was licensed as a practical nurse having been issued license number PN 0877941 by petitioner, Department of Professional Regulation, Board of Nursing (Board). She has been licensed as a practical nurse since 1987. There is no evidence that respondent has been the subject of disciplinary action prior to this occasion. When the events herein occurred, respondent was an agency nurse for Underhill Personnel Services, Inc., an agency that furnished nurses to various health care facilities, including Methodist Medical Center in Jacksonville, Florida. She was employed at all times as a licensed practical nurse. On November 17, 1990, respondent was scheduled to work the 11 p.m. - 7 a.m. shift at Methodist Medical Center. Although her duty shift began at 11:00 p.m., respondent arrived a few minutes late and reported directly to the medical-surgical- orthopedic wing instead of signing in at the nursing office as required by hospital rules. After reporting to her work area, respondent went to the assignment board to review her assignment for that evening. Her specific duties that evening were to care for five patients in the medical-surgical-orthopedic wing. While respondent was at the assignment board, a registered nurse, Lynn Ivie, came to the board to ascertain her assignment. At that time, Ivie reported that she smelled a "strong odor of alcohol" on respondent's breath. However, Ivie said nothing at that time since she wanted to give respondent the benefit of the doubt. Around midnight, one of respondent's patients awoke in his room with severe chest pains. Both Ivie and respondent immediately went to the room. Although Ivie instructed Brooks to get a vital signs machine (also known as the Dynamap), Brooks ignored the instruction and "wiped the patient's face with a wet cloth". Ivie then brought the machine into the room and respondent was instructed by Ivie to take the patient's vital signs (blood pressure, temperature and pulse). This merely required her to place an attachment around the patient's arm and push a button to start the machine. The operation of the machine is considered a basic nursing skill. According to Ivie, respondent could not focus on the machine and did not seem to remember how to operate it. After waiting a few moments with no response from Brooks, Ivie finally took the patient's vital signs herself. During this encounter, Ivie again smelled alcohol on respondent's breath and concluded that her inability to assist in the care of the patient and to operate the machine was due to alcohol. Within a few moments, the patient was transferred to the intensive care unit (ICU) on another floor. Before accompanying the patient to the ICU, Ivie instructed respondent to chart the incident and action taken in the nurse's notes and then meet her in the ICU with the completed notes. These notes should be completed in an expedited manner so that the nurses in the ICU wing can utilize them in providing follow-up care to the patient. However, respondent did not chart the incident nor bring the notes to the ICU. Indeed, she failed to chart the notes on any of the patients assigned to her that night. By failing to chart any notes that evening, respondent contravened the requirement that a nurse file a report or record (nursing notes). Around 1:30 a.m. on November 18, Ivie and Joyce Biddix, the nursing supervisor, went to the room of one of the patients assigned to respondent and found the patient, a confused elderly male, sitting nude in a chair with the bed stripped of all linens. He had previously been tied to the bed to prevent him from falling. The linens were soiled with urine and were lying in a heap on the floor. Although respondent had taken the patient out of the bed, disrobed him, and removed the linens, she had left him unattended in the room and had not returned. Biddix called down the hall for someone to bring fresh linens and observed respondent "floating" down the hall saying "I can't find the linens" in a "singsong" voice. When she got closer to respondent, Biddix smelled alcohol on respondent's breath. It may reasonably be inferred from the evidence that respondent's conduct with this patient was unprofessional and constituted a departure from acceptable and prevailing nursing practice. After being confronted by Biddix regarding the alcohol, respondent told her she had drunk one beer with her meal around 10:30 p.m., or just before reporting to duty that evening. However, she denied she was intoxicated or unable to perform her duties. Respondent was then told to leave work immediately. The incident was later reported to Underhill Personnel Services, Inc. and that agency contacted the Board. After an investigation was conducted by the Board, an administrative complaint was filed. At hearing, respondent did not contest or deny the assertion that by reporting to work with alcohol on her breath, she was acting in an unprofessional manner and deviated from the standards of acceptable and prevailing nursing practice. In this regard, she acknowledged that she had drunk alcohol (which she claimed was only one tall beer) with her meal around 10:30 p.m., or just before reporting to duty. However, she contended that all of her previously scheduled shifts at the hospital had been cancel led and she assumed her shift that evening might also be cancelled. In response to the allegation that she could not operate the vital signs machine, respondent offered a different version of events and suggested that the machine in the patient's room was inoperative. Therefore, it was necessary for Ivie to bring a Dynamap into the room and Ivie took the vital signs without respondent's assistance. She justified leaving the elderly patient alone without clothes in his room on the grounds there was no clean gown, the patient was not combative, and she was only gone from the room for a few moments. Finally, she contended that she charted the notes for one of her patients but did not chart the others because the remaining patients were removed from her care by Ivie and Biddix when she was sent home at 1:30 a.m. However, these explanations are either deemed to be not credible or, if true, nonetheless do not justify her actions. Although there was no testimony concerning the specific issue of whether respondent is unable to practice nursing with reasonable skill and safety by reason of use of alcohol, taken as a whole respondent's conduct on the evening of November 17, 1990, supports a finding that her capacity was impaired that evening by virtue of alcohol. Accordingly, it is found that respondent was unable to practice nursing with reasonable skill and safety by reason of use of alcohol.
Recommendation Based upon the foregoing findings of facts and conclusions of law, it is, RECOMMENDED that respondent be found guilty of violating Subsections 464.018(1)(f), (h), and (j), Florida Statutes (1989), and that her nursing license be suspended for six months but that such suspension be stayed upon respondent's entry into and successful completion of the Intervention Program for Nurses. Respondent's failure to remain in or successfully complete the program will result in the immediate lifting of the stay and imposition of the six-month suspension. Thereafter, said license shall not be reinstated until such time as respondent appears before the Board and can demonstrate that she can engage in the safe practice of nursing. DONE and ENTERED this 16th day of December, 1991, in Tallahassee, Florida. DONALD R. ALEXANDER 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 16th day of December, 1991. APPENDIX TO RECOMMENDED ORDER CASE NO. 91-5033 Petitioner: Partially adopted in finding of fact 1. Partially adopted in finding of fact 3. Partially adopted in finding of fact 8. Partially adopted in finding of fact 3. 5-6. Partially adopted in finding of fact 4. 7-10. Partially adopted in finding of fact 5. 11-14. Partially adopted in finding of fact 6. 15-16. Partially adopted in finding of fact 7. 17-18. Partially adopted in finding of fact 8. COPIES FURNISHED: Roberta L. Fenner, Esquire 1940 North Monroe Street, Suite 60 Tallahassee, Florida 32399-0792 Ruthie Mae Owens Brooks 1604 S.W. 40th Terrace, #A Gainesville, Florida 32607 Jack L. McRay, Esquire 1940 North Monroe Street, Suite 60 Tallahassee, Florida 32399-0792 Judie Ritter, Executive Director 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202
The Issue The issue posed for decision herein is whether or not the Respondent, based on conduct which will he set forth hereinafter in detail, engaged in acts and/conduct violative of Subsection 464.21(1)(d) and (g), Florida Statutes.
Findings Of Fact Based on my observation of the witnesses and their demeanor while testifying, the arguments of counsel, the documentary evidence received and the entire record compiled herein, the following relevant facts are found. Michael Ray Hernicz, R.N., is a licensed registered nurse who holds license No. 0985972. Additionally, the Respondent has been certified as a Certified Registered Nurse Anesthetist (CRNA) and an Advanced Registered Nurse Practitioner (APNP). By its eight-count Administrative Complaint filed March 14, 1979, the Petitioner, Florida State Board of Nursing, seeks to place on probation, suspend or revoke the Respondent's license to practice nursing based on allegations that: During the week of January 15, 1979, Respondent caused to be advertised in the DeLand Sun News, a newspaper of general circulation the opening of an office in the 4 Towns Shopping Center, Orange City, Florida, for the general practice of medicine and used in connection with his name designation, "M.D." to imply or designate himself as a medical practitioner while not licensed, in violation of Florida Statutes Sec. 458.152(a), (b) and (c). On or about February 9, 1979, in Orange City, Florida, Respondent administered medical treatment to Steven H. Gaffney which action was not within the purview of the Nurse Practice Act, Florida Statutes Chapter 464. On or about February 9, 1979, Respondent practiced medicine as defined by Florida Statutes Sec. 458.13, in that he diagnosed, treated and prescribed medication for Steven Gaffney although not licensed to practice medicine in Florida and without the responsible supervisory control of a licensed physician, in violation of Chapter 453 and the Nurse Practices Act, Chapter 464, Florida Statutes. On or about February 16, 1979, Respondent was arrested by law enforcement officers of the Volusia County Narcotics Task Force at his office in Orange City, Florida, and was found to be in unlawful possession of controlled substances as set forth in Florida Statutes Chapter 893. On or about February, 1979, Respondent, for a fee, treated and prescribed medication for patient, Gladys M. Mossman, which treatments and medications were not prescribed or authorized by a person licensed to practice medicine in Florida. Respondent, for a fee, also treated and administered medications to cardiac patient, Nils Ljunberg, which treatment and medications were not prescribed or authorized by a person licensed in the State to prescribe medications or treatment, in violations of Florida Statutes Chapters 458 and 464. On numerous occasions from January 15, 1979, through February 9, 1979, Respondent unlawfully practiced medicine in violation of Chapter 458 by prescribing medications for various patients and treating said patients when he was not licensed to do so and while he was not acting under the responsible supervisory control of a licensed physician or without the purview of the Nurse Practices Act, Florida Statutes Chapter 464. In conclusory fashion, it is alleged that the Respondent is therefore guilty of engaging in the possession of controlled substances as set forth in Chapter 893, Florida Statutes, in violation of Florida Statutes 464.21(1)(d) and (g). The facts surrounding the allegations in the Administrative Complaint filed herein are not in dispute. What is in dispute, however, is the nature and scope of treatment authorized by nurse practitioners, such as Respondent, in view of the additional acts apparently approved by the Joint Advisory Committee on Advanced Nursing Practices. Section 464.021, Florida Statutes. Respecting the allegations that the Respondent caused to be advertised in the DeLand Sun News, an advertisement to the effect that he was opening an office for the general practice of medicine, Steve Blais, an advertising official of the Deland Sun News, appeared and testified that the day following the advertisement which appeared in the local paper, Respondent telephoned his office to alert the paper's advertising staff that a mistake had been made and that the initials "M.D." should not have followed the designation in his ad as he was not a licensed medical doctor in Florida. Mr. Steve Blais offered Respondent a letter of correction such that he could show to customers or anyone who needed documentation. Mr. Blais testified that the ad with the M.D. format ran on January 13, 14 and 17, and that the change was made on or about January 24 to delete the designation "M.D." from the ad. As stated, the facts surrounding the treatment aspect of the allegations are undisputed. However, Respondent contends that based on the supervisory arrangements and the written protocol that he had with Dr. Randal Whitney, M.D., and the working relationship that he had with Dr. Jeffrey Rudell, he was authorized to do the acts which he is here charged with as being violative of the Nurse Practice Act and Chapters 458 and 893, Florida Statutes. As originally conceived, the Respondent planned to practice with Dr. Jeffrey Rudell, who was then licensed in Alabama and who had applied for licensure by endorsement in Florida. This application by Dr. Rudell for licensure by endorsement was denied and Respondent entered into a supervisory relationship with Dr. Randal Whitney of Daytona Beach, Florida. Dr. Whitney appeared and testified that he had in fact entered into a supervisory relationship with Respondent and that he was consulted by Respondent on the treatment of several patients. Dr. Whitney's testimony is that of these patients about when Respondent consulted with him, he concurred with the method of treatment outlined and/or prescribed by Respondent. Respondent testified that he reached a decision that he could properly treat patients while working under the supervision and control of a licensed medical doctor or other specialized practitioner after considerable reflection on the latitude granted Advanced Registered Nurse Practitioners. In support of this decision, Respondent points to the fact that the Joint Committee, by its official Minutes, pointed out in Section 210-11.03, acts which were proper to be performed by an Advanced Registered Nurse Practitioner. Therein, the Board authorized various categories of functions that Advanced Registered Nurse Practitioners may perform at advanced and special levels which are recognized by the nursing profession and which are currently included in the curricula of advanced nursing education programs by the Board (Petitioner). Additionally, the Board authorized Advanced Registered Nurse Practitioners to perform such additional acts as was recognized by the Advisory Committee created by Florida Statutes Subsection 464.021(2)(a)(4) as proper to be performed by an Advanced Registered Nurse Practitioner. Petitioner requested the minutes from numerous meetings of the Board from 1977 through 1978 and noted that Board Member Charles D. MacIntosh during a meeting with the Board of Nursing advised that the Board of Medical Examiners had met on April 2, 1978, and ratified a new appendix D regarding Advanced Registered Nurse Practitioners. Dr. MacIntosh urged the Board that in light of the ratification by the Board of Medical Examiners, the Joint Advisory Committee should jointly meet to work out a proposed formulary of drugs that would he available to Advanced Registered Nurse Practitioners. The Board thanked Dr. MacIntosh for apprising them of the medical board's actions and Petitioner's counsel stated his opinion that, based upon the interpretations of subject Section 465.031, no conflict would result if the Joint Advisory Committee agreed that prescriptions and medications would be an additional act defined by Florida Statutes 464.021. Page 4 of the minutes indicate that with respect to Advanced Registered Nurse Practitioners, they are authorized to perform those additional acts which are performed within protocols which are jointly established by the Advanced Registered Nurse Practitioner and the M.D., D.O., or D.D.S., or the appropriate medical staff of a healthcare facility. Respondent entered into an arrangement with Dr. Whitney and explained to him the manner in which he expected to treat patients coming to his office and Dr. Whitney agreed to allow him the latitude he envisioned. (TR 259 through 261.) Accordingly, Respondent perceived his actions as falling within the purview of the regulation authorized by the joint committee. (TR 263 through 264.) Additionally, Respondent denied that he represented to anyone in this State that he was a licensed medical doctor. Respondent reiterated his position that he immediately notified the paper and asked them to change the designation to reflect that he was not a medical doctor. (Respondent's Exhibit 17.) On February 16, 1979, Respondent's office was searched by the law enforcement officers of Volusia County Narcotics Task Force in Orange City, Florida, and Respondent was given a list of drugs taken from his office by the law enforcement officers. (Petitioner's Exhibit 5.) No evidence was offered to establish that the Respondent has been found guilty of the unlawful possession of controlled substances as set forth and defined in Florida Statutes Chapter 893.
Conclusions In summation, the Respondent established that he, in addition to being a Registered Nurse, has been further certified as an Advanced Registered Nurse Anesthetist. Dr. Randal Whitney established that he entered a relationship with Respondent under the laws of the State of Florida to be his supervisory or sponsoring physician, to consult with him in the practice, and to call or talk personally with Respondent about problems or cases that might be a potential problem or possibly outside his field of expertise as to what to do about them. A similar arrangement was shown to exist between the Respondent and Dr. Paul Andrews, Additionally, Dr. Rene Almiron, M.D., testified that he agreed to read and interpret EKG's for Respondent. Subsection 464.021(2)(a), Florida Statutes, provides that performance of assessment, diagnosis, counselling and health teaching of the ill are within the definition of professional nursing. It thus appears that all of the acts and/or conduct engaged in by Respondent were permissible acts within the responsible supervisory control of Dr. Randal Whitney or were for medications within the approved formulary for Advanced Registered Nurse Practitioners. Respondent credibly testified that he consulted with Dr. Whitney, who supervised him in the treatment of all of his patients. (TR 261.) Finally, although it was alleged in Count IV of the Administrative Complaint that Respondent was found to be in the unlawful possession of controlled substances in violation of Florida Statutes Chapter 893, the Respondent denies this, and no evidence was offered by Petitioner to counter Respondent's assertion. The record herein reflects that while some of Respondent's acts and/or practices may have been questionable based on the conflicting directions embarked upon by the various joint committees, in view of the latitude granted to Advanced Registered Nurse Practitioners by the Nurse Practices Act and the established working relationship entered into between Respondent and Dr. Randal Whitney, the undersigned concludes that Respondent acted within his authority in his treatment of patients referred to herein. I shall so recommend.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is hereby, RECOMMENDED: That the Administrative Complaint filed herein be DISMISSED IN ITS ENTIRETY. RECOMMENDED this 4th day of December, 1979, in Tallahassee, Florida. JAMES E. BRADWELL, Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675
Findings Of Fact Wright is a licensed practical nurse in Florida, holding license number PN 185281. In accordance with her licensure, Wright worked as a practical nurse at Manor Care Nursing Center in Jacksonville, Florida. On January 15, 1991, patient R.B. was admitted to Manor Care for recovery from multiple factures and organic brain damage. R.B. was receiving nourishment, Jevity, through a nasogastric tube (NGT). On January 18, 1991, at approximately 5:00 p.m., R.B. removed the NGT. R.B.'s mental confusion was such that she would attempt to remove the NGT regularly and mittens were used to prevent this behavior. Wright was the nurse responsible for R.B.'s care from approximately 4:00 p.m. to midnight on January 18, 1991. She recorded R.B.'s removal of the NGT. At some point thereafter, registered nurse Rosalina Harrell came and reinserted the NGT. At 9:30 p.m., Wright's notes indicate that R.B. was coughing and that she checked the placement of the NGT. Placement is checked to insure that the tube is inserted into the stomach and not into the trachea and lungs. According to Wright's notes and testimony, she discontinued feeding to give R.B. a rest, even though the placement checks were negative, meaning that the checks did not show that the tube was in the trachea or lungs. Wright restarted the feeding of Jevity (a white liquid food supplement). At 10:30 p.m., Wright's notes showed that R.B. was coughing up "large" amounts of white frothy phlegm. Wright again held the tube feeding for a short time. Another practical nurse, Margaret Patti, came on duty to replace Wright as the nurse in charge of R.B.'s care. In discussing R.B.'s condition with Wright, Wright informed Patti that R.B. had been coughing since the tube was inserted by Harrell. Wright said she did not remove the tube because she was not sure it was indeed in the wrong place. Wright and Patti then both did one test for placement and it was negative to show that the tube was incorrectly placed . Wright then did two other tests while Patti was out of the room, but she reported to Patti that those tests were also negative. Because of the concerns expressed by Wright, Patti monitored R.B. closely after Wright left around midnight. Patti observed some coughing and white sputum between 11:30 p.m. and 2:00 a.m., January 19, 1991. Again at 2:00 a.m. Patti recorded the R.B. was coughing and there was a moderate amount of white sputum present. Then the coughing became continuous and Patti removed the NGT. At 4:00 a.m., Patti recorded that R.B.'s respirations were even and unlabored and that tube feeding remained discontinued. At 5:00 a.m., Patti was advised by the nursing assistant that R.B. had no respiration or heartbeat. Patti called the doctor at 5:40 and R.B. was dead. An autopsy revealed that R.B. had died from asphyxia due to aspiration of Jevity. The lungs were full of Jevity and the bronchioles were plugged by the soft white material. There was nothing in R.B.'s stomach. As it relates to Wright's actions that night, at no time did Wright call a supervisor, registered nurse or doctor to express concern about the placement of the NGT or to indicate the presence of coughing or a white frothy substance around R.B.'s mouth. The presence of coughing and white frothy sputum or phlegm around the mouth is a danger sign that the NGT is in the trachea instead of the stomach. The minimum standard of acceptable and prevailing nursing practice requires that a licensed practical nurse report coughing or frothiness to her supervisor or to an R.N. If the practical nurse did not place the tube, she should contact the person who did insert the tube. If no one is available, then the practical nurse should remove the tube and contact the supervisor, an R.N., or the doctor, by telephone. There is no other acceptable level of care except to stop the food immediately and then report the coughing and presence of white frothy sputum to the appropriate person. At Manor Care that night, no supervisor or R.N. was on the premises, but Wright made no attempt to reach anyone by telephone regarding the situation. Wright's failure to meet these minimum standards of care constitutes unprofessional conduct as that term is defined in Section 464.018(1)(h), Florida Statutes (1991).
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Professional Regulation enter a Final Order and therein: Issue a reprimand to Geraldine McNeal Wright. Place Wright on probation for six months subject to attendance at continuing education courses relative to the omissions in this case, to include a review of danger signs and appropriate responses in patients with nasogastric tubes and a refresher on the appropriate administration of procedures for checking the placement of such a tube. Impose a fine of $100. DONE and ENTERED this 11th day of February, 1993, in Tallahassee, Florida. DIANE K. KIESLING 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 11th day of February, 1992. APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 92-4573 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted by the parties in this case. Specific Rulings on Proposed Findings of Fact Submitted by Petitioner, Department of Professional Regulation, Board of Nursing Each of the following proposed findings of fact is adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1-7(1-5); 7(7); 9(12); 10(10); 11(11); 12(11); and 15(12 & 16). [Note--There are two different sets of paragraphs numbered 7, 8, and 9. A review of the actual Finding of Fact will clarify to which paragraph these specific rulings apply.] Proposed findings of fact 8, 9, 8, and 14 are subordinate to the facts actually found in this Recommended Order. Proposed findings of fact 13 and 16 are unsupported by the competent and substantial evidence. Specific Rulings on Proposed Findings of Fact Submitted by Respondent, Geraldine McNeal Wright As indicated above, Wright's proposed findings of fact are in a form which does not permit clear specific rulings. Those proposed findings of fact which are based on the documents attached to the proposed order, which were not part of the evidentiary record, are rejected. Additionally, those proposals which constitute argument are rejected. The proposed findings of fact which are consistent with the facts found herein are adopted. All other proposed findings of fact are subordinate to the facts actually found in this Recommended Order. COPIES FURNISHED: Charles Faircloth Senior Attorney Department of Professional Regulation 1940 N. Monroe St., Ste. 60 Tallahassee, FL 32399-0792 Geraldine McNeal Wright 7925 Merrill Road, Apt. 216 Jacksonville, FL 32211 Jack McRay, General Counsel Department of Professional Regulation 1940 N. Monroe St. Tallahassee, FL 32399-0792 Judie Ritter, Executive Director Board of Nursing Daniel Building, Room 50 111 E. Coastline Dr. Jacksonville, FL 32202
The Issue An administrative complaint dated August 16, 1989 alleges that Respondent, Atalia Dacosta G. Sagastume, L.P.N., violated certain provisions of Chapter 464, F.S., related to the practice of nursing, by failing to properly chart the administration of controlled substances to patients. The issue in this proceeding is whether the alleged violations occurred, and, if so, what discipline is appropriate. Procedural Matters Ms. Sagastume responded to the administrative complaint with a request for formal hearing. The case was referred to the Division of Administrative Hearings and was scheduled for hearing on May 9, 1990. On April 24, 1990, Ms. Sagastume called the hearing officer to request a continuance, as she was working with the U.S. Census Bureau and also had surgery scheduled. She asked that the case be reset for the end of June, or thereafter. She was told to check with opposing counsel regarding her request, and later she confirmed that there was no objection. The hearing was cancelled, and Ms. Sagastume was asked to follow up her oral request in writing. No written request was filed. The hearing officer's secretary made several efforts to contact Ms. Sagastume and left messages on her answering machine or with whomever answered her phone. On June 4, 1990, when nothing further was heard from Ms. Sagastume, the amended notice of hearing was mailed, establishing a new hearing date of August 30, 1990. The notice was not returned, nor was any communication received from Ms. Sagastume. She did not appear at the hearing. Instead, she sent a certified letter to Lisa Bassett, then counsel for Petitioner, postmarked August 27, 1990 and received August 29, 1990. The letter requested that the hearing be rescheduled for sometime in November, as she was still working for the Census Bureau. No return address nor telephone number was listed on the letter or envelope. When Respondent did not appear at the hearing, the hearing officer tried to contact her at the telephone number in the file, 407-348-4450, but the number had been discontinued. Mr. Tunnicliff informed the hearing officer that he had not spoken with Ms. Sagastume. The DPR investigator had attempted to reach her by phone, or in person at her house, several times, but was unsuccessful. Ms. Sagastume had returned the call once, but left no telephone number. Since Ms. Sagastume had successfully obtained a continuance in the past, it was deemed that she is aware of the proper procedure and was attempting to avoid the proceeding. Petitioner was prepared to present its case and the hearing commenced at 9:50 a.m. In support of the allegations, Petitioner presented the testimony of Mary Elizabeth Duchaine, Helen Louis Shipley, Jacquette Cockrell, and Patricia Allen Zimmerman. Petitioner's exhibits #1-9 were admitted, which exhibits include the letter from Ms. Sagastume referenced above, patient records, Respondent's license file and a final order and complaint in another disciplinary action against the same Respondent. No transcript was filed and the right to file a proposed recommended order was waived by counsel for Petitioner.
Findings Of Fact During the relevant period, Respondent Atalia Dacosta G. Sagastume was licensed by the State of Florida as a practical nurse holding license number PN 0824781, issued on March 31, 1986. Her address of record was 316 Florida Parkway, Kissimmee, Florida, 34743-6325. Ms. Sagastume was employed by Kissimmee Memorial Hospital as a "pool nurse" in November, 1988. A pool nurse is not a regular employee, but serves on call during times of need, and receives a premium salary with no regular benefits. Pool nurses are considered experienced nurses and are held by the hospital to the same nursing standards as regular staff. Ms. Sagastume received orientation as to hospital procedures at Kissimmee Memorial Hospital all day on November 28, 1988, and on five additional days throughout the next few months. The orientation included methods of appropriate record-keeping, which methods are also standard nursing practice. On January 18, 1989, Ms. Sagastume signed out the narcotic, Demerol, two times on the sign out sheet for Patient "D". Ms. Sagastume was not the attending nurse for this patient and no entries on this patient's chart were made by Ms. Sagastume, as observed by Jacque T. Cockrell, R.N., the Director of Nursing at Kissimmee Memorial at the time of the incident. Ms. Cockrell and another nurse supervisor met with Ms. Sagastume and prepared a counselling report on January 19, 1989. Ms. Sagastume was reminded that she may administer medications only to her own patients and that she must document narcotics on the patient's chart (progress notes) as well as on the narcotics record sheet. At that time the supervisors considered the problem was educational and felt they had remedied it. On February 6, 1989, Ms. Sagastume signed out narcotic medications for two patients, "W" and "M". She altered the times on the signout sheet by simply writing over the entries, rather than by striking through, writing "error", and then correcting the entry as she had been instructed. In addition, on February 6, 1989, Ms. Sagastume signed out narcotic medications to patient "M" four times during her evening shift: 15:05 (3:05 p.m.), 19:00 (7:00 p.m.), 21:00 (9:00 p.m.), and 23:10 (11:10 p.m.). This is unusual, and some notation should have been made that the physician was called about the patient's pain. The notes on the patient's chart do not reflect a need for the medication, particularly since the 7:00 p.m. entry by Ms. Sagastume indicates that the pain was relieved. Ms. Sagastume's careless, improper or incomplete record-keeping violate minimal standards of acceptable prevailing nursing practice. Kissimmee Memorial Hospital discharged Ms. Sagastume on February 20, 1989. A separate administrative complaint in DPR case #89-001399 was filed against this Respondent on March 8, 1990. That complaint alleges other violations of nursing practice standards at St. Cloud Hospital in April, 1989. These violations involved irregularities in narcotics record keeping, as well as the observation of unsteady, erratic behavior and the presence of fresh needle marks on the Respondent's arms. Respondent failed to respond to that complaint and on July 10, 1990, the Board of Nursing entered its Final Order finding that the investigative file supported the allegations of the complaint. The license of Atalia Sagastume was ordered suspended until she personally appears before the Board and demonstrates her ability to safely engage in the practice of nursing. (Petitioner's Exhibit #9).
Recommendation Based on the foregoing, it is hereby, RECOMMENDED: That a Final Order be entered finding Respondent guilty of unprofessional conduct as alleged, and suspending her license to practice nursing, concurrently with the suspension already imposed in DPR case #89-001399. DONE and RECOMMENDED this 4th day of October, 1990, in Tallahassee, Florida. MARY CLARK Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 4th day of October, 1990. COPIES FURNISHED: Atalia Dacosta G. Sagastume 316 Florida Parkway Kissimmee, FL 32743-8413 and 710 Royal Palm Drive Kissimmee, FL 34743 Charles Tunnicliff, Esquire Department of Professional Regulation 1940 North Monroe Street, Suite 60 Tallahassee, FL 32399-0792 Kenneth E. Easley General Counsel 1940 North Monroe Street Tallahassee, FL 32399-0792 Judie Ritter, Executive Director Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202
Findings Of Fact In October 1978 Bonnie Ray Solomon Crawford, LPN was employed at the West Pasco Hospital, New Port Richey, Florida as a licensed practical nurse provided by Upjohn Company's rent-a-nurse program. On 7 October 1978 Respondent signed out at 10:00 a.m. and 2:00 p.m., and on 8 October 1973 at 8:00 a.m. and 1:00 p.m. for Demerol 75 mg for patient Kleinschmidt (Exhibit 2). Doctor's orders contained in Exhibit 4 shows that Demerol 50 mg was ordered by the doctor to be administered to patient Kleinschmidt as needed. Nurses Notes in Exhibit 4 for October 7, 1978 contains no entry of administration of Demerol at 10:00 a.m. and at 2:00 p.m. shows administration of 50 mg. and Phenergan 25 mg. Exhibit 3, Narcotic Record for Demerol 50 mg contains two entries at 8:15 a.m. on October 7, 1978 and one entry at 12:30 p.m. where Respondent signed out for Demerol 50 mg. for patients King, Zobrist and King in chronological order. Nurses Notes for King, Exhibit 6, and Zobrist, Exhibit 5, contain no entry that Demerol was administered to patient Zobrist at 8:15 a.m. or to patient King at 12:30 p.m. on 7 October 1978. In fact, the record for Zobrist shows that Zobrist was discharged from the hospital on October 5, 1978. Failure to chart the administration of narcotics constitutes a gross error in patient care and is not acceptable nursing practice. Similarly it is not acceptable nursing practice to withdraw narcotics not contained in doctors orders or administer medication not in doctors orders. When confronted by the Nursing Administrator at West Pasco Hospital with these discrepancies in the handling of Demerol, Respondent stated that she failed to check the identity of the patient before administering medication and that she didn't feel she should be giving medications any more. Following this confrontation with the hospital authorities, Respondent was fired for incompetency. No evidence was submitted regarding Respondent's 1975 disciplinary proceedings.
The Issue The issues in dispute in this case result from an administrative complaint brought by Petitioner against Respondent accusing Respondent of inappropriate conduct by placing a controlled substance, within the meaning of Chapter 893, Florida Statutes, in the possession of a fellow nurse practitioner, which controlled substance had not been prescribed for the benefit of the other nurse. Respondent is also accused of misappropriating an amount of that controlled substance for her personal use. Purportedly, these actions violate Subsection 464.018(1)(f), Florida Statutes, in that Respondent was guilty of unprofessional conduct departing from the minimal standards of acceptable and prevailing nursing practice and in violation of Subsection 464.018(1)(g), Florida Statutes, by engaging or attempting to engage in the possession, sale, or distribution of controlled substances within the meaning of Chapter 893, Florida Statutes, other than for legitimate purposes.
Findings Of Fact On August 18, 1982, the Secretary, State of Florida, Department of Professional Regulation, filed the Administrative Complaint which is the subject of this hearing. This case is being prosecuted by that Department pursuant to Chapter 464, Florida Statutes. Respondent disputed factual allegations within the Administrative Complaint, which led to the formal hearing on February 11, 1983. Respondent is licensed by the State of Florida, Board of Nursing, in the category of licensed practical nurse and at all times pertinent to this case held License No. 39013-1. On April 29, 1982, Respondent was working in the capacity of a licensed nurse at the University Hospital, Jacksonville, Florida. She was serving as a floor nurse at that time. A patient who had been admitted to the hospital, was discharged and 30 Tylenol Number 3 tablets, a scheduled substance within Chapter 893, Florida Statutes, which had been dispensed for the benefit of that patient, were left in the hospital following the patient's discharge. Tylenol Number 3 contains Codeine phosphate, 30 mg. Respondent retrieved those tablets on the date in question and approached another nurse practitioner who was working on the same floor on that evening. This nurse is Bonnie Booth who is licensed as a registered nurse in the State of Florida. While in Booth's presence, Respondent stated, "these were left by a patient who probably doesn't want them anyway and, you know, the patient is gone. So, what's the difference if they go back to the pharmacy or not?" Respondent additionally mentioned having a problem with her knee and taking one of the Tylenols for that difficulty. Booth told Respondent that the tablets should be locked in the medication security area and gave the keys to Respondent that would unlock that narcotics cabinet. Respondent walked away and while standing by a medication cart, Respondent counted the tablets, walked back to Booth, and placed 16 of those tablets in Booth's laboratory coat pocket. While standing there, Respondent told Booth that Booth and Respondent should split the pills "50/50", meaning an equal share of the controlled substance. Respondent then left the area, taking with her the remainder of the Tylenol tablets. Booth subsequently turned in the tablets in her possession by giving them to hospital officials. Those items were introduced in the hearing as Petitioner's Exhibit No. 1. Later on that same evening, following Booth's provision of the tablets which she had received to officials within the hospital, Respondent spoke to Booth. Respondent asked Booth why she had told the hospital officials and was answered, to the effect, that Booth did not involve herself with drugs. Respondent then asked Booth to return the tablets which Respondent had given her and was told that it was too late to do that. According to Debra Fitzgerald, Advanced Nurse Practitioner, certified by the State of Florida, the actions by Respondent involving the Tylenol were not in keeping with minimal and acceptable standards of nursing practices in the State of Florida. This opinion is correct.
The Issue The issues in this proceeding are whether the Respondent has committed violations of statutes pertaining to the practice of nursing as alleged in the Amended Administrative Complaint, and, if so, what disciplinary action is appropriate.
Findings Of Fact At all times material to this proceeding, the Respondent has been licensed by the Petitioner as a licensed practical nurse. From approximately May 21, 1980 until May 29, 1981, the Respondent was employed as an "LPN charge nurse" at Huntington Square Convalarium, Inc., in Daytona Beach, Florida. She had previously been employed at Huntington Square in the same capacity for approximately two months. She then went on maternity leave before she was reemployed. Persons in this capacity at Huntington Square supervised several nurses' aides, and performed usual nursing duties which included assessment of patients, preparation, administering and charting of medications, public relations duties with members of patients' families, telephone duties, being aware of safety conditions in the building, and the like. During the time that she served as a charge nurse at Huntington Square, the Respondent, on a recurring and frequent basis, engaged in unprofessional conduct which departed from the minimal standards of acceptable and prevailing nursing practice. Respondent was experiencing extreme personal difficulties during that period, and she was subject to extreme mood swings while on the job. While in depressed moods, the Respondent would occasionally become inattentive to patients' needs and, on a few occasions, she failed to respond to obvious needs such as a catheter misplacement or edema. Respondent was subject to frequent crying fits. Other than occasional inattentiveness, the Respondent would, during her depressed episodes, inadequately chart and document procedures, use loud and profane language, and engage in extended conversations with staff members, visitors, and even patients regarding her personal problems. Respondent's conduct was disruptive and upsetting to the staff at Huntington Square, especially to those persons whom the Respondent supervised. Respondent's preoccupation with her own problems caused her to give too little attention to the needs of her patients, both directly and through persons she supervised. There was no testimony from which it could be concluded that any serious repercussions were imposed upon the Respondent's patients by her conduct. The conduct did, however, fall below minimal and acceptable standards of nursing practice in the State of Florida. Respondent's depression appears to have reached a peak in May, 1981. At that time, she was involved in an incident at Pick Shoe Store in Daytona Beach. The Respondent was dating an employee of the store. Respondent showed up at the store in an extremely agitated condition with a hand gun. Respondent was ultimately forced out of the store, the door was locked behind her, and she was handled by the police. What the Respondent's specific intent was at that incident is not known. She did admit to various persons, however, that on at least one occasion she attempted suicide at approximately that time. The Respondent suffers from a condition, recurrent depression, which is properly classified as a mental illness. The condition has in the past affected her ability to perform nursing functions. The condition is, however, controllable. Respondent was hospitalized in connection with a suicide attempt. Since October, 1951, she has engaged in regular counselling services at the Human Resources Center in Daytona Beach. Her condition has stabilized, and she has taken positive steps to improve her personal relationships. If the Respondent's condition remains stable, she is fully able to practice nursing effectively. If the Respondent continues to engage in a regular counselling program, it is likely that her condition will remain stable. Since November, 1981, the Respondent has worked at Bowman Nursing Center as a supervisor nurse. She is charged with responsibilities for examining reports; taking controlled drug counts; setting up, administering and charting medications; assisting with feeding; reporting on patients' progress; and making written evaluations. The Respondent has performed her job functions in an acceptable manner, and her job performance has steadily improved during her employment.
The Issue Whether Respondent violated Section 464.018(1)(h), Florida Statutes, as alleged in the Administrative Complaint? If so, what disciplinary action should be taken against her?
Findings Of Fact Based upon the evidence adduced at hearing, and the record as a whole, the following Findings of Fact are made: The Agency is a state government licensing and regulatory agency. Respondent is now, and has been since June 18, 1993, licensed as a practical nurse in the State of Florida. Her license number is PN 1113121. Respondent trained to be a practical nurse at the Sheridan Vocational School (hereinafter referred to as "Sheridan") in Hollywood, Florida. She graduated from Sheridan in January of 1993, the recipient of the Jeanette Lindsey Shirley Nursing Service Award. Respondent was employed by Aventura Hospital and Medical Center (hereinafter referred to as "Aventura") from approximately March of 1993, to January of 1994, when she was terminated as a result of the incident which led to the issuance of the Administrative Complaint that is the subject of the instant case. For the first three months of her employment at Aventura Respondent worked as a GPN (Graduate Practical Nurse). After receiving her nursing license in June of 1993, Respondent was promoted to an LPN (Licensed Practical Nurse) position. She held this LPN position until her termination in January of 1994. Throughout the period of her employment, Respondent was assigned to the hospital's mental health unit. Respondent was a dedicated and loyal employee who, as general rule, got along well with the patients under her care, as well as her coworkers. Not infrequently, she would voluntarily remain on the unit after the end of her shift to make sure that her patients received the care and attention their physicians had ordered. Prior to the incident that resulted in the termination of her employment, Respondent had an unblemished employment record at Aventura. The incident in question occurred on or about January 17, 1994. On the day of the incident Respondent was working the 12 midnight to 8:00 a.m. shift at the hospital. One of the patients under her care that day was B.H. B.H. was an elderly woman receiving treatment for depression. She required the nursing staff's assistance with Activities of Daily Living (ADLs), including dressing. B.H. was a "very difficult" patient. She was generally uncooperative and frequently resisted, with physical force and violence, the nursing staff's efforts to provide her the help and assistance she needed with her ADLs. On the day in question B.H. had a scheduled, early morning appointment to see her attending physician, Dr. Greener. Dr. Greener had given explicit instructions to the nursing staff that B.H. be awakened and dressed before the scheduled appointment. Toward the end of her shift, Respondent went into B.H.'s room to get her ready for Dr. Greener. Respondent was able to awaken B.H., but B.H. refused to get out of bed. Respondent decided to leave B.H. and take care of the other tasks she needed to complete before the end of her shift. When Respondent returned to B.H.'s room it was after 8:00 a.m. Although her shift had ended, Respondent felt an obligation to remain at the hospital and follow through with her efforts to fully comply with the instructions that Dr. Greener had given concerning B.H. Dr. Greener had already arrived at the hospital and was ready to see Respondent. Respondent pleaded with B.H. to cooperate with her. B.H., however, ignored Respondent's pleas and remained in bed. Dr. Greener was a demanding physician who expected the nursing staff to timely comply with his every instruction. He expressed, in no uncertain terms, his disappointment when these expectations were not met. Respondent did not want to disappoint Dr. Greener. She therefore attempted to dress B.H. even though B.H. would not get out of bed. B.H. responded to Respondent's efforts to dress her by kicking, swinging her arms and spitting at Respondent. Despite receiving such resistance, Respondent continued to try to dress B.H. She did call for assistance, however. Todd Sussman, who was employed as a Mental Health Technician at the hospital, was on the unit that morning and responded to Respondent's call for help. When Sussman discovered the nature of the assistance Respondent required, he left B.H.'s room to obtain surgical gloves. Shortly thereafter, he returned to the room wearing such gloves. As Sussman walked back into the room, he saw Respondent, who was still struggling with B.H., slap B.H. in the face and pinch B.H.'s lips together in an effort to prevent B.H. from spitting at her. Sussman helped Respondent attempt to dress B.H. by holding B.H. by the arm. At one point, he let go of B.H. to allow Respondent to remove B.H.'s night shirt. Once her arm was free, B.H. swung it in Respondent's direction and hit Respondent in the face. Respondent reacted by slapping B.H. "fairly hard" on or slightly above the wrist, a reaction that was witnessed by Sussman, as well as another employee of the hospital, Barry Butler, an LPN who had entered the room shortly before B.H. had struck Respondent in the face. Both Sussman and Butler reported to their supervisor what they had observed take place in B.H.'s room that morning. Respondent's employment with the hospital was subsequently terminated based on the information Sussman and Butler had provided. At no time while struggling to dress B.H. on or about January 17, 1994, did Respondent intend to, nor did she actually, harm or injure B.H. Nonetheless, during the struggle (specifically when she purposefully slapped B.H. in the face and on or slightly above the wrist and pinched B.H.'s lips together), 2/ Respondent acted in an unprofessional manner that did not conform with the minimal standards of acceptable and prevailing nursing practice. 3/ The use of such physical force against B.H. was unnecessary and therefore inappropriate. 4/ There were other, safer (and therefore more appropriate) options (of which Respondent should have been aware in light of her training) that were available to Respondent to deal with the difficult situation she faced.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Board of Nursing enter a final order finding Respondent guilty of the violation of subsection (1)(h) of Section 464.018, Florida Statutes, alleged in the Administrative Complaint and disciplining her for having committed this violation by fining her $250.00 and placing her on probation (of the type specified in subsection (1)(g) of Rule 59S-8.006, Florida Administrative Code: "[p]robation with specified continuing education courses in addition to the minimum conditions") for a period of eighteen months. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 4th day of January, 1996. STUART M. LERNER, 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 4th day of January, 1996.
