Findings Of Fact Respondent, Carol O'Donnell (O'Donnell), was at all times material hereto licensed as a registered nurse in the State of Florida, and held license number 1498442. On May 15, 1986, O'Donnell was employed as a registered nurse at Broward General Medical Center, Broward County, Florida, on the 3:00 p.m. to 11:00 p.m. shift. At or about 7:30 p.m., O'Donnell abandoned her employment, without notice or authorization, and thereby left her patients unattended. Although the period that elapsed between the time O'Donnell abandoned her position and the time her absence was discovered was apparently of short duration and there was no proof any patient suffered from her absence, her conduct constituted a departure from and failure to conform to the minimum standards of acceptable and prevailing nursing practice in the community.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Respondent, Carol O'Donnell, be reprimanded, and that an administrative fine of $500.00 be imposed upon her. DONE and ENTERED this 20th day of August, 1987, in Tallahassee, Florida. WILLIAM J. KENDRICK Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 20th day of August, 1987. APPENDIX Petitioner's proposed findings of fact are addressed as follows: 1. Addressed in paragraph 1. 2-4. Addressed in paragraph 2. 5. Addressed in paragraph 3. COPIES FURNISHED: William M. Furlow, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Ms. Carol O'Donnell 109 North Birch Road, #4 Ft. Lauderdale, Florida 33312 Judie Ritter, Executive Director Board of Nursing 111 East Coastline Drive Room 504 Jacksonville, Florida 32201 Van Poole, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Joseph A. Sole General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
The Issue Whether Respondent's license to practice nursing in the state of Florida should be revoked, suspended or otherwise disciplined under the facts and circumstances of this case.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made: At all times material to this proceeding, Respondent Teresa Iva Smith Lobato (Lobato) was licensed as a Registered Nurse in the state of Florida, holding license number RN-1655102, and was employed by the Bayfront Medical Center (Bayfront) located in St. Petersburg, Florida as a Registered Nurse. On May 13, 1990 Lobato was to work the 7:00 a.m. to 3:00 p.m. shift, and upon arriving for work was told that she was being "floated" from the Coronary Care Unit (CCU) where she regularly worked to the Progressive Care Unit (PCU) where she had never worked. Bayfront had a policy whereby nurses were "floated" from one unit to another, and at the time Lobato was employed by Bayfront she was made aware of this "floating" policy. Floating means that a nurse is assigned temporarily to a unit other than the nurse's regularly assigned unit. On May 12, 1990 Lobato was aware that she was to be "floated" on May 13, 1990, but had informed the Acting Director of CCU that she would rather cancel her work assignment than be "floated". However, upon arriving for work on May 13, 1990, and being told that she was being "floated" to PCU she accepted the assignment on PCU although she was not pleased about the situation. Bayfront has a policy that requires the outgoing nurse to audiotape a report for the oncoming nurse regarding the condition of the patients and any events occurring during the outgoing nurse's shift or if no tape is made to give report verbally to oncoming nurse. Upon arriving at PCU Lobato, along with PCU Charge Nurse (CN), listened to the audiotaped reports from the outgoing nurse on the following patients D. L. L., A. S., E. H., C. L. S., and H. K. As the morning progressed, Lobato became more and more displeased with her assignment, and let her displeasure be known to the PCU Charge Nurse. However, Lobato did not ask to be relieved from her assignment, although there was testimony that she indicated to the CN that she wanted to go home. Although the record is not clear as to the time the following events occurred, the sequence of those events are as follows: Around 9:00 a.m. Lobato was offered help by the CN but declined; Around 9:30 Lobato went on break, and again was offered help but declined; While on break Lobato talked to the Assis- tant Director of Nursing (ADON) about her under- standing of not being required to "float", and became upset with the ADON's response; After returning from break Lobato was again offered help by the CN which she accepted. The CN brought Michelle Nance, Medical Surgical Technician, and two RNs whose first names were Jessica and Melinda to the unit to assist Lobato. Around 10:30 a.m. Lobato and the CN dis- cussed Lobato's patient assignments, and Lobato advised the CN that everything was done, in- cluding all a.m. medication, other than the missing vasotec doses, and that she had some charting to do. Also, the patient's baths had been completed. Shortly after Lobato and the CN discussed her patients' assignments, the ADON came to the unit to determine what was troubling Lobato. The ADON and Lobato met and there was a confrontation wherein Lobato advised the ADON that she was quitting and the ADON advised Lobato that she was fired. After Lobato's confrontation with the ADON, Lobato left the unit and Bayfront without completing the balance of charting her patients' notes, and without giving the CN a report of the patients even though the CN requested her to do so. Lobato's reasons for not giving the CN a report was that she had discussed the patients with the CN throughout the morning, and that the CN knew as much about the patients as did Lobato at that time, and therefore, she had made a verbal report. Lobato's reasons for not completing the charting of her patients' notes was that when the ADON fired her on the spot the ADON accepted full responsibility for the patients, and Lobato's responsibility to both Bayfront and to the patients assigned to her ceased at that time, notwithstanding her understanding of the importance of charting so that appropriate care could be given to the patients on the next shift. By her own admission, Lobato left Bayfront around 10:30 a.m. on May 13, 1991 before the end of her shift without completing the balance of charting her patients' notes and without giving a report to the CN, other than the ongoing report given during the morning. Earlier while Lobato was still on the unit working the CN had obtained two registered nurses (RN) and a medical surgical technician to assist Lobato. One of the nurses whose first name was Jessica (last name not given) was the RN assigned to Lobato's patients by the ADON when Lobato left and she received a report on the patients from Janice Ritchie, CN. (See Respondent's exhibit 1, and Petitioner's exhibit 1 and Janice Ritchies' rebuttal testimony.) Although Lobato's failure to chart the balance of her patients' notes and make a report to the CN before she left may have caused some problems, there was no showing that any patient failed to receive proper care or suffered any harm as a result of Lobato leaving. While some of the patients may not have received all their medication before Lobato left, the record is not clear as to whether the medication was made available to Lobato to administer or that she was shown where the medication was located in the floor stock. The patient is the nurse's primary responsibility, and the minimal standards of acceptable and prevailing nursing practice requires the nurse, even if fired (unless prevented by the employer from performing her duties), to perform those duties that will assure the patient adequate care provided for after her absence. In this case, the failure of Lobato to compete the charting of her patients' notes and the failure to make a report to the CN, notwithstanding her comments to the CN upon leaving, was unprofessional conduct in that such conduct was a departure from and a failure to conform to minimal standards of acceptable and prevailing nursing practice.
Recommendation Based upon the foregoing, it is recommended that the Respondent be found guilty of violating Section 464.018(1)(h), Florida Statutes, and that she be given a reprimand. RECOMMENDED this 31st day of May, 1991, in Tallahassee, Florida. WILLIAM R. CAVE 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 31st day of May, 1991. APPENDIX TO RECOMMENDED ORDER, CASE NO. 90-7828 The following contributes my specific rulings pursuant to Section 120- 59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties in this case. Rulings on Proposed Finding of Fact Submitted by the Petitioner 1. Adopted in Finding of Fact 1. 2. Adopted in Findings of Fact 1 and 2. 3.-4. Adopted in Findings of Fact 3 and 4, respectively. 5.-6. Adopted in Finding of Fact 4 and 5. 7.-8. Adopted in Finding of Fact 5. 9. Adopted in Findings of Fact 6 and 7. 10. Adopted in Finding of Fact 7. 11.-12. Rejected as not being supported by substantial competent evidence in the record, but even if this testimony was credible it is not material or relevant to the conclusion reached. Adopted in Finding of Fact 8, as modified. Rejected as not being supported by substantial competent evidence in the record, but even if this testimony was credible it is not material or relevant to the conclusion reached. Rejected as not being supported by substantial competent evidence in the record. Adopted in Finding of Fact 8, as modified. Rejected as not being supported by substantial competent evidence in the record. 18.-20. Adopted in Finding of Fact 9 and 12, as modified. Adopted in substance in Findings of Fact 9 and 12. Rejected as not being supported by substantial competent evidence in the record. See Findings of Fact 10, 11, 13 and 14. Adopted in Finding of Fact 11. Rejected as not being supported by substantial competent evidence in the record. 25.-27. Adopted in Findings of Fact 3, 15 and 15, respectively. Paragraph 28 is ambiguous and, therefore, no response. Rejected as not being Finding of Fact but what weight is to be given to that testimony. Rulings on Proposed Findings of Fact Submitted by the Respondent 1.-2. Rejected as being argument rather than a Finding of Fact, but if considered a Finding of Fact since there was other evidence presented by other witnesses. The first sentence is rejected as not being supported by substantial competent evidence. The balance of paragraph 3 is neither material nor relevant. Neither material nor relevant, but see Findings of Fact 6, 7, and 8. Rejected as not being supported by substantial competent evidence in the record, but see Findings of Fact 6, 7, and 8. Neither material nor relevant since the Respondent assisted in selecting those items to be included in Respondent's exhibit 1. First sentence adopted in Finding of Fact 8. The balance of paragraph 7 is argument more so than a Finding of Fact, but see Findings of Fact 12 and 14. More of an argument than a Finding of Fact, but see Findings of Fact 7(c), 12 and 14. 9.-11. More of an argument as to the credibility of a witness rather than a Finding of Fact. More of an argument than a Finding of Fact but see Findings of Fact 7(d) and 13. More of a restatement of testimony than a Finding of Fact, but see Findings of Fact 8 and 9. More of an argument than a Finding of Fact, but see Finding of Fact 10. More of an argument than a Finding of Fact, but see Findings of Fact 7(e) and 9. Not necessary to the conclusions reached in the Recommended Order. 17.-19. Rejected as not being supported by substantial competent evidence in the record, but see Findings of Fact 9 and 12. 20. More of an argument as to the credibility of a witness rather than a Finding of Fact. 21.-23. More of an argument than a Finding of Fact. COPIES FURNISHED: Lois B. Lepp, Esquire Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, FL 32399 Teresa Iva Smith Lobato 6870 38th Avenue North St. Petersburg, FL 33710 Judie Ritter, Executive Director Board of Nursing 504 Daniel Building 111 East Coastliinne Drive Jacksonville, FL 32202 Jack McRay, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792
Findings Of Fact Respondent B. Delores Lane Eckard holds a Florida license as a registered nurse, No. 1091372. She has been so licensed since September 10, 1979. Petitioner's Exhibit No. 1. Before she was fired in July of 1983, respondent worked twelve-hour night shifts in the surgical intensive nursing unit at Baptist Hospital in Pensacola. A burn victim, Marc MacInvale, was among the patients respondent attended, during the shift that began at seven o'clock on the evening of June 15, 1983. Because of the extent of his burns, Mr. MacInvale had been placed in a private room, and hospital staff observed "reverse isolation" techniques. In or on his nightstand, Ms. Eckard found two, ten milligram ampules of Valium. Knowing that it was against hospital policy for the ampules to be there, she picked them up, intending to return them to the medication cart. She put them in her pocket for safekeeping, while she finished tasks in Mr. MacInvale's room. After she got home from work, on the morning of June 16, 1983, she undressed and went to bed. When she awoke and gathered up her clothes for washing, she discovered that the ampules were still in the pocket of her uniform. She was aware that a nurse had been fired two weeks earlier when Valium had been discovered in her locker at Baptist Hospital; and she decided against notifying the hospital or anybody she worked with of the whereabouts of the Valium. Instead, she placed the ampules in a clear plastic bag together with a piece of paper with Marc MacInvale's name on it and put the clear plastic bag in her "work purse," with the intention of returning the Valium to the hospital, when she next went to the hospital. In these circumstances, failure to report promptly that she had removed a patient's medicine from his room and that he did not receive it fell below minimal standards of acceptable and prevailing nursing practice, according to uncontroverted testimony. The clear plastic bag with the ampules and the piece of paper with "Marc MacInvale" written on it were still in Ms. Eckard's purse when she was arrested in the early morning hours of June 17, 1983, for driving under the influence of intoxicants. Celebrating with friends at a restaurant in anticipation of her June 18 birthday, she had drunk two glasses of wine and a "brandy manhattan," but had ingested no other intoxicating substances, before setting out for home. After her arrest, she demonstrated poor coordination and balance, slurred speech and difficulty in understanding. After twice registering less, the breathalyzer registered 1.0. Formal charges were apparently filed, and, on October 19, 1983, respondent pleaded nolo contendere. Petitioner's Exhibit No. 2. The police examined the contents of respondent's purse on June 17, 1983, and an assistant state's attorney eventually inquired of William Allen Foster, Baptist Hospital's director of security, whether Valium had been prescribed for Marc MacInvale. Norma Jean Vaughan, respondent's supervisor, confronted her, after she learned that Ms. Eckard had been arrested with Valium in her purse. Respondent volunteered blood and urine samples for analysis. The results of analysis were negative, but Baptist Hospital terminated her employment nevertheless. At the time, things were not going well on the domestic front, either. Ms. Eckard's husband had beaten her, and they were separated. In despair, she recorded the following: "Begin a good-bye tape. Um, I don't want anybody feeling sorry for me. I just want everyone to know why - I never thought that I would come to this point in my life. Cir- cumstances have, uh, made it so that I have, and the decision has been made and is irrevocable. In my forty-three years, I've spent the first (voice shaky, clearing throat) well, five years, with a divorced mother. Then, I spent until I was eleven in an orphanage. This taught me a lot of compassion, if, nothing more. Through my teen years, I had various stepfathers; many were - had means and, uh, were very good to me. I married young and was very happy - raised three chil, well, two children, and, uh, thought I did a decent job. Thought our marriage was well organized and pretty happy, overall. We had everything under control. We saved our money. We made good investments. Everything was going our way. I decided after the children were grown that I wanted to be a nurse. I could do what I wanted to do now. My job with the children was over as far as their, their primary needs were concerned. They had other interests in their lives, and I accepted my displacement. I went to nursing school and, uh, worked very hard to make the grades that I did. I went far and beyond what I had to do to advance my knowledge in medicine and to prepare myself to be the best nurse that I could be. I've worked five years in nursing and, uh, even though I worked Surgical Floor, many people feel like all you do is change bandages, do your job and that's it. The emotional needs of the patient are completely ignored. They hurt, you give them pain meds or you tell them, 'That's too bad; you can't have any pain medicine for another so many hours. And then, that's it. There's no, there's no, uh, efforts to make them more comfortable during that waiting period where they, where they're suffering so much. Or maybe they feel that nobody loves them. Nobody cares. They feel the isolation (pause) the, like no one's with them. They're in an alien environment. A lot of this is ignored by a lot of nurses. I was in reverse isolation when I was burned, and I spent three months in a wheelchair. I know what it is to be alone in an isolation room and, uh, the nurses saying, 'Oh, my God, do I have to dress that again?'. You know. Nobody, it's not a very pleasant thing, but I know the feeling of isolation. I know the feeling of not feeling wanted even though you are. Uh, and I've tried to take, in my nursing, the total body into, to mind to try to fill the needs of the total person, not just the colostomy. It's not a colostomy patient. It's not, it's not a cardiac, and uh, and uh, an abdominal mass, a tumor or whatever. It's a person to me. The compassion that my patients and the families feel that I've afforded has been given freely because I do care about that person as a human being. I have found though (choked up - brief pause - then voice somewhat shaky), now that my life has essentially fallen apart. The marriage that I thought would last forever, you know. Now, we're in our middle years and the kids are grown and we're making good money and we can afford nice things, uh, we can have a nice bank account. We can go places and do things, but then you find that this doesn't happen - that somewhere along the, that time of getting there, that you've lost what originally drew you together. Those dreams of making it there. You've made it. Where is there to go? (Big sigh.) I guess, and with my husband's illness, he can't help, I guess, what he said to me. I never thought anyone would want to hurt me. I've been fairly well protected all my life. I'm not a worldly person as far as the streets are concerned or, or what goes on in this world. I'm well versed in politics and, and in things like that, but my world consists of my work and my home. Now, I come home to an empty house, and I have no goal as far as nursing is concerned. That's been taken away from me also. So - and I feel sort of deserted because, with the exceptions that I've made for other people and for the hospital, things that, things that I would like to change that, that bother me have never been changed and never will be. Those are accepted. Uh, doctors that harm my patients - that has had to be accepted - reported and nothing really accomplished by it. That person is still there. (Click. Recorder apparently turned off and then back on. Clearing throat and then continuing in a somewhat deeper tone of voice.) Yet, when I, as a nurse, inadvertently make an error without malice or without forethought, and with every intention of correcting my error, my only thought was protecting my job - a job that I love dearly, that I was afraid of losing. This was the only reason it wasn't reported to you by myself. Then, I am terminated. And the only other reason for my existence is taken away from me. This is not to make you feel guilty. I know you have your job to do. I know there have been exceptions made. I know of one girl in particular where her whole life was a damn exception, and she has actually come close to killing patients, and it could be proven by records, etc. by actual observations. And yet, she's welcomed with open arms when she comes back. She left in a world of glory. It's as one of our other nurses said, 'She could fall in a bucket of (pause) and come up smelling like a rose very time.' My assets are frozen now. I have no means of support other than my job. I have no other place I want to go or would go. I've thought it over, and I know where my place in life lies and I know what my future holds. It holds nothing at this point because I can't make that decision to divorce my husband or to have him come back here. Those are my options at this point for survival. Those decisions I cannot make. The decision to work - the only reason I had any medication at all was the fact that I had been beaten half to death, and I was forced to go to Dr. - to the doctor simply as a, because I needed the slip to come back to work. At that point, he saw that I was just falling apart as far as my nerves were concerned, simply because my system couldn't adjust to the beatings that I had, had been inflicted upon me. He suggested that I take something until I got over that hump. I've never taken medication before, and, uh, as I told you, I told him I didn't want anything heavy because my system was just not used to medication and anything that I took, even an aspirin, one aspirin, would cure a headache. So, uh, my system is super sensitive to medication apparently. Therefore, he prescribed what he did and, uh, I took it. It's the lowest dosage he could have give - that he could give me. Uh, he said I could take up to 30 milligrams without any harm. The maximum I took was 10, and this was only, you know, when I was really upset and, or felt that I was not in control. For instance, like when I had to meet with my husband or things like this due to the legal matters, or uh, other business interests that we had that brought us together. I'm not making this tape to defend myself. I don't think any defense really is necessary because I've done nothing really wrong. I made an error in judgement, and I've paid dearly, both financially, emotionally, etc...I've lost everything for one error in judgement. I would hope that this would never happen to anyone else because it leaves you with very few options in your life. So, I appreciate your support as far as your confidence in my nursing care. (Click. Recorder apparently turned off and then back on.) I appreciate the fact that you didn't take my license away. I guess that would have been the ultimate defeat. Um (pause) at this point, as I said, um, I have no options. I feel that you're put on this earth for a purpose. My purpose has ended." She mailed the tape recording to Baptist Hospital where various people listened to it on July 8, 1983. Mr. Foster tried to reach respondent by telephone, but got a busy signal. He then called the police department. Three policemen appeared at her home to find her talking to a friend on the telephone. At least one of the policemen stayed to talk for an hour or two, then left and called Mr. Foster. He told Mr. Foster he did not think that Ms. Eckard "needed to be Baker Acted," but said that he would look in on her again later in the day. On December 4, 1983, Ms. Eckard was arrested a second time for allegedly driving under the influence of alcohol, but the state's attorney's office did not pursue these charges. The arresting officer testified at the hearing in the present case. Neither his testimony that she was driving nor his testimony that she was intoxicated has been credited.
The Issue The issue is whether Respondent's license as a practical nurse should be disciplined for the reasons given in the Administrative Complaint.
Findings Of Fact Based upon all of the evidence, the following findings of fact are determined: In this disciplinary proceeding, Petitioner, Department of Health, Board of Nursing (Board), has alleged that Respondent, Sheila Key, a licensed practical nurse, failed to conform to minimal standards of acceptable nursing practice while employed as a practical nurse at Florida Christian Health Center (FCHC), in Jacksonville, Florida, in the Fall of 1999. Respondent holds license number PN 0792331 issued by the Board. The allegations against Respondent arose as a result of a routine Agency for Health Care Administration (AHCA) licensure survey of the facility on October 1, 1999. On that date, an AHCA survey team found an elderly resident with a head injury whose nursing notes had not been properly charted; a resident in the recreation area with blood on her gown and requiring medical attention; and a third resident with unattended sores on his ankles. All were under the direct care of Respondent. As to the first resident, the Board charged Respondent with failing to document the resident's head injury or condition in her nursing notes. In the second case, she was charged with failing to notify a physician or other responsible party in a timely manner about the injury and applying "steri-strips without a physician's order." Finally, Respondent was charged with failing and refusing "to comply with the surveyors' request" that she "remove [the patient's] socks so the ankle area on his feet could be observed." Each of these charges will be discussed separately below. Around 5:15 p.m. on September 30, 1999, A. B., an eighty-seven-year-old male resident at FCHC, acidentally fell and sustained an injury to his head that required emergency room treatment. A. B. returned to FCHC from the emergency room sometime after 9:00 p.m. Respondent reported for duty at 7:00 p.m. that same evening. Although good nursing practice dictated that Respondent promptly perform a neurological check on A. B. after he returned from the hospital, she failed to do so and did not perform one until 7:00 a.m. the next day (October 1). Even then, she failed to document any of her findings in the resident's nursing notes. By failing to document "the fall or his condition" in the nursing notes until the morning following the injury, Respondent failed to conform to the minimal standards of acceptable prevailing nursing practice. Around 7:40 a.m. on October 1, 1999, M. C. suffered a laceration on her neck while being transferred from her bed to a wheelchair. Respondent applied steri-strips to the wound, but she did not have a physician's order to do so. Also, she failed to document the neck wound or her treatment of the wound until 10:45 a.m., or more than three hours later. Finally, M. C.'s physician was not notified about the injury until around 12:15 p.m. FCHC has a written policy entitled "Changes in a Resident's Condition Status," which requires that the nurse promptly notify the resident, the resident's physician, and the resident's family of changes in the resident's condition. Thus, a nurse must notify the resident's attending physician and family whenever the resident is involved in any accident or incident that results in an injury. If the injury is of an emergency nature, such notification is required within thirty minutes to an hour. The evidence establishes that M. C.'s injury was of a type that required notification within this short time period. By waiting for almost five hours to notify M. C.'s physician about the injury, Respondent failed to conform with minimally acceptable nursing practices. She also violated the same standard by applying steri-strips to the injury without a doctor's order. Finally, she failed to conform to minimally acceptable nursing practices by not charting the injury in the nursing notes until more than three hours had elapsed. During the October 1, 1999, inspection, a member of the survey team asked Respondent to remove the socks and dressings on J. R., a resident. The request was made since the team could see a brown discharge on the inner aspects of his socks. Respondent would not do so, and eventually an assistant director of nursing performed that task. After the socks were removed, the survey team found old dressings through which drainage had soaked. They also observed sores that had thick yellow or serosanguinous drainage. Even though the sores had been there for at least a week or so, dressings had been previously applied, and the soaked socks were clearly visible, Respondent had failed to check the resident and was therefore unaware of his condition. Despite this omission, however, Respondent was only charged with failing and refusing "to comply with the surveyors' request," and not with inappropriate conduct with respect to the care of the resident. By failing to respond to a reasonable and legitimate request to remove the resident's socks so that a suspicious area could be observed, Respondent failed to conform to minimally acceptable standards of prevailing nursing practice. Respondent failed to admit responsibility for any of the foregoing violations. As to the resident with the neck wound, Respondent contended that the wound was not serious. However, it was serious enough that the resident's physician believed emergency room treatment was necessary. Respondent also contended that the assistant director of nursing (Widhalm) advised her that she (Widhalm) would call M. C.'s physician, an assertion which Widhalm credibly denied. Respondent further contended that she failed to chart A. B.'s nursing notes because the chart was in the hands of the surveyors. Under those circumstances, however, acceptable protocol requires that the nurse request the return of the notes so that essential information can be timely recorded. Finally, Respondent contended that the surveyor had told her that she could finish her "medication pass" before removing the socks and could do so whenever she had time. This assertion is not deemed to be credible.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Nursing enter a final order finding that Respondent is guilty of the violations described in the Administrative Complaint. It is further recommended that Respondent be fined $1,000.00, given a reprimand, and placed on probation for two years subject to such conditions as the Board deems appropriate. DONE AND ENTERED this 7th day of November, 2000, in Tallahassee, Leon County, Florida. DONALD R. ALEXANDER 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 7th day of November, 2000. COPIES FURNISHED: Ruth R. Stiehl, PhD., R.N., Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Diane K. Kiesling, Esquire Agency for Health Care Administration Building 3, Room 3231A 2727 Mahan Drive Tallahassee, Florida 32308 Sheila Key 3651 Dignan Street Jacksonville, Florida 32254 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way Bin A02 Tallahassee, Florida 32399-1701
The Issue Whether the Respondent committed the offenses set forth in the Administrative Complaint filed in this case and, if so, what disciplinary action should be taken.
Findings Of Fact Respondent, Ruth Theresa Healey, was, at all times material hereto, licensed as a registered nurse in the State of Florida, having been issued license number 0983072 by the Board of Nursing. On May 20, 1988, Respondent was employed as a registered nurse at Broward Convalescent Home for the 11:00 p.m. to 7:00 a.m. shift. Included in Respondent's responsibilities were the assessment of each patient under her care; the administration of medication to her patients according to the physician's orders; and the correct documentation of each medication administration on each patient's medical chart. Under Respondent's care on May 20, 1988 was the patient, E.M. The physician's orders for E.M. during Respondent's shift indicated that she was to be fed with one-half strength Entrition at 60 cc's per hour with water flushes through the gastrostomy tube (G Tube) which had been inserted into her abdomen. One-half strength Entrition is a nutrition substitute which is supplied in a self-contained package. On May 20, 1988, the supply of one-half strength was on special order and would not be available for use at Broward Convalescent Home until the next morning during the 7:00 a.m. to 3:00 p.m. shift. E.M.'s G Tube was clearly marked on E.M.'s chart and easily observed upon patient assessment since it was protruding from her abdomen. Sometime during Respondent's shift, a naso-gastric tube, NG Tube, was also inserted into E.M. Without a physician's order, the insertion of a NG Tube into a patient with an existing G Tube could prove harmful to the patient and is contrary to the minimal standard of acceptable and prevailing nursing practice. It was Petitioner's contention that Respondent inserted the NG Tube into her patient. Petitioner's position was supported by the testimony of Geraldine Hamilton, a nurse who came on duty the morning of May 21, 1988. Ms. Hamilton recalled that Respondent admitted to Ms. Hamilton that Respondent was in trouble because she, "put an NG Tube in one of the patients who has already got a G Tube." However, Respondent, at the hearing, consistently denied having made the statement. She asserted, instead, that a co-worker, Bunster Martinez, inserted the NG Tube. During Respondent's shift, she had sought Mr. Martinez's advice concerning the procedure she should use to feed E.M. since the one-half strength Entrition was not available. Mr. Martinez was not present at the hearing. Respondent's speech pattern, as observed at the hearing and as noted through the testimony of others is not clear. Rather, it is cryptic and disjointed. Given Respondent's poor diction and syntax, Respondent's consistent denial that she inserted the NG Tube and the lack of corroborating evidence that Respondent did, in fact, insert the NG Tube, the literal meaning of Respondent's statement to Ms. Hamilton is unclear. Respondent did not perform an assessment of E.M. which would have revealed the G Tube. Instead, contrary to the physician's order, Respondent began the administration of full strength Entrition through the NG Tube. In an attempt to create one-half strength Entrition, Respondent knowingly administered full strength Entrition for one hour at 85 cc. per hour followed by water flushes. However, the quality of one-half strength Entrition can not be obtained by diluting full strength Entrition in this manner, and the administration of full strength Entrition could have harmed F.M. Respondent's failure to perform an assessment of her patient and her action with regard to this feeding were contrary to the minimal standards of acceptable and prevailing nursing practice and constituted unprofessional conduct on her part. Also, although Respondent administered to E.M. full strength Entrition through the NG Tube, she entered the feeding on E.M.'s chart as Entrition one- half strength at 60cc/hour via G tube. Accordingly, Respondent knowingly falsified the medication administration report. The following morning, May 21, 1988, when the presence of the NG Tube was questioned, Respondent abruptly and forcibly removed the NG Tube from E.M. The procedure Respondent used to remove the NG Tube was also contrary to the minimal standards of acceptable and prevailing nursing practice, constituting unprofessional conduct on her part and placing her patient in more jeopardy. Respondent acted somewhat incoherently on several occasions around the end of May, 1988. She was observed "talking to herself", was unresponsive to questions and appeared disoriented. No competent evidence was presented that such conduct resulted from a physical or mental condition or from medication. Respondent was previously suspended by the Board of Nursing and required to undergo psychiatric treatment. She was subsequently reinstated. No competent and substantial evidence was presented that Respondent disobeyed the previous order or any order of the Board of Nursing.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED the a final order be entered suspending Respondent's license for a period of one year, and thereafter, until she can demonstrate the ability to practice nursing in a safe and proficient manner. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 12 day of October 1989. JANE C. HAYMAN 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 12 day of October 1989. APPENDIX TO RECOMMENDED ORDER CASE NO. 89-3401 Petitioner's proposed findings of fact are addressed as follows: Addressed in paragraph 1. Addressed in paragraph 2. Addressed in paragraph 2. Subordinate to the result reached. In part, addressed in paragraph 3 ;in part, subordinate to the result reached. Not necessary to result reached. Not necessary to result reached. Not necessary to result reached. In part, subordinate to result reached; in part, addressed in paragraph 3. Addressed in paragraph 3. Subordinate to the result reached. Subordinate to the result reached. Subordinate to the result reached. Addressed in paragraphs 7 and 9. Addressed in paragraph 9. Addressed in paragraph 9. In part, addressed in paragraphs 5 and 6; in part, subordinate to result reached. Addressed in paragraph 8. Addressed in paragraph 3. Addressed in paragraph 7. In part, not supported by competent and substantial evidence, in part, subordinate to the result reached. Not supported by competent and substantial evidence. Not supported by competent and substantial evidence. Addressed in paragraphs 2 and 3. Addressed in paragraph 4. In part, addressed in paragraphs 10 and 11. In part, subordinate to the result reached, in part, not supported by competent and substantial evidence. Not supported by competent and substantial evidence. Subordinate to the result reached. Subordinate to the result reached. Subordinate to the result reached. Addressed in paragraph 7. Addressed in paragraphs 7 and 8. Addressed in paragraph 10. COPIES FURNISHED: Lisa M. Bassett, Esquire Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0729 Ruth Theresa Healey, R.N. 1075 N.E. 39th Street, Apartment 110 Fort Lauderdale, Florida 33308 Judie Ritter Executive Director Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, Florida 32201 Kenneth E. Easley General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0729
Findings Of Fact Mary Karen Fasolka at all times here involved was licensed by the Florida Board of Nursing as a Registered Nurse and was employed by Broward General Medical Center in that capacity. On April 21, 1978, Respondent signed on the narcotic records for 50 mg. Demerol at 10:15 a.m., 11:30 a.m., and 12:15 p.m. and thereon indicated the medication was for patient Pustelnick. At 10:30 a.m. on the same date Respondent signed out for 30 mg/ml of Codeine to be administered to Ms. Pustelnick. Doctor's orders in effect at this time authorized the administration of Demerol every four hours to Ms. Pustelnick as necessary for pain. There were no orders in effect authorizing administration of Codeine to Ms. Pustelnick. Neither the patient's medication administration record nor the nurses' notes showed either medication had been administered to Ms. Pustelnick to Ms. Pustelnick at or about the time they were signed out by Respondent. On April 19, 1978, Respondent signed two entries on the narcotic record. The first entry was 10:45 a.m., Demerol withdrawn for patient Dominico and marked "wasted". The following entry also signed by Respondent showed a time of 9:00 a.m. for the withdrawal of Demerol for Dominico. Dominico was admitted to the hospital at 2:55 p.m. on April 19, 1978, and doctor's orders authorizing administration of Demerol every four hours as needed were entered at 4:40 p.m. Neither of these signouts appeared on patients' medication administration record or in nurses' notes. On April 21, 1978, Respondent signed out for Demerol at 10:30 a.m. to be administered to patient Davis. No physician's orders were in effect for such medication, and the medication was charted on neither the patient's medication administration record nor the nurses notes. On April 15, 1978, Respondent signed out for Demerol at 10:00 a.m., at 11:00 a.m., at 2:00 p.m. and at 2:30 p.m. for patient Surless. Doctor's orders authorized Demerol every four hours as needed for pain. Patient's medication administration record does not show this medication was administered and nurses' notes signed by Respondent show patient resting quietly at 10:00 a.m. with no entries respecting administration of Demerol. A 2:40 p.m. entry stated "IV and PO sedation given as ordered". Acceptable nursing practice requires the charting of medication given a patient in order that other nurses and doctors can ascertain what the patient has received in case an emergency arises after the nurse who administered the medication has gone off duty. Not knowing that narcotics had recently been administered to the patient could lead to the administering of an overdose by another doctor or nurse. Administering medication not included on doctors' orders or on standing orders is not an accepted medical practice. Taking or using narcotics that have not been prescribed, by a nurse on duty entrusted with the care of seriously ill patients, is also an unacceptable nursing practice. Testifying in her own behalf Respondent averred that she was not addicted to Demerol and never tried to sell Demerol or to take same from the hospital. She acknowledged that failure to chart medications and failure to follow doctors' orders respecting the administration of narcotics were grave errors which could lead to serious consequences and harm to the patient. No evidence in mitigation of the offenses alleged was submitted. Supervisors of Respondent had no particular problems with Respondent's performances of duty during the two and one-half years she had worked at Broward General other than the incidents leading to the charges here considered.
The Issue The issue in the case is whether the allegations set forth in the Administrative Complaint filed against the Respondent are correct and, if so, what penalty should be imposed.
Findings Of Fact The Petitioner is the state agency charged with the responsibility for regulation and discipline of nursing practice within the State of Florida. The Respondent is a registered nurse holding Florida license number 2551692. On June 1, 2000, the Respondent was employed as a registered nurse at Harborside Healthcare Nursing Home. The Respondent was assigned to provide patient care including administration of medications to residents. L. M. was a resident of Harborside Healthcare. L. M. was a diabetic and required insulin injection as a part of her treatment for the diabetes. On June 1, 2000, the Respondent attempted to administer an insulin injection to L. M. Two Certified Nursing Assistants were present in L. M.'s room at the time of the injection. When the Respondent began the injection, L. M. "jumped" or "jerked," and the Respondent struck L. M.'s arm with the Respondent's closed fist. Both of the nursing assistants reported the incident to the facility's Director of Nursing. The Director of Nursing investigated the incident and discussed it with the Respondent, who initially admitted the striking although she later denied the event. The Respondent was immediately suspended from her employment and was subsequently terminated. Minimal standards of professional nursing practice prohibit the striking of a patient.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Department of Health, Board of Nursing, enter a Final Order imposing an administrative fine of $1,000, and suspending the Respondent's licensure until such time as the Respondent provides to the Board proof of her ability to practice nursing safely, after which the Respondent shall be placed on probation for a one-year period under such conditions as the Board deems appropriate. DONE AND ENTERED this 27th day of August, 2001, 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 27th day of August, 2001. COPIES FURNISHED: Beverly Cooper 2801 Belle Chase Circle Tampa, Florida 33634 Michael J. Kapperman, Esquire Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Ruth R. Stiehl, Ph.D., R.N., Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714
