The Issue Whether Respondent is in violation of Section 464.21(1)(b) and 464.21(1)(f), Florida Statutes. The Administrative Complaint in this matter charged the Respondent with ten statutory violations. At the commencement of the hearing, Petitioner withdrew Paragraphs 2 and 6 of the Administrative Complaint. During the course of the hearing, Petitioner also withdrew Paragraphs 3, 4, 8 & 9 of the Complaint.
Findings Of Fact Respondent is a licensed registered nurse in the State of Florida, License No. RN-41209-2. During the period August 31 - September 1, 1975, Respondent was charge nurse of an 11:00 P.M. - 7:00 A.M. shift at Mercy Hospital, Orlando, Florida. A hospital Narcotic and Hypnotic Disposition Record, dated August 28, 1975, Number 13580, for Seconal capsules, 100 mg., reflects that on August 31, 1975 at 12:00 A.M., Respondent signed out for a Seconal capsule for patient John Marks. Hospital records, including Nurse Medication Record, Nurses' Supplementary Medication Record, and Nurses Notes do not reflect that the patient received the aforesaid medication. Hospital policy requires that all controlled drugs such as Seconal be "charted", i.e., shown in the appropriate medical record that the drug was administered to the patient by the nurse. Respondent admits that she failed to "chart" the medication that she gave to patient Marks. A similar Seconal charting omission by another nurse as to patient Marks occurred on September 3, 1975. (Testimony of Werner, Cahill, Mincevich, Moore, Petitioner's Exhibits 1, 3) A hospital Narcotic and Hypnotic Disposition Record for "Meperidine Amp., 75 mg." dated August 28, 1975, Number 46620, reflects that at 1:15 A.M., August 31, 1975, Respondent signed out 75 mg. of the drug for patient Jesse Elfrud. Meperidine is a controlled drug known as "Demerol" and is used for the relief of pain. Hospital records, including Nurse Medication Record, Nurses' Supplementary Medication Record, and Nurses Notes for the patient on that date fail to show administration of the drug. Respondent admits that she neglected to make the required entry on the appropriate record. (Testimony of Mincevich, Moore, Petitioner's Exhibits 2, 4) A hospital Narcotic and Hypnotic Disposition Record for "Meperidine Amp. 100 mg." dated August 16, 1975, Number 47653, reflects that on September 1, 1975 at 1:30 A.M. and 6:00 A.M. Respondent signed out for 100 mg. of the drug for patient Eugene Catalina. Although the Nurses' Supplementary Medication Record shows that "Demerol, 100 mg." was administered to the patient at 1:30 A.M., hospital records do not reflect that the patient received the drug at 6:00 A.M. on September 1st. A hospital supervisor interviewed Catalina later that day and he informed her that he had had an injection about 5:30 A.M. when he awakened. Respondent admits that she neglected to "chart" the Demerol that she had signed out for at 6:00 A.M., September 1, 1975. (Testimony of Mincevich, Moore, Petitioner's Exhibits 5, 6, supplemented by testimony of Reynolds.) On October 14, 1975, Respondent was employed at the Barrington Terrace Nursing Home, Orlando, Florida, assigned to the 4:00 P.M. - 12:00 A.M. shift as nurse in charge. At approximately 3:45 P.M., she arrived for duty and was observed by three licensed practical nurses. She was disheveled, uncoordinated, staggering, and bumping into things as she came down the corridor. Her speech was slurred and her breath smelled of alcohol. She entered the medicine room and had difficulty placing her key in the lock of the narcotics cabinet. She was not in a fit condition to carry out her duties and appeared to be under the influence of alcohol. One of the nurses reported the matter to the hospital Administrator who had the Assistant Administrator meet her in the office of the Director of Nursing and inform her that her employment was terminated. The Respondent had been involved in a similar incident at the nursing home on October 2, at which time she manifested the same appearance, but did not have the odor of alcohol on her breath. At that time, inquiries established that her condition had been brought about by a prior injection of Demerol and Compazine from her physician for the relief of a migraine headache. In spite of the circumstances surrounding the prior incident and the Administrator's knowledge that Respondent suffered from a disease called diabetes insipidus, he did not inquire into the possibility that Respondent might have been ill on October 14th, because of the reports from other employees that she was intoxicated. (Testimony of Cole, Stonecipher, Smith). Respondent testified that she suffers from diabetes insipidus. The illness is controlled by the use of Diaped nasal spray. Occasionally, she takes a shot of Pitressin to restore her hormone balance. The disease manifests itself by dizziness, slurred speech and the presence of a sweetish smelling breath from acidosis. The general appearance of an individual with the disease during an attack is similar to that of intoxication. It is also possible that an observer might mistake the breath odor for that of alcohol if unfamiliar with the disease. Prior to going to work on October 14, Respondent felt herself in the early stages of dehydration from the disease and administered nasal spray to herself. She does not recall the events of that day after arriving at the hospital. Although Respondent's credibility was impaired to some degree by a showing that she had falsified an application for employment at the Barrington Terrace Nursing Home by omitting the fact that she had previously been employed at Mercy Hospital, it is found that, under the circumstances, the evidence is insufficient to establish that Respondent was in an intoxicated condition by reason of alcohol at the time she reported for duty on October 14, 1975. (Testimony of Moore, Morris, supplemented by Respondent's Exhibit 1). In extenuation of her admitted "charting" errors, Respondent testified that a nurse had difficulty maintaining proper records during the night shift because of the scarcity of support personnel during that period. The Director of Nursing at Medic-home Health Center, Winter Garden, Florida, where Respondent has been employed for the past year, and her present supervisor at that institution, testified that charting errors are common and that such omissions happen more frequently on a night shift due to the heavier patient load. However, Respondent and these witnesses acknowledged that such omissions can have serious consequences if the nurse on the next shift is not aware that medication previously had been given to a patient. Respondent has done an excellent job at her present place of employment under close scrutiny, even though she lost her son in an automobile accident during the period of employment. (Testimony of Moore, Morris, Blackmer).
Recommendation That Respondent Jacqueline Carroll Moore, R.N., License Number RN-41209-2, be issued a written reprimand and that her license to practice nursing be suspended for unprofessional conduct in violation of Section 464.21(1)(b), Florida Statutes. DONE and ENTERED this 6th day of December, 1976, in Tallahassee, Florida. THOMAS C. OLDHAM Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 COPIES FURNISHED: Julius Finegold John T. O'Shea 1130 American Heritage MURRAH, DOYLE and O'SHEA, P.A. Building Morse Boulevard Professional Jacksonville, Florida 32202 Center 800 West Morse Boulevard P.O. Box 1328 Winter Park, Florida 32789 =================================================================
The Issue The issues are whether Respondent, on or about October 2000, while employed by St. Joseph's Hospital, withdrew controlled substances (Demerol) from the Pysix system for patients and inaccurately and or incompletely documented the administration and or wastage of said medications, and, if so, what penalty is appropriate for Respondent's failure to conform to minimum standards of acceptable and prevailing nursing practice in violation of Subsection 464.018(1)(h), Florida Statutes.
Findings Of Fact Based upon observation of the witnesses and their demeanor while testifying, the documentary materials received in evidence, and the entire record complied therein, the following relevant and material facts are found. The Division of Administrative Hearings has jurisdiction over the parties and subject matter of this case. Subsections 120.57(1) and 464.018(1)(h), Florida Statutes. Respondent is, and has been at all times material hereto, a licensed registered nurse (RN) in the State of Florida, having been issued license number RN 3141652 by the Florida Board of Nursing. Respondent, at all times material hereto, was employed by St. Joseph's Hospital (St. Joe's), in Tampa, Florida. At all times material to this case, Respondent was working in the Intensive Care Unit (ICU), wherein is situated a Pysix medication dispensing machine. The Pysix medication dispensing system is comprised of a central control panel located in the office of the hospital's pharmacist. There are multiple outlets located in various units throughout the hospital. Access to medication contained in the several Pysix system outlets is similar in operation to access to money in an ATM machine, to wit: each authorized nurse is given by the hospital a personal password (like personal identification numbers for an ATM). A nurse enters the patient's name (for whom the medication is to be given and logged), then enters their personal password, and enters the desired medication number before the Pyxis machine will dispense the medication. All access entries to Pysix and dispensing of prepackaged medication by Pysix are recorded. The amount of medication administered to the patient is required to be recorded simultaneously on the patient care record (PCR) and on the hospital's Medication Administration Record (MAR). These records are required to be maintained and are reviewed periodically by doctors, nursing staff, and staff supervisors for accuracy and quality assurance purposes. It is the policy requirement of St. Joe's hospital that should a nurse not administer the entire amount of medication dispensed under his or her private password to the named patient, the acquiring nurse must retain the "waste" medication (unused medication). The accessing nurse shall then secure the presence of another nurse who shall witness the disposal of the "waste" medication. The nurse disposing of "waste" medication shall then enter into the Pyxis, his/her personal password and the amount of disposed "waste" medication. The witness nurse shall enter his/her personal password as having witnessed the actual "waste" medication disposal. At all times material and specifically in October and November 2001, Lynn Kelly, RN (Kelly), was the nursing manager for the ICU at St. Joe's and was Respondent's supervising nurse. In her capacity as nursing manager, Kelly's responsibilities included the following: hiring, firing, duty scheduling, performance evaluation, employee counseling, auditing medical records, quality control, risk management, management investigations, education and policy writing. In her capacity as a supervisor, Lynn Kelly received, reviewed and analyzed monthly reports that detailed controlled medication usage on her unit (ICU). The reports detailed the number of times a nurse accessed the Pysix system for narcotics as compared to the number of days that nurse worked a shift during the month. St. Joe's Hospital developed a standard deviation to be used when analyzing and reviewing records. Should a nurse's number of accesses to Pysix's narcotics fall outside the standard deviation, it was Kelly's duty to check that nurse's assignments to determine, if possible, a reasonable explanation for narcotic accesses beyond the standard deviation guidelines; a particular nurse could have been continually assigned to a particular patient who required more than normal narcotic medication for pain. A cross-check of the patient's medication records (PCR) and the hospital's MAR would be made upon discovery of assess outside standard deviation guidelines. After receiving a report on Respondent's narcotics (Demerol) withdrawals from the Pysix system that were outside the standard deviation, Kelly compared and analyzed Respondent's Pyxis access records to his assigned patients administration records with his narcotic waste records, for a two-month period, September 27 through November 2000. Kelly found instances where 25 milligrams and 50 milligrams units of Demerol were accessed by Respondent, but were not administered to the assigned patient. They were not entered as waste, and they were not documented in the MAR records. The discrepancies revealed that between October 2, 2001, and October 23, 2001, Respondent withdrew a total of 1,075 milligrams of Demerol from the Pysix narcotics dispensing system for administration to patients without documenting administering the medications or wasting the medications. Respondent suggested that "someone" could have or did look over his shoulder, observed and remembered his personal password as he typed it in, and later use his password to access the Pysix machine for Demerol. Respondent testified that on many occasions other nurses would come up behind him and instead of his logging out the Pysix machine, he would withdraw their narcotics for them and hand it to them. It was common practice for several nurses to be in the Pysix room at the same time. Respondent's responses and suggestions without other supporting evidence, are insufficient to account for the 1,075 milligrams of Demerol accessed by Respondent, not administered to the assigned patient, and not documented as waste medication as required. Proper and correct documentation of accessed medication is important and essential for the prevention of potential overmedication by a subsequent nurse due to the lack of proper and correct documentation by the preceding nurse in this case, Respondent. The record was left open from January 25, 2002, to March 4, 2002, for subsequent submission of evidence regarding theft of passwords by other employees at St. Joe's during the time material to the allegation in the Administrative complaint; the parties made no subsequent submissions.1 Petitioner has proven by clear and convincing evidence that in October 2001 while employed by St. Joe's Hospital, Respondent, using his personal password, withdrew controlled substances from the Pysix narcotics system and did not document, as required, administering the withdrawn controlled substances to the patients for whom the withdrawals were made, and did not document wasting the controlled substances withdrawn.
Recommendation Based on the foregone, it is
The Issue Whether Respondent committed the offenses set forth in the Second Amended Administrative Complaint and, if so, the penalties that should be imposed.
Findings Of Fact At all times relevant hereto, Respondent, Diahann James, held license numbered 1266532 as a registered nurse (RN) and held license numbered 36309-1 as a practical nurse (PN). Both of these licenses had been issued to Respondent by Petitioner and entitled Respondent to engage in the practice of nursing within the scope of her licensure in the State of Florida. Respondent's RN license was, at the time of the formal hearing, suspended following Petitioner's order of suspension entered December 13, 1990. This suspension was based on Respondent's alleged failure to comply with the terms of her previously established probation. Respondent's PN license has been on an inactive status since April 1, 1983. Respondent has until April 1, 1993, to seek reactivation of her PN license pursuant to Rule 210-14.005(1), Florida Administrative Code. Unless reactivated, her PN license will permanently expire after April 1, 1993. On February 15, 1985, Respondent's RN license was suspended pursuant to an order entered by the Board of Nursing (Board) as the disposition of the Department of Professional Regulation's (DPR) Administrative Complaint Number 0051651. On June 23, 1986, Respondent's RN license was conditionally reinstated pursuant to an order of the board, contingent upon Respondent's submission of a favorable psychological evaluation. On August 11, 1986, Respondent submitted a satisfactory psychological evaluation and her license was reinstated effective August 27, 1986. Upon reinstatement, Respondent's RN license was placed on probation for a period of two years subject to specific terms and conditions. Respondent did not submit the quarterly reports required by the terms of her probation and the Board filed a complaint with DPR against Respondent on April 22, 1988, based on her failure to comply with the terms of her probation. On October 18, 1988, DPR filed Administrative Complaint 0098524 against Respondent based on the complaint the Board had filed on April 22, 1988. On April 1, 1989, Respondent's RN license 1266532 became inactive due to Respondent's failure to apply for renewal. In May 1989, Respondent applied for reactivation of her RN license. Accompanying this application was an affidavit that Respondent had executed on April 3, 1989. This affidavit affirmed that she had earned the continuing education hours during 1987-89 to meet the requirements set by DPR for renewal of her license. At the Board's request, Respondent submitted copies of continuing education certificates from Psycho- Awareness Continuing Education Provider as documentation that she had met the continuing education requirements as represented by her affidavit dated April 3, 1989. The continuing education certificates submitted by Respondent had been altered to reflect her participation and attendance at these continuing education programs in 1988. Respondent attended these programs not in 1988 (which would have met the continuing education requirements), but in 1986 (which would not meet the continuing education requirements). The affidavit Respondent signed on April 3, 1988, was false, and the certificates she submitted in support of that affidavit were altered. Respondent's submitted continuing education certificates were deemed to be forgeries by the Board. On June 23, 1989, Respondent was advised that her continuing education certificates were unacceptable, that her license remained on an inactive status, and that she was not entitled to work as a nurse. In July 1989, Respondent worked as a registered nurse at Cedars Medical Center, Miami, Florida. Respondent did not inform the Board's probation supervisor of her employment at Cedars Medical Center, even though the terms of her probation required her to do so. Respondent answered "no" on the Cedars Medical Center employment application to the question of whether her license had ever been revoked, suspended, or placed on probation. At no time during the term of her employment at Cedars Medical Center did she reveal that her licensure was on an inactive status and on probation. During the course of her employment at Cedars Medical Center on July 11-12, 1989, and on July 25-26, 1989, (these events occurred during the night shift) Respondent wrote telephone orders, allegedly from physicians, for various medications for several different patients. Respondent signed at least two of said telephone orders with the name of "L. Hemingway", a coworker. Respondent submitted these telephone orders to the pharmacy and obtained various medications, including controlled substances. The physicians named by Respondent on the telephone orders denied giving Respondent authorization to order those medications on the dates specified, and none of said orders were an existing part of the patients' records. On July 28, 1989, Respondent was confronted by her superiors regarding the numerous discrepancies that had been discovered through the pharmacy regarding her deviation from the normal procedure for obtaining and administering medications. Respondent denied any diversion of drugs and further denied writing the fraudulent telephone orders. Respondent was then asked to submit to a urine test, and she submitted a urine sample under controlled conditions. The urine sample was thereafter tested using appropriate methodology and equipment. Her urine tested positive for cocaine, meperidine (Demerol, a schedule II controlled substance, and pentazocine (Talwin, a schedule IV controlled substance). Respondent did not produce any valid prescriptions to account for the positive results of her urinalysis. On August 1, 1989, Respondent's employment at Cedars Medical Center was terminated. On July 28, 1989, the Board filed a Final Order in DPR case 0098524, the case DPR had filed against Respondent's RN license on October 18, 1988. This Final Order extended Respondent's existing probation for a period of two years and imposed conditions of probation similar to those initially imposed on August 27, 1986. On August 27, 1989, Respondent's RN license, which had been on an inactive status since April 1, 1989, was reactivated, but remained on probationary status. In December 1989, Respondent was employed at Doctors Hospital, Coral Gables, Florida, as a registered nurse. Respondent failed to inform her probation supervisor of her employment as a nurse, though she was required to do so by the terms of her probation. On December 4-5, 1989, Respondent worked the 11 p.m. to 7 a.m. shift at Doctors Hospital. The narcotic records on which Respondent signed out for narcotics for patients under her care and the medication record on which she charted the medication for these patients were falsified to reflect that these patients had received more narcotics than had actually been administered to them. These false records, for which Respondent was responsible, permitted Respondent to obtain excess narcotics from the hospital's pharmacy. On January 18, 1990, Respondent rendered a urine specimen for drug analysis pursuant to the terms of her probation. The subsequent analysis tested positive for propoxyphene (Darvone, a schedule IV controlled substance). Respondent provided no valid prescription to account for the positive result of her urinalysis. On March 1-2, 1990, Respondent was employed at Coral Gables Hospital, Coral Gables, Florida. Respondent failed to inform her probation supervisor of her employment, although she was required to do so by the terms of her probation. While working the 11 p.m. to 7 a.m. shift at Coral Gables Hospital, on March 1, 1990, Respondent admitted to her nursing supervisor that she had self-administered 150 mg. of Demerol. Respondent was accompanied to the Emergency Room where she received medical assistance. The nursing supervisor immediately began a review of Respondent's patients' charts. From this review, it was established that Respondent had obtained 250 mg. of Demerol, and that the patients for whom Respondent had signed out the narcotics did not possess physicians' orders for same. Respondent falsely charted on the medical records of two patients the administration of Demerol. On March 8, 1990, Respondent rendered a serum sample for drug analysis at the request of Coral Gables Hospital. Said specimen subsequently tested positive for the presence of Demerol. On July 15, 1990, Respondent rendered a urine specimen for drug analysis, pursuant to the terms of her probation. The preliminary results of that testing detected the presence of certain controlled substances and were classified as presumptive positive. The specimen Respondent had given was not of sufficient quantity to permit the completion of testing, and the preliminary findings were not confirmed. On December 13, 1990, Respondent's R.N. license was suspended due to her failure to comply with the terms of her probation. Based on the expert testimony presented at the formal hearing, it is found that Respondent is an impaired individual suffering from chemical dependency; that Respondent's practice of nursing is below the minimum standard of safe patient care for the State of Florida; and that Respondent is unable to practice nursing with reasonable skill and safety to patients because of her chemical dependency.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered which revokes Respondent, Diahann James's license as a registered nurse (number 1266532) and which revokes her license as a practical nurse (number 36309-1). DONE AND ORDERED in Tallahassee, Leon County, Florida, this 18th day of July, 1991. CLAUDE B. ARRINGTON 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 18th day of July, 1991. APPENDIX The proposed findings of fact submitted on behalf of the Petitioner are adopted in material part by the Recommended Order. The only post-hearing submittals by Respondent were in the form of two brief letters addressed to the undersigned, one filed May 8, 1991, and the other filed May 30, 1991. To the extent that either letter is construed to contain proposed findings of fact, those proposed findings are rejected as being either irrelevant, unsupported by the record, or contrary to the findings made. COPIES FURNISHED: Tracey S. Hartman, Esquire Roberta Fenner, Esquire Department of Professional Regulation 1940 North Monroe Street, Suite 60 Tallahassee, Florida 32399-0792 Diahann L. James 676 N.W. 48th Street, No. 4 Miami, Florida 33127 Judie Ritter, Executive Director 504 Daniel Building 111 East Coastline Drive Jacksonville, Florida 32202 Jack McRay, General Counsel Department of Professional Regulation 1940 North Monroe Street, Suite 60 Tallahassee, Florida 32399-0792
