Findings Of Fact The Petitioner, Department of Professional Regulation, Board of Nursing, is an agency of the State of Florida having jurisdiction over the licensing, regulation of licensure status, and regulation of practice of professional nurses in the State of Florida. The Respondent, Patricia J. Canfield, is a licensed practical nurse, holding license No. 27935-1 authorizing the practice of practical nursing in the State of Florida. The Respondent has been so licensed at all times material to this proceeding. At all times material to this proceeding the Respondent has been employed as a licensed practical nurse in the infirmary at the Florida School for the Deaf and Blind located in St. Augustine, Florida. The Respondent was employed on November 29 and November 30, 1981, in the infirmary at the School for the Deaf and Blind when student Aaron Henderson was checked into the infirmary. Petitioner's Composite Exhibit 1 consists of the medication records by which nurse-employees obtained medication, as pertinent hereto Darvon, from the school infirmary dispensary. The Respondent, when she obtained Darvon from the dispensary, initialed this record with the initials "PC." On the dates in question the medication administration records in evidence established that the Respondent signed as having received into her possession one Darvon tablet, reputedly to be administered to patient Aaron Henderson on each of the days, November 29 and November 30. Aaron Henderson, testifying for the Petitioner, was shown a unit of Darvon established to be identical to that dispensed at the infirmary during the material time period in November, 1981. Witness Henderson stated he had never received such a pill from the Respondent, whom he identified as the nurse on duty in the infirmary when he was there on the two days in question. Witness Patty Grant was a patient in the infirmary on November 16, 1981. It was established that the Respondent signed the medication administration record as having received from the dispensary a Darvon tablet, reputedly to be administered to patient Grant on that date. Patient Grant received asthma medication from the Respondent on that date, but maintained that she had never received a Darvon tablet from the Respondent on that date after being shown a sample Darvon tablet established to be identical to that dispensed by the infirmary during November, 1981. Student-patient Stratton was a patient in the infirmary on October 22, 1981. On that date the Respondent signed the subject record indicating that she checked out a unit of Darvon from the dispensary on behalf of patient Stratton. Patient Stratton recalled receiving some medication from the Respondent on that date, but did not recall her administering to him a pill of the appearance of the Darvon tablet in use by the dispensary during the time in question. The Respondent initialed the Darvon medication chart for November 13, 1981, indicating that she had received from the dispensary a Darvon tablet to be administered to patient Diane Matthews. Patient Matthews testified that the Respondent had never given her a Darvon tablet on the date in question. Included as a part of Petitioner's Composite Exhibit 1 are the Nurses' Notes for the various patients named in the Administrative Complaint. With regard to patient Aaron Henderson, the medication administration records revealed that the Respondent signed for and obtained a unit of Phenaphen on December 8, 1981, for that patient, but the administration of the drug is not recorded in the nursing notes pertaining to patient Henderson. With regard to patient John Wise, the medication administration records revealed that on November 13, and November 16, 1981, the Respondent signed out Darvon tablets on behalf of that patient, but the Nurses' Notes pertaining to patient Wise made no reference whatever to the ultimate disposition of the Darvon. The medication administration records pertaining to patient Ray Jackson for November 4, 1981, established that the Respondent signed for a unit of Darvon for that patient, but the Nurses' Notes for that patient on that date do not reflect any notation regarding the administration or disposition of that unit of Darvon. The medication administration records for patient Duffy for the date of October 16, 1981, establish that Respondent obtained from the dispensary one unit of Darvon on behalf of that patient; however, her Nurses' Notes contain no indication of the ultimate disposition of that unit of Darvon. Expert testimony presented by the Petitioner establishes that the failure to document the administration of a drug on a patient's chart does not meet the minimum acceptable and prevailing standards of nursing practice, and that any licensed nurse knows or should know that documenting the administration of medication is a proper and required procedure. The Respondent testified on her own behalf and established that she has been licensed since 1969 in Michigan and Florida and has worked in St. Augustine at the subject school since 1975. Her duties involve general nursing duties and she customarily sees 50 to 100 student-patients per day on her shift. Frequently, she signs for medication which is obtained from the dispensary or secure area and another person on duty actually administers it, which would explain in part the students not remembering that she administered any Darvon. Often this procedure involves the Respondent working in the back room of the infirmary, obtaining the medication or signing for the medication, and the nurse on duty at the front desk actually giving it to the patient, with that nurse generally keeping the record slip made of the administering of the Darvon. The Respondent acknowledged, however, that Mrs. Harvey, the Head Nurse, had talked to her on one occasion about her neglecting to "chart medication." The Respondent also established that she was under Dr. Gurling's care in November and December of 1981 for a physical condition involving severe vascular headaches, for which she took Darvoset. She took Darvoset, containing Darvon and Tylenol (different from the Darvon tablets involved in this proceeding), because she has an allergy to aspirin and codeine. She filled her prescription for Darvoset in November, 1981, as Dr. Gurling directed and also filled a prescription for December, 1981, at the direction of her doctor. She maintains she never signed out for a drug and converted that drug to her own use and has never improperly taken drugs from the infirmary. She established that although she signed out for some Darvon orders, that they were requested by other nurses who would have been responsible for administering it to the particular students involved. She admits, however, that at times she either forgot to chart medication administered by her or lost the record slip which she normally uses for charting. In corroboration of her testimony regarding her own medical condition and the use of her own prescriptions for Darvon or Darvoset, Harold E. Waldron, a licensed pharmacist (testifying for the Petitioner), established that a large amount of Darvon had been obtained from his pharmacy by the Respondent in November of 1981 through prescriptions from her doctor. Mr. Waldron's recollection was that she received approximately 180 units of Darvon from his pharmacy in November of 1981. Although Mr. Waldron feels this may indicate some dependency on the drug, his testimony was not allowed on that theme because it was too speculative and non-expert in nature. Indeed, the fact that she received a large amount of Darvoset pursuant to legitimate prescriptions during November and December of 1981, militates in part against a finding that she converted drugs from the dispensary to her own use.
Recommendation Having considered the foregoing Findings of Fact, Conclusions of Law, the evidence in the record, the candor and demeanor of the witnesses, and the pleadings and arguments of the parties, it is, therefore RECOMMENDED: That a Final Order be entered by the Petitioner imposing a one-year probationary term on the licensure status of the Respondent, Patricia J. Canfield, L.P.N., and that she be required to take a continuing education course designed to enhance her competency in the area of properly accounting for, recording and conducting transactions with medications, especially controlled substances. DONE and ENTERED this 2nd day of December, 1982, in Tallahassee, Florida. P. MICHAEL RUFF Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 FILED with the Clerk of the Division of Administrative Hearings this 2nd day of December, 1982. COPIES FURNISHED: W. Douglas Moody, Esquire 119 North Monroe Street Tallahassee, Florida 32301 Charles Pellicer, Esquire 28 Cordova Street St. Augustine, Florida 32084 Helen P. Keefe, Executive Director Board of Nursing Room 504 111 East Coastline Drive Jacksonville, Florida 32202 Samuel R. Shorstein, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
The Issue The issue in the case is whether the allegations of the Administrative Complaint filed by Petitioner are correct and, if so, what penalty should be imposed against Respondent.
Findings Of Fact Petitioner is the state agency charged with regulation of the practice of nursing in State of Florida. At all times material to this case, Respondent has been licensed as a registered nurse in the State of Florida, holding license no. 2003552, with a last known address of 1407 Wekewa Nene, Tallahassee, Florida 32301. Respondent was employed at all times material to this case by Tallahassee Memorial Hospital (TMH) until December 1, 2000, when her employment was terminated. On November 23, 1999, Respondent was working a day shift at TMH as a nurse at 1300 Miccosukee Road, Tallahassee, Florida. On November 23, 1999, Sharissa Holloway was a student nurse from the Florida State University (FSU) School of Nursing and happened to be doing a clinical rotation on the TMH orthopedic/neurological floor. Respondent was the primary nurse for the patients on that floor who were under the care of the student nurse. The student nurse received the patient assessment sheets from Respondent prior to 8:00 a.m. with entries already charted by Respondent for estimating Patient N.C.'s pain, and a sedation scale already charted by Respondent covering the period of time that stretched all the way to 12 o'clock noon. When handing the patient assessment sheets to the student nurse at approximately 7:30 a.m., Respondent stated "I have already started the notes." The note entries had Respondent's initials next to them in the appropriate column. Narrative notes on Patient N.C. had already been written indicating that a dressing change of a surgical wound had been done at 8:00 a.m. These notes bore Respondent's signature. The student nurse also got these notes from Respondent before 8:00 a.m. Concerned with the advanced notations that she discovered, the student nurse took the patient assessment sheets which bore Respondent's entries for future times up to 12 o'clock noon to her FSU clinical nursing instructor who was on the premises at the time. Proceeding to Patient N.C., the instructor verified that the patient's wound dressing had not been changed. The student nurse did the dressing change at approximately 8:30 a.m. The nursing instructor took the documents to the head nurse for the orthopedic/neurological floor, Kay Keeton. Keeton requested that both the student nurse and the nursing instructor submit independent written statements. They complied with Keeton's request. Contemporaneously with the drafting of statements by the clinical nurse instructor and the student nurse, photocopies of the patient assessment sheets were made at least two hours prior to 12 o'clock noon. Keeton made notes on the sheets to show entries charted by Respondent as opposed to entries charted by the student nurse. Keeton is familiar with Respondent's signature. After determining that Respondent had charted something that had not been done yet, Keeton made her report to the TMH administration. When questioned about the entries on December 1, 1999, Respondent denied making the entries. She was given a disciplinary form entitled "Notice of Corrective Action." Upon her refusal to sign the form, Respondent was terminated from her employment. Respondent has experienced employment problems at TMH for which Notices of Corrective Action were issued which date back to 1996. This history, in conjunction with Respondent's demeanor while testifying and her lack of candor, dictate that her denial of improper action in this case, cannot be credited. Minimal acceptable standards of prevailing nursing practice require that documentation of care provided to patients be recorded contemporaneously with the provision of the care. Respondent's "before the fact" documentation of care provided to the patients identified herein fails to meet minimally acceptable standards of prevailing nursing practice. The placing of a care provider's initials on a medication administration record indicates that medication has been administered to patients. "Pre-initialing" or signatures on medication administration records poses a risk of confusion to other care providers working in the facility and is not an acceptable practice.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Petitioner enter a final order against Respondent, imposing a fine of $250, requiring completion of appropriate continuing education in nursing records documentation in addition to any existing continuing education requirement, and placing the Respondent on probation for a period of one year under such conditions as the Board of Nursing determines are warranted. DONE AND ENTERED this 24th day of October, 2000, in Tallahassee, Leon County, Florida. DON W. DAVIS 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 24th day of October, 2000. COPIES FURNISHED: Michael E. Duclos, Esquire Agency for Health Care Administration 2727 Mahan Drive Building 3, Room 3240 Tallahassee, Florida 32308 Donna H. Stinson, Esquire Broad & Cassel 215 South Monroe Street, Suite 400 Post Office Box 11300 Tallahassee, Florida 32302 Ruth R. Stiehl, Ph.D., R.N. Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A00 Tallahassee, Florida 32399-1701
Findings Of Fact Because the Respondent Marjorie Sue Fancher, L.P.N., was not present at the Hearing, although commencement of the Hearing was delayed for thirty minutes, careful inquiry into the correct address of Marjorie Sue Fancher was made. From the personnel records of Community General Hospital, it was determined that Marjorie Sue Fancher had resided at 551 Emerald Avenue, Lake Wales, Florida, 33856, with her mother. Notice in this cause was sent to Marjorie Sue Fancher at 551 Emerald Avenue, Lake Wales, Florida, 33856, by first-class mail. Notice of the Hearing sent Marjorie Sue Fancher was not returned to the Division of Administrative Hearings by the United States Postal Service. Marjorie Sue Fancher is a licensed practical nurse holding license number, LPN 37287-1. Marjorie Sue Fancher was employed by Community General Hospital in Dade City, Florida on approximately February 9, 1976. After undergoing an orientation at the hospital, she was moved from the day shift to the night shift. On February 22, 1976 Marjorie Sue Fancher was medication nurse on the eleven to seven shift at Community General Hospital. As medication nurse, Marjorie Sue Fancher was responsible for the administration and charting of the administration of medications to patients in Rooms 101 through 114 in the East Wing of Community General Hospital. As medication nurse, Marjorie Sue Fancher was responsible for the medication cart which contained the narcotics safe which had only one key. The procedure of the hospital called for the oncoming medication nurse to inventory the narcotics with the medication nurse being relieved. When the oncoming medication nurse was satisfied with the inventory, the oncoming nurse would relieve the nurse going off duty and the key would be turned over to the nurse coming on duty. This key was on a long ribbon and worn around the neck of the medication nurse. The hospital medical records for patients of the hospital in Rooms 101 to 114 on the East Wing were identified by Marian Newell, a registered records administrator and Records Administrator for Community General Hospital. The narcotic control records were identified by William Connors, Registered Pharmacist and Pharmacist for Community General Hospital. Elizabeth Kutsch, L.P.N., was the medication nurse who relieved Marjorie Sue Fancher on the morning of February 23, 1976. Kutsch found that the narcotic control sheets had not been filled out, chartings for the patients not been done, and nurse's notes on the patients had not been made by Fancher when Kutsch relieved her on the morning of February 23, 1976. Because the narcotics on hand did not agree with the narcotics control records, Kutsch refused to relieve Fancher and assume responsibility for the narcotics safe and its contents. Kutsch called Dawn Bell, Registered Nurse, Acting Director of Nurses at Community General Hospital, who initiated an investigation. Bell immediately interviewed Marjorie Sue Fancher. Fancher at that time appeared to Bell, a nurse with twenty-one (21) years of experience, to be under the influence of drugs. Fancher was unable to respond coherently to questions, could not remember what she had done during her shift, was somnolent and staggered when she walked. Bell's review of the patient records, their narcotics control records, and nurse's notes revealed many discrepancies. These records conflicted on whether Fancher had administered preop medications to a patient, Elmer Wile. Although the narcotics control sheet indicated that Fancher had withdrawn 10 mgs of morphine sulphate at 7:30 a.m., the drug administration records and nurse's notes had not been filled out indicating administration of the drug to the patient. Fancher had failed to administer insulin and pronestyl, a heart medication, as directed in the medication administration records for Hush Walker, a patient. Fancher had failed to administer inderal to Rena Bell at 6:00 a.m. as prescribed and had indicated this by circling the time on the medication administration record but no explanation of why the drug was not administered was entered in the nurse's notes by Fancher. Fancher had failed to administer kafsol to Florence Profe, as prescribed at 6:00 a.m. No entry was made on the medication administration records and no explanation was made in the nurse's notes by Fancher. Fancher failed to administer ampicillin and phenobarbital to Tonya Harnage at 6:00 a.m. as prescribed. The medication administration record shows no entry and no explanation was made in nurse's notes. Fancher administered talwin intramuscularily to Martha Jackson, a patient, instead of talwin compound prescribed to be administered per oz. Fancher signed out for 15 mgs of morphine sulphate on the narcotics control record for administration to the patient, Catherine Dolan, but no indication of administration of the drug was made in the medication administration record or in the nurse's notes for the patient Dolan. Fancher withdrew 10 mgs of morphine sulphate for administration to patient, Bessie Wolf, who had a preoperative order for the administration of 5 mgs of morphine sulphate and .2 mg of atrophine. The narcotics control record did not indicate the wastage of 5 mgs of morphine sulphate. The medication administration record indicated the administration of .2 mg of atrophine while the Nurse's notes indicated that .6 mgs of atrophine had been administered. The patient Wolf had been prescribed demerol PRN. The narcotics control record for demerol indicated that an entry showing 25 mgs had been withdrawn by Fancher for administration to the patient, Bessie Wolf, had been lined out. Inventory of demerol on hand in the narcotics safe for which Fancher was responsible, indicated an overage of one ampule of demerol. Fancher had failed to have the narcotics control record corrected by the pharmacist as required in accordance with hospital operating procedure when an erroneous entry was made. Patients who were scheduled for laboratory workups on the morning of the twenty-third and who were to receive no medications after twelve, midnight, had had medications administered to them by Fancher contrary to direction. Patients who were to receive preoperation medication did not have these medications administered. The records of the shift which Marjorie Sue Fancher had worked were so confused and incomplete that it was impossible to determine what medications had been administered to what patients. Marjorie Sue Fancher's physical condition was such that she could not remember what she had done during the shift to include what medications she had administered to what patients.
Recommendation The Hearing Officer having considered the Findings of Fact and Conclusions of Law recommends that the Florida State Board of Nursing revoke the license to practice nursing of Marjorie Sue Fancher. DONE and ORDERED this 11th day of October, 1976 in Tallahassee, Florida. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1130 American Heritage Building Jacksonville, Florida 32202 Marjorie Sue Fancher 551 Emerald Avenue Lake Wales, Florida 33856 Mrs. Geraldine Johnson State Board of Nursing Suite 201 6501 Arlington Expressway Jacksonville, Florida 32211
The Issue The issue in the case is whether the allegations of the Administrative Complaint filed by the Petitioner are correct and, if so, what penalty should be imposed against the Respondent.
Findings Of Fact The Petitioner is the state agency charged with regulation of the practice of nursing in State of Florida. At all times material to this case, the Respondent has been licensed as a practical nurse in the State of Florida, holding license number PN 0741801. At all times material to this case, the Respondent was employed as a practical nurse at the Harborside Health Care facility in Naples, Florida. At all times material to this case, Patient F. D. was a resident of Harborside Health Care. On or about August 17, 1998, at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to F. D. According to the medication administration record, F. D. was to receive the nutritional supplement at approximately 2:00 p.m. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to F. D. At all times material to this case, Patient L. G. was a resident of Harborside Health Care. On or about August 17, 1998, at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to L. G. According to the medication administration record, L. G. was to receive the nutritional supplement at approximately 2:00 p.m. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to L. G. At all times material to this case, Patient R. T. was a resident of Harborside Health Care. On or about August 17, 1998, at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to R. T. According to the medication administration record, R. T. was to receive the nutritional supplement at approximately 2:00 p.m. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to R. T. Minimal acceptable standards of prevailing nursing practice require that nurses accurately document the provision of supplements and nourishment to nursing home patients. Minimal acceptable standards of prevailing nursing practice require that documentation of care provided to patients be recorded contemporaneously with the provision of the care. The Respondent's documentation of care provided to the patients identified herein fails to meet minimally acceptable standards of prevailing nursing practice. The placing of a care provider's initials on a medication administration record indicates that medication has been administered to patients. "Pre-initialing" of medication administration records poses a risk of confusion to other care providers working in the facility and is not an acceptable practice. The Respondent acknowledges that she initialed each medication administration record at about 11:00 a.m., several hours prior to the actual administration of the supplement's to the patients. She asserts that she did not record the amounts of supplement each patient consumed (100 percent in all three cases assuming the records are accurate) until after the patient had consumed the supplement. The rationale for the Respondent's practice is unclear. The Respondent suggests that she had "a few moments" at about 11:00 a.m. and so she went ahead and initialed the documents, knowing that she could complete the charting at a later time. The Respondent's suggestion is the intent of the practice is to save time; however, any time saved is at best minimal. If the Respondent's testimony regarding post- administration record completion is credited, the practice requires that each record be handled twice to complete a single task. The Respondent suggests that she returns to each individual record after administering the supplement and charts the amount of supplement consumed by writing in a space approximately one-quarter inch beneath the "pre-initialed" space. In reality, "pre-initialization" doubles the time required to complete the documentation and increases the potential for confusing other care providers involved in patient care and charting. The Respondent continues to assert that the "pre- initialization" practice is acceptable. The assertion is clearly contrary to minimally acceptable standards of nursing practice, and to common sense.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Petitioner enter a final order against the Respondent, imposing a fine of $500, requiring completion of appropriate continuing education in nursing records documentation in addition to any existing continuing education requirement, and placing the Respondent on probation for a period of one year under such conditions as the Board of Nursing determines are warranted. DONE AND ENTERED this 30th day of August, 2000, in Tallahassee, Leon County, Florida. WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of August, 2000. COPIES FURNISHED: Reginald D. Dixon, Esquire Agency for Health Care Administration 2727 Mahan Drive Post Office Box 14229 Tallahassee, Florida 32317-4229 Harry A. Blair, Esquire Harry A. Blair, P.A. 2180 West First Street, Suite 401 Ft. Myers, Florida 33901 Ruth R. Stiehl, Ph.D., R.N., Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Angela T. Hall, Agency Clerk Department of Health 4052 Bald Cypress Way Bin A02 Tallahassee, Florida 32399-1703 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way Bin A02 Tallahassee, Florida 32399-1703
Findings Of Fact The Respondent is a registered nurse holding License No. 0936792 issued by the Florida State Board of Nursing. The Respondent was employed as a registered nurse at Shands Teaching Hospital in Gainesville, Florida, from August of 1978, until April, 1979. Her duties were as a nursing team leader and medication nurse on the fourth floor. The fourth floor unit to which the Respondent was assigned was a 52-to-56- bed unit. Staff on this floor consisted of a charge nurse in charge of the floor and two to four registered nurses. Patient census on this unit ran from 40 to 56 patients. This was a general medical ward whose patients included the chronically ill. (a) Regarding the allegations of Count 1 of the Administrative Complaint related to the patient Gussie Sims Gardner, the hospital records reveal the patient was not admitted to the hospital until 2225 hours on March 24, 1979. The individual responsible for initial preparation of the medication administration record (MAR) did not cross through the times prior to the administration of the patient's first medications as required by the hospital's protocols. See Exhibit 1, Medication Record (Form No. 15-02-41-2), page 2, paragraph 5. Because of this failure, the initial entries for medication administered to the patient on March 25 were transposed to the date of March 24, and the entries for March 26 were placed in the column far March 25. After two days this error was apparently discovered, and no entries were made in the column for March 26. The Respondent cannot be held responsible for this error, because she was not on duty when the patient was admitted. Under the hospital's standard operating procedures (SOP), the first individual administering medication should have crossed out the dates and times in such a manner that this error could not occur. (b) Regarding Counts 1 and 2 of the Administrative Complaint, the Control Substance Form (CSF) does reflect that the Respondent withdrew two Darvon 65, a Class IV controlled substance, on March 25, 1979. The Respondent recorded the administration of the Darvon at the appropriate time but under the date of March 24, 1979. Only the administration of this medication at 0830 hours on March 25 was noted by the Respondent in the nurses' notes. (c) Regarding the allegations of Count 4, recording of the entries for March 25 and 26 under the dates of March 24 and 25 resulted in no entries being made on the MAR on March 26 by any of the nursing staff. (d) Regarding the allegations of Counts 6 and 8 that the physician's order entered March 24 for Oarvom 65 was no longer effective on March 28, Exhibit 1, the Formulary, page VIII, provides that stop orders occur automatically at the end of 48 hours for narcotics and at the end of seven days for all other drugs unless renewed. The Formulary differentiates on page IX between narcotics and other controlled substances. Darvon, while a controlled substance, is not a narcotic and therefore would not be terminated at the end of 48 hours, but at the end of seven days. The administration of this drug by the Respondent on March 28 was not precluded by the hospital's regulations. (e) Regarding the allegations contained in Counts 3, 5, 7 and 9, there is no substantial evidence that the Respondent possessed any controlled substance for any purpose other than the administration of the substance to the patient. No substantial and competent evidence was presented that the medications were not administered to the patient as recorded in the written records of the hospital. (a) Regarding the allegations concerning the patient Mary Lee Love Graham contained in Count 10 of the administrative Complaint, the CSF reflects two doses of Codeine were signed out by the Respondent for this patient on March 25, 1979. The appropriate entries were made on the MAR by the Respondent. Although the 1200 hour administration of medication was charted in the nurses' notes, the administration of the medication at 0830 hours was not charted by the Respondent. Similarly, the administration of Codeine 60 to this patient at 2200 hours was not charted by Nurse Wigginton on March 24, 1979. (b) Regarding Count 12 of the Administrative Complaint, the MAR reflects that Graham received Codeine 60 at 0400 hours from Wigginton and at 0800 hours from the Respondent on march 26, 1979. The nursing notes do not reflect the administration of Codeine 60 at either time. On March 27, 1979, the Respondent apparently administered no medications to this patient; however, the administration of Codeine 60 to this patient at 1600 hours on March 27, 1979, was not charted in the nursing notes. (c) Regarding the allegations of Count 14 in the Administrative Complaint, the MAR and CSF agree regarding the administration of Codeine 60 to Graham on March 26, 1979, at 0800 and 1400 hours by the Respondent. The administration of the medication at 0800 hours was not charted in the nursing notes, as was the administration of the same medication at 2300 hours on the same date by another nurse. Although the physician's orders were not renewed and therefore terminated at the end of 48 hours as discussed above, the MAR was not changed to reflect discontinuation of this medication, and all staff nurses, to include the Respondent, continued to administer Codeine 60 to this patient after the physician's orders ceased. (d) Regarding the allegations contained in Counts 11, 13 and 15, there is no substantial and competent evidence that the Respondent possessed any controlled substance for any purpose other than its administration to a patient. There is no substantial and competent evidence that the medications were not administered as charted. (a) Regarding the allegations contained in Count 16 concerning the patient Marshal Rex Burk, the MAR and CSF records reflect administration of Darvon 65 by the Respondent to this patient at 1000 hours on March 24, 1979. This was not charted by the Respondent in the nursing notes. As stated above, the drug Darvon 65 is not a narcotic drug and not subject to automatic termination at the end of 48 hours. Thee administration of Darvon 65 on March 24, 1979, was pursuant to a physician's order entered on March 19, 1979. (b) Regarding the allegations of Count 18, the CSF and MAR reflect administration of Darvon 65 to Burk at 1000 hours on March 25, 1979, by the Respondent. The Respondent did not chart this in the nurses notes. The physician's order for Darvon remained valid on March 25, 1979. (c) Regarding the patient Burk, the MAR reflects that Dalmane, a Class IV controlled substance, was administered March 21, 22, 23 arid 25 by a staff nurse. The administration of this medication was not charted in the nursing notes, and a review of the physician's orders for this patient does not reflect an order for Dalmane being entered until March 29, 1979. A review of the nursing notes for this patient reveals no charting for March 27, 1979. The SOP for charting provides a minimum of one charting for each patient per shift. (d) The allegations contained in Counts 17 and 19 are not proven. The records reflect the Respondent signed out for Darvon 65 and administered it to the patient. (a) Regarding the allegations contained in Count 20 of the Administrative Complaint concerning the patient Willie Mae Bender Tison, the CSF shows the Respondent signed out for two doses of Darvon 65 on March 24, 1979, for this patient. The MAR reflects administration at 0330 hours on March 24, 1979. The nursing notes do not reflect administration of Darvon 65 to his patient on March 24, 1979. One Darvon 65 was not accounted for in the records. (b) Regarding this patient, his MAR indicates the patient started receiving drugs on March 17, 1979; however, the admitting data and nursing notes reflect that this patient was not admitted until 1450 hours on March 21, 1979. The data contained in the MAR from March 17 until March 24 is clearly in error. (c) Regarding Count 21, although the facts indicate the Respondent did not chart the administration of one Darvon 65 to the patient Tison, no evidence was introduced that the Respondent took the medication herself or retained the medication for sale or distribution. (a) Regarding the allegations in the Administrative Complaint contained in Count 22 relating to the patient Frances Louise Blocker Medina, the MAR reveals that Percodan was administered to this patient on March 24, 1979, at 0530 hours, 0930 hours by the Respondent, 1300 hours by the Respondent and 2200 hours. The CSF reflects that the Respondent withdrew two doses of Percodan for the Respondent on March 24, 1979. The Respondent recorded the administration of the medication to this patient at 1300 hours in the nursing notes. No entries were made in the nursing notes for March 24, 1979, reflecting the administration of Percodan at 0530 hours, 0930 hours and 2200 hours by the Respondent and others. (b) Regarding the allegations of Count 24, the MAR reflects that the Respondent administered Percodan to this patient at 0700 hours and 1100 hours on March 25, 1979. The Respondent charted the administration of this medication to this patient in the nursing notes at 0730 hours and 1030 hours. The CSF shows the Respondent signed out for two Percodan for this patient on March 25, 1979. The MAR also reveals that this patient received Percodan at 1830 hours on March 25, 1979, from another nurse. The nursing notes do not reflect charting of this medication. (c) Regarding the allegations in Count 26, the CSF reflects that the Respondent signed out for two doses of Percodan for this patient on March 26, 1979. The MAR reflects administration of Percodan to this patient at 0200 hours, 0800 hours by the Respondent, 1400 hours by the Respondent and 2000 hours on March 26, 1979. The nursing notes reflect only the administration of this medication for 2000 hours. (d) Regarding the allegations of Count 28, the medical records of this patient reflect that staff nurses, to include the Respondent, continued to give the patient Percodan, a narcotic, although the physician's order for this medication automatically terminated. (e) Regarding the allegations of Count 30, the MAR and CSF reflect that the Respondent administered one Percodan to this patient on March 28, 1979. The Respondent failed to chart the administration of this medication to this patient in the nursing notes. (f) Regarding Counts 23, 25, 27, 29 and 31, no substantial and competent evidence was presented that the Respondent maintained possession of any drug. The records reflect that all drugs signed out by the Respondent were administered to the patient. (a) Regarding allegations contained in Count 32 of the Administrative Complaint concerning the patient Ruby Lee Denson Standback Woodburne, the times on the exhibit copies of the CSF are illegible. However, the MAR and CSF do reflect that the Darvon 65 checked out for this patient by the Respondent on Marcy 24, 1979, was administered to the patient. The nursing notes reflect administration of the medication to the patient. (b) Regarding the allegations in Count 34, the CSF shows the Respondent signed out for Darvon 65 two times on March 25, 1979, for this patient. The MAR reflects the Respondent administered Darvon 65 to the patient at 0830 hours and 1200 hours. The nursing notes reflect that Darvon 65 was administered at 1200 hours but not at 0830 hours. (c) Regarding the allegations of Count 36, the MAR and CSF records show the Respondent medicated the patient at 0800 hours and 1200 hours on March 26, 1979, with Darvon 65. The Respondent charted the administration at 1200 hours in the nursing notes but failed to chart the administration at 0800 hours. (d) Regarding the allegations of Count 38, the CSF reflects the Respondent withdraw one Darvon 65 for this patient on March 27, 1979. The MAR does not reflect administration of this medication; however, the nursing notes reflect the administration of Darvon at 0830 hours on March 27, 1979. (e) The medical service orders for this patient were renewed March 22, 1979, after Use patient's surgery. Presumably, this would have renewed the Darvon 65 order of March 17, 1979, and it would have been effective through March 29, 1970. (f) Regarding Counts 33, 35, 37 and 39, there is no evidence that any medication was net administered to the patient as reflected in the records. Although the MAR entry was not made on March 27, 1979, a nursing note does reflect administration of Darvon 65 on that date by the Respondent. (a) Regarding the allegation contained In Count 40 of the Administrative Complaint concerning the patient Willie Mae Hair, the CSF and MAR records reflect the Respondent administered Darvon 65 to this patient at 0830 hours on March 24, 1979. No entry was made in the nursing notes by the Respondent for this date. Although the patient was discharged on March 24, she was medicated for pain in the evening of March 23, and the nursing note for 0145 hours of March 24 reflects that the nursing staff apparently expected her to experience pain. (b) There is no substantial and competent evidence to support the allegation of Count 41. All medications checked out by the Respondent for this patient were administered according to the records. Regarding Count 42 of the Administrative Complaint, Exhibit 11 reveals that on several occasions the Respondent wasted medications without the required countersignatures of another staff member. There was no substantial and competent evidence presented that the Respondent converted any of the drugs wasted to her own use. To the contrary, although improperly witnessed, the records reflect that the medications were wasted. Review of Exhibit 1, containing extracts of the hospital's SOP's for controlled substances and charting, does not reveal any requirement that the specific time of withdrawal of a controlled substance be entered on the CSF. Exhibit 1 does reflect that medication may be prepared and placed upon a lockable medicine cart. The nature of the entries on the MAR reflect that medications were drawn at one time from the controlled substance container for administration to patients during a shift. The SOP for charting nursing notes does not require that the administration of medication be noted. However, the SOP for administration of medication would require noting the patient's complaint and the patient's response to medication in the nursing notes if a prn medication were administered. Gross departures from the hospital's SOP's regarding controlled substances and charting of nursing notes occurred among staff nurses employed on the fourth floor at the time in question due to staffing shortages.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer would recommend that no action be taken against the Respondent. DONE and ORDERED this day of January, 1980, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Michael I. Schwartz, Esquire Suite 201, Ellis Building 1311 Executive Center Drive Tallahassee, Florida 32301 Irving J. Whitman, Esquire 9595 North Kendall Drive, Suite 103 Miami, Florida 33176 Geraldine B. Johnson, R. N. State Board of Nursing 111 Coastline Drive East, Suite 504 Jacksonville, Florida 32202
The Issue The issue presented herein is whether or not the Respondent's licenses as a registered and practical nurse should be revoked, suspended or otherwise disciplined based on allegations that she violated various provisions of Chapter 464, Florida Statutes, as more specifically set forth hereinafter, in detail, as alleged in the Amended Administrative Complaint filed herein.
Findings Of Fact Based upon my observation of the witnesses and their demeanor while testifying, documentary evidence received and the entire record compiled herein, I hereby make the following relevant findings of fact. At all times material herein, Respondent was licensed as a registered and practical nurse having been issued license numbers 76324-2 and 28359-1 by the State of Florida. (Petitioner's Exhibit 1.) Between November 13, 1978 and October 1, 1979, Respondent was employed as a nurse at Broward General Medical Center. On October 1, 1979, Respondent's resignation was requested by Julia Trenker, Director of Nursing Services and Assistant Administrator of Nursing Services for Broward General Medical Center. The reason for the resignation request by Ms. Trenker was alleged discrepancies in the charting of narcotics performed by Respondent. The practical effect of the resignation request of Respondent was the same as a termination inasmuch as Respondent was given the option of either voluntarily resigning or being terminated. (Tr. pages 97, 190, 193 through 197.) By letter dated October 2, 1979, Ms. Trenker notified the Florida State Hoard of Nursing of Respondent's employment termination from Broward General Medical Center due to charting discrepancies. (Tr. page 193 and Petitioner's Exhibit 25(a).) On or about March 22, 1982, Respondent completed an application for employment as a registered nurse with Doctor's Hospital of Hollywood, Inc. On the employment application, Respondent listed her previous employment with Broward General Medical Center and gave as the reason for leaving the need for increased salary because she gave was head of her household. (Petitioner's Exhibit 19.) At no time prior to employment with Doctor's Hospital 2/ of Hollywood, Inc. did Respondent notify Doctor's Hospital of the true reasons for the severance of her employment relationship with Broward General Medical Center (charting discrepancies). (Petitioner's Exhibit 2 and Tr. page 132.) Respondent admitted to Lucille Markowitz, an investigator with the Petitioner and Maureen Lake, then the Assistant Director of Nursing for Doctor's Hospital of Hollywood, Inc., that she had been terminated from Broward General Medical Center because of her failure to chart. Respondent did not list that reason on her employment application because she considered that it would have been too hard for her to be considered for employment. (Tr. 41.) Respondent was employed as a registered nurse at Doctor's Hospital of Hollywood, Inc. from March, 1982 through October, 1982. While employed at Doctor's Hospital, Respondent worked in Unit 2 East. Patient care was provided in that Unit under the "team care concept." Each team consisted of a registered nurse, licensed practical nurse and an aide. The team leader was responsible for overseeing team members, administering medications, setting up IVs, and administering IV medications, performing charting for the aide that the LPN could not do, coordinating patient x-rays, operating room (OR) and doctor's orders, transcribing such orders, taking telephone orders and making "rounds" with physicians. (Tr. pages 153 to 154.) There were two nursing teams on Unit 2 East at Doctor's Hospital of Hollywood, Inc. and the patient census was, at maximum, 35. Patients on Unit 2 East were split evenly between the two teams. The team leader was responsible for the "hands-on care" of at most four patients. The remaining patients were assigned to the other team members and assignments were overseen by the team leader. (Tr. pages 149 through 153.) Medications for each team are kept in separate medication carts. Each cart contained patient drawers for each patient on that team. The medication cart contains a narcotic drawer which is locked with the keys for each narcotic drawer kept by the cart's team leader or the LPN for that team when the team leader was unavailable. The medication administration record (MAR) and a 24- hour narcotic control drug record (narcotics sheet) is placed on each cart. The policy at Doctor's Hospital with reference to the administration of medications was that medications would be administered to a team: s patient only from that team's medication cart. Patients were not to be cross-medicated from other carts. (See Petitioner's Exhibit 2) The Policy and Procedure Manual for Doctor's Hospital of Hollywood, Inc. states that "when a medication is given, it is to be charted." (Tr. page 185.) At Doctor's Hospital, it was the team leader's responsibility to remove all post-operative orders for patients returning to Unit 2 East from surgery and to fill out a new MAR for that patient. (Tr. page 293.) Charting must be performed in the administration of all narcotics. When a narcotic is withdrawn from the narcotic drawer, the withdrawal must be noted on the narcotics sheet. The narcotics sheet is an audit tool for pharmacy and reflects the withdrawal and addition of narcotics in the narcotic cart. Once a narcotic has been administered to a patient, the administration should be immediately charted on the MAR. Charting involves making a notation on the MAR of the time that the narcotic was given and placing one's signature (who administered the narcotic) in the appropriate space. The MAR is the most accurate record of the administration of medications and the MAR along with the Nurse's Notes, unlike the narcotics sheet, becomes a part of the patient's medical history. In practice, the Nurse's Notes are usually completed within one hour of the administration of the medication and is acceptable if performed prior to the completion of one's shift provided other charting is performed in a timely manner. On September 1, 1982, at approximately 12:10 p.m., patient Katherine Kerwin was returned to Unit 2 East after eye surgery. Respondent's team was responsible for Ms. Kerwin's care on September 1, 1982. Respondent, as team leader for Unit 2E, received Ms. Kerwin from surgery. (Petitioner's Exhibit 7.) Upon Ms. Kerwin's return from surgery, Respondent administered 35 milligrams of demerol intramuscular to Ms. Kerwin. Under the physician's order, Kerwin was to receive that dosage once every six (6) hours as needed for twenty-four (24) hours. Respondent noted the withdrawal of the demerol on the narcotics sheet at or before the time of administration to Ms. Kerwin. (Petitioner's Exhibits 4 and 7.) When Respondent withdrew demerol from the narcotics drawer, she withdrew a 50 milligram vial. Ms. Kerwin was to receive a 35 milligram dosage of demerol. Respondent therefore had to waste 15 milligrams of demerol which wastage was witnessed by Lonna Wlodarczyk, an LPN on Respondent's team. (Petitioner's Exhibit 4.) Although Wlodarczyk witnessed the wastage, she did not inquire and was not required to inquire as to the patient for whom the wastage was performed. At the time of administering demerol to Ms. Kerwin, Respondent did not chart the administration of medication on either the Nurse's Notes or the MAR. Respondent did not prepare an MAR upon Kerwin's return from surgery. Sometime after 1:00 p.m. on September 1, 1982, patient Kerwin requested pain medication from Wlodarczyk. Wlodarczyk asked Kerwin if she had received pain medication and she replied that she had not. Wlodarczyk checked patient Kerwin' s chart to see if any post-operative orders had been taken off and none had been removed. Wlodarczyk further checked the MAR and determined that there was not one for patient Kerwin. Wlodarczyk further checked the Nurse's Notes to see if patient Kerwin had received anything for pain prior to the time Wlodarczyk answered patient Kerwin's buzzer. There was no record in the Nurse's Notes that demerol had been administered to patient Kerwin upon her return from surgery. (Tr. pages 291-292.) After determining that there was no record of the administration of demerol to patient Kerwin on the Nurse's Notes or the MAR, Wlodarczyk drew up 35 milligrams of demerol from a 50 milligram vial. Jean Ellis witnessed the wastage of the excess demerol for patient Kerwin. Wlodarczyk noted the withdrawal on the narcotics sheet and had Ellis sign the narcotics sheet as a witness to the wastage of the excess. (Petitioner's Exhibit 4.) Wlodarczyk did not check the narcotics sheet to determine whether demerol had been withdrawn previously for patient Kerwin. (Tr. page 293.) Wlodarczyk prepared an MAR sheet for patient Kerwin by taking down the post-op orders and placed them on the MAR sheet. After administering the demerol to patient Kerwin, Wlodarczyk charted the administration of demerol on the MAR. When Wlodarczyk went to chart the administration of demerol to patient Kerwin on the Nurse's Notes, after having administered the demerol. Wlodarczyk noted that the Nurse's Notes indicated that an identical dosage of demerol had been previously administered by Respondent. The entry noting said administration by Respondent was not in the Nurse's Notes when Wlodarczyk originally checked them. The entry was made some time between the time Wlodarczyk originally checked the Nurse's Notes and the time that Wlodarczyk went to chart the administration of demerol and give it to patient Kerwin (approximately 1:30 p.m.). (Tr. page 292.) The double dosage of patient Kerwin resulted in an incident. An incident was reported by Wlodarczyk to Marsha Hogg, Supervisor. Supervisor Hogg prepared an Incident/Accident Investigation Report. Hogg counseled Respondent on proper procedures in making out MAR and charting the administration of medications immediately. (Petitioner's Exhibit 21 and Tr. pages 137-138, 362, and 366-368.) On or about September 4, 1982, Respondent administered 75 milligrams of demerol intramuscular to Elizabeth Dobson at 9:00 a.m. and at 2:50 p.m. (See Petitioner's Exhibits 8, 10 and 12.) On September 4, 1982, Respondent was team leader for Team 1, Unit 2 East. Elizabeth Dobson was a patient being cared for by Team 2, Unit 2 East. The team leader for Team 2 was Cecelia Falis. The procedures in effect at Doctors' Hospital during September, 1982 were that when administering medication to patients on another team, it was incumbent upon the staff person administering the medication to first determine whether a team mother for that patient was available to medicate the patient and thereafter if no such person was available to medicate the patient, the patient should be medicated from that team's cart. In administering demerol to Elizabeth Dobson, Respondent withdrew two 75 milligram vials of demerol from her own team's medication cart. Respondent did not withdraw the demerol from the Team 2 medication cart even though Team 2 was responsible for Ms. Dobson's care. (Petitioner's Exhibits 8 and 9.) Respondent did not immediately chart the 9:00 a.m. administration of demerol to patient Dobson on the MAR. When Falis checked the MAR later in the afternoon, the 9:00 a.m. entry was not on the MAR. Falis checked the MAR for patient Dobson at 7:30 and 9:00 a.m., 12:00 and 1:00 p.m., and immediately prior to the close of her shift, 3:00 p.m. (Tr. pages 324 and 332.) At a time uncertain, Respondent charted the 9:00 a.m. administration of demerol to patient Dobson on her Nurse's Notes. However, Respondent did not sign the entry for that administration. (Petitioner's Exhibit 12.) When Falis reported to the incoming 3 - 11 shift employees on September 4, 1982, she first discovered that Respondent had administered two (2) 75 milligram doses of demerol to patient Dobson. Falis looked on the MAR for patient Dobson and discovered that entries had been made documenting the administration of demerol to patient Dobson at both 9:00 a.m. and 2:50 p.m. Prior to the end of the shift, Falis was certain that Respondent had not charted the administration of demerol to patient Dobson on September 4, 1982. On or about September 4, 1982, Joyce Murphy, Administrative Nursing Supervisor for the 7 - 3 shift at Doctors' Hospital, conducted an audit of the charting performed by Respondent on September 4, 1982. After reviewing Respondent's charting with reference to patient Dobson, Supervisor Murphy asked Respondent to go back and complete her charting for patient Dobson. At that time, Respondent had not charted the 2:50 p.m. administration of demerol to patient Dobson on the Nurse's Notes. (Tr. pages 378 through 380 and 394.) Pursuant to Murphy's request, Respondent made a "late entry" under Nurse's Notes for patient Dobson, documenting the administration of 75 milligrams of demerol and 25 milligrams of vistaril. (Petitioner's Exhibit 12 and Tr. page 394.) On September 8, 1982 at approximately 8:30 a.m., Respondent administered a percocet tablet to Carmela DeLora, by mouth. Pursuant to the physician's order for patient DeLora, she was to receive one percocet tablet every six (6) hours by mouth, as needed. (Petitioner's Exhibit 15.) Respondent noted the withdrawal of one percocet tablet for patient DeLora on the narcotics sheet some time between 9:00 a.m. and 10:15 a.m. (Petitioner's Exhibit 13.) Respondent also did not immediately chart the administration of a percocet tablet to patient DeLora on September 8th on either the Nurse's Notes or the MAR. (Petitioner's Exhibits 15 and 16 and Tr. page 344.) On September 8, 1982, Crystal Reeves, an RN at Doctors' Hospital, was called to relieve Respondent during lunch for a period of approximately 30 minutes. Reeves and Respondent made a narcotics count and Reeves assumed responsibility for the narcotics keys. While Respondent was at lunch, Carmela DeLora requested pain medication from Reeves. Reeves checked the doctor's orders for DeLora. Reeves thereafter checked the Nurse's Notes and the MAR for DeLora. Reeves found nothing charted for patient DeLora since the night of September 7, 1982. (Tr. page 344.) At approximately 12:00 p.m. after checking both the Nurse's Notes and the MAR for patient DeLora, Reeves administered one tablet of percocet by mouth to DeLora. Reeves charted the withdrawal of the medication on the narcotics sheet and after administering the percocet tablet to DeLora, Reeves charted the administration of percocet on the MAR. (Tr. pages 344, 346 and Petitioner's Exhibits 13 and 15.) Reeves did not chart the administration of percocet on the Nurse's Notes because there was nothing charted on the Nurse's Notes for the entire morning and when serving in a relief capacity, Reeves, following the practice then in effect at Doctor's Hospital, merely filed an oral report with the nurse she relieved, Respondent. When Respondent returned to Unit 2 East on September 8, 1982, Reeves informed her that she had medicated DeLora with percocet. Respondent then advised Reeves that DeLora had been medicated earlier. (Tr. page 347.) Due to this medication error, Reeves completed an incident report at Doctor's Hospital of Hollywood, Inc. The incident report was submitted to Marsha Hogg who prepared an Incident/Accident Investigation Report. Hogg counseled Respondent about the importance of charting on the MAR. Hogg also reviewed procedures for properly administering and charting medications. Finally, Hogg gave Respondent a written warning notice. (Petitioner's Exhibits 22 and 23 and Tr. pages 347, 362- 363, and 369-370.) Respondent offered (to Hogg) no reason for her failure to timely chart the administration of medications on the MAR or Nurse's Notes. On or about September 24, 1982, patient Will LaBree was sent to X-Ray at Doctor's Hospital of Hollywood, Inc. with two name bracelets. Respondent was the team leader responsible for LaBree's total patient care. The responsibility for placement of identification bracelets is primarily a responsibility resting with the Admission's Office. Respondent's Position As to the failure to chart and the failure to timely chart allegations, Respondent contends that Unit 2 East of Doctor's Hospital where she served as team leader was usually at capacity and that in addition to the responsibility for caring for 4 of the 17 or 18 patients, she also had the duties of making rounds with physicians, providing IV therapies, starting IV's, transcription of physician's orders and ensuring that all the treatment plans and care for those patients were completed on her tour of duty. According to Respondent, waiting to chart the MAR was a frequent occurrence and was acceptable at Doctor's Hospital in September of 1982. Respondent admits that while failure to chart the administration of medications upon a patient's MAR was unacceptable, late charting on the MAR by a nurse before she left duty was acceptable. Further, Respondent testified that she faced constant interruptions while team leader at Unit 2E; that it was customary as a team leader to chart Nurse's Notes after making rounds with physicians; that generalized accusations and innuendos were leveled at her and that following such accusations, she generally felt emotionally upset. She testified that this, in fact, happened in the administration of the percocet to patient DeLora, resulting in a failure to chart the MAR. When relieved by nurse Reeves to have lunch, Respondent returned to find that she had not charted the administration of percocet to patient DeLora. As to the allegation respecting the discovery of two arm bracelets upon patient Will LaBree on September 24, 1982, a nurse other than Respondent admitted patient LaBree at 6:30 a.m. onto the floor of Unit 2E and it is herein specifically found that it was not the Respondent's responsibility for ensuring or otherwise making out the patient's name tag for the patient's bed or to make sure that it matched the bracelet on LaBree's arm. As to the Respondent's stated reasons on her employment application submitted to Doctor's Hospital for employment and the given reasons for leaving Broward General Hospital Center as "needed higher salary (head of household)," Respondent contends that she relied upon Investigator Markowitz's representation to her that such would be a satisfactory answer as to her reason for leaving Broward General Medical Center. 3/
Recommendation Based on the foregoing findings of fact and conclusions of law, it is hereby recommended that the Respondent's licenses as a registered and practical nurse be suspended for a period of two (2) years. Respondent may apply for reinstatement at the end of one (1) year of said suspension if she submits the following to the Board of Nursing: a satisfactory in-depth psychological evaluation prepared by a qualified psychiatrist, psychologist or other qualified mental health counselor recommending or otherwise representing that Respondent is currently able to practice nursing with reasonable skill and safety to patients; verification of successful completion and documentation that Respondent has successfully completed a refresher course in basic nursing skills including the procedures for charting the administration of medications prior to reinstatement. The terms of the probation are as follows: Respondent shall not violate any federal or state laws or rules or orders of the Board of Nursing. Respondent agrees to submit to random blood or urine tests and shall cause results of analysis to be furnished to the Board if collected by an agent other than an authorized representative of the Department. At such time as the blood and/or urine sample is collected, it shall be Respondent's responsibility to provide pertinent information regarding her usage of prescribed or over-the- counter medication consumed. Additionally, Respondent shall provide documentation of valid prescriptions for any medication or controlled substances consumed for legitimate purposes. Respondent shall not consume, inject or otherwise self- medicate with any controlled substance or prescription drug which has not been prescribed by an duly licensed practitioner. Respondent shall obtain or continue to obtain counseling with a psychiatrist, psychologist or other mental health counselor and shall cause progress reports to be furnished to the Board or probation supervisor every three (3) months during treatment as scheduled by the probation supervisor. RECOMMENDED this 16th day of May, 1984, in Tallahassee, Florida. JAMES E. BRADWELL Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904)488-9675 FILED with the Clerk of the Division of Administrative Hearings this 16th day of May, 1984.
The Issue At issue is whether Respondent committed the offenses set forth in the Second Amended Administrative Complaint and, if so, what penalty should be imposed.
Findings Of Fact Stipulated Facts The Petitioner is the State Agency charged with the regulation of the practice of nursing pursuant to Chapters 20,456 (formerly Chapter 455, Part II; see Chapter 2000-160, Laws of Florida) and 464, Florida Statutes. Pursuant to the authority of Section 20.43(3)(g), Florida Statutes, the Petitioner has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative and prosecutorial services required by the Division of Medical Quality Assurance, councils or boards, as appropriate, including the issuance of emergency orders of suspension or restriction. Respondent is Cynthia Chance. Respondent is a Licensed Practical Nurse in the State of Florida, having been issued license No. PN 0855441. On or between March 1997-May 1997, Respondent was employed by Health Force, a nurse-staffing agency. In or about March 1997, Respondent was assigned to work various shifts at Baptist Medical Center-Beaches. In or about March 1997, Respondent submitted time slips to Health Force alleging that she had worked an eight-hour shift on March 18, 1997. In or about March 1997, Respondent submitted time-slips to Health Force alleging that she had worked an eight-hour shift on March 21, 1997. Findings of fact based on the evidence of record Missing Drugs On May 13, 1997, Health Force received a "late call" from Cathedral Gerontology Center (Cathedral) needing a "stat" nurse because one of their nurses had not come to work. Tresa Streeter (now Calfee), administrator for Health Force, called Respondent who reported to Cathedral at 6:50 p.m. Kim Harrell, R.N., a supervisor at Cathedral, was the nurse who stayed until Respondent arrived. Also at 6:50 p.m. on May 13, 1997, Barbara Kelley, R.N., received and signed for a delivery of medications for residents from American Pharmaceutical Services. Included in that delivery was an order of Alprazolam (Xanax) and an order of Diazepam (Valium) for two residents on the floor where Respondent was working that evening. The delivery came with a separate medication or narcotics card for each medication. There were two floors of residents at Cathedral. Each floor had its own medication cart and its own nurse assigned to the floor. Controlled medications have a separate box in the medication cart with a separate key. The nurse on each floor had a key to her own medication cart but did not have a key to the medication cart of the other floor. The Director of Nursing (DON) also had a key to both medication carts in the event of an emergency such as a lost key. After receiving and signing for these drugs, Nurse Kelley locked the medications that belonged to her medication cart in it and inserted the narcotic cards for those medications into the notebook that corresponded to her cart. She then gave the medications and control sheets that belonged to Respondent's medication cart to Respondent, placing them in Respondent's hand. Nurse Kelley told Respondent that these were controlled drugs and instructed Respondent to lock up the medications in Respondent's medicine cart. There is conflicting testimony as to what happened next. Respondent admits to receiving the medications and the control cards. However, Respondent maintains that she placed the medications in the locked drawer of the medication cart and inserted the cards into the notebook in front of Nurse Kelley, whereas Nurse Kelley maintains that she walked away immediately after giving the drugs and cards to Respondent and did not see her place the drugs in the controlled drug lock box or the cards in the notebook. It was a policy at Cathedral for the out-going nurse to count controlled drugs with the on-coming nurse. When Respondent arrived on the night in question, she counted the controlled medications with Nurse Harrell. The narcotics count for both narcotics cards and actual doses was 16. At the end of her shift, Respondent counted the controlled medications with the on- coming nurse, Pamela Schiesser. The number of narcotics cards and tablets or doses was 16, the same as when Respondent came on duty. Nurse Schiesser was scheduled to work a double shift, 11 to 7 and 7 to 3. During the 11 to 7 shift, Nurse Schiesser was the only nurse for both floors of residents and she, therefore, had the key to both medication carts. Sometime during the 7 to 3 shift on May 14, 1997, Nurse Schiesser called the pharmacy to find out about a medication order she had placed for two residents so they would not run out. She was informed by the pharmacy that the drugs had been delivered the evening before and that they had been signed for by Nurse Kelley. She checked the delivery sheets and confirmed that Nurse Kelley had signed for the medications. After determining that there were no cards for the missing drugs and the drugs were not in the cart, she then reported to her supervisor, Kim Harrell, that the medication had been delivered but could not be located. Nurse Schiesser and Nurse Harrell checked the entire medication cart, the medication cart for the other floor and the medication room but did not find the missing medications. Nurse Harrell then notified the Assistant Director of Nursing (ADON), Lu Apostol, and the Director of Nursing (DON), Fely Cunanan, regarding the missing medications. The ADON began an investigation and secured written statements from all of the nurses on her staff who had access to the drugs: Nurses Kelley, Harrell, and Schiesser. She called Nurse Kelley to confirm that she had received the medications from the pharmacy and confirmed that the two missing medications, Alprazolam (Xanax) and Diazepam (Valium), were given by Nurse Kelley to Respondent. The ADON also called Tresa Streeter (now Calfee), the administrator of Health Force for whom Respondent worked to notify her of the missing medications. On May 14, 1997, Ms. Streeter (Calfee) called Respondent and informed her about the missing drugs. On May 15,2000, Ms. Streeter and Respondent went to Cathedral for a meeting. They were informed that the two missing drugs had not been located and they were shown the written statements of the other nurses. Respondent admitted that the drugs had been given to her the night before by Nurse Kelley, but stated that she had locked the drugs in her cart. She denied any further knowledge about the drugs. At Ms. Streeter's suggestion, Respondent took a blood test on May 15, 2000.1 The drug test result was negative thus indicating that the drugs were not in her blood at the time of the test, which was two days after the drugs were missing. No competent evidence was presented as to how long it takes for these drugs to leave the bloodstream. Cathedral had a policy that required that all controlled substances be properly accounted for and secured by each nurse responsible for the drugs. This policy was verbally communicated from the off-going nurse to the oncoming nurse. When Nurse Kelley gave the drugs and drug cards in question to Respondent, she specifically instructed Respondent to lock up the drugs in the narcotics drawer. Respondent maintains that other people had keys to her medication cart and could have taken the drugs after she put them in the locked narcotics box. This testimony is not persuasive. Every witness from Cathedral testified unequivocally that there was only one key in the facility for each medication cart and that key was in the possession of the nurse assigned to that cart. The only other key, which was in the possession of the Director of Nursing, was not requested or given to anyone at anytime material to these events. The persuasive testimony is that Respondent was the only person during her shift with a key to her medication cart. That key was passed to Nurse Schiesser who discovered that the drugs and narcotics cards were not in the medication cart or notebook. The count of the drugs and the cards on hand did not show that anything was missing at the change of shift from Respondent to Nurse Schiesser as the count was 16, the same as when Respondent came on the shift. If Respondent had put the drugs and corresponding cards in the medication cart, the count should have been 18. The only logical inference is that Respondent did not put the drugs or cards in the cart. In the opinion of the two witnesses accepted as experts in nursing and nursing standards, Respondent's failure to properly secure the narcotics and to document the receipt of these controlled drugs constitutes practice below the minimal acceptable standards of nursing practice. Time-Slips While employed by Health Force as an agency nurse, Respondent was assigned at various times to work at Baptist Medical Center-Beaches (Beaches). Respondent submitted time cards or slips for each shift she worked to Health Force so that she would be paid for the work. Respondent submitted time-slips for working at Beaches on March 18 and 21, 1997. When Health Force billed Beaches for these two dates, Anne Hollander, the Executive Director of Patient Services, the person responsible for all operations at Beaches since 1989, determined that Respondent had not worked on either March 18 or 21, 1997. Ms. Hollander faxed the time-slips back to Health Force for verification. She advised Health Force that Respondent was not on the schedule as having worked on either of those dates. She also advised Health Force that the supervisor's signatures on the two time-slips did not match anyone who worked at Beaches. Ms. Hollander is intimately familiar with the signatures of all the supervisors who are authorized to sign time-slips at Beaches and none of them have a signature like the signatures on the two time-slips. Health Force did an investigation and ended up paying Respondent for the two days, but did not further invoice Beaches. Health Force was never able to determine whose signatures were on the time-slips. Health Force did have Respondent scheduled to work at Beaches on March 21, 1997, but not on March 18, 1997. Beaches keeps a staffing sheet for every day and every shift. The supervisors are responsible for completion of the staffing schedules to ensure that the necessary staff is scheduled to work on each shift. These staffing sheets are used for both scheduling and doing the payroll. According to Ms. Hollander, it is not possible that Respondent's name was just left off the staffing sheets. The staffing sheets are the working sheets. If a person works who is not originally on the staffing sheet, the supervisor writes that person's name into the correct column at the time they come to work. Ms. Hollander has been familiar with these staffing sheets for 12 years and does not recall any time when someone's name has been left off the staffing sheet when he or she had worked. The two supervisors who testified, Erlinda Serna and Carol Lee, are equally clear that in their many years of experience as supervisors at Beaches, no one has worked and not been on the staff schedules. Anybody who worked would show up on the schedule. Every shift and every day should be on the staffing schedules. Ms. Serna is unaware of any time in her 10 years at Beaches that someone's name was left completely off the schedules, but that person actually worked. Respondent's name was on the staffing schedule for March 21, 1997, but it was crossed out and marked as cancelled. When agency nurses are scheduled at Beaches, but are not needed, they are cancelled with the agency. If the agency fails to timely notify the nurse and the nurse shows up for work, the agency must pay her for two hours. If the hospital fails to notify the agency timely and the nurse shows up for work, then the hospital must pay the nurse for two hours. In no event is a nurse who is cancelled paid for more than two hours. There are times when a nurse is cancelled and shows up for work, but the hospital has a need for the nurse either as a nurse or in another capacity such as a Certified Nursing Assistant (CNA). If that happens, the nurse's name is again written into the nursing unit staffing schedule. For March 18, 1997, Respondent's name is not on the schedule for Beaches. She did not work in any capacity on March 18, 1997. For March 21, 1997, Respondent's name was on the schedule, but she was cancelled. Even if she had not been timely notified that she was cancelled and she showed up for work, the most she could have billed for was two hours. If she had stayed and worked in a different capacity, her name would have been rewritten into the staffing schedule. Beaches is very strict and follows a specific protocol. No one except the supervisors is allowed to sign time cards. The signatures on these two time cards do not belong to any supervisor at Beaches. Therefore, it can only be concluded that Respondent did not work on March 18 or 21, 1997, at Beaches and that she submitted false time-slips for work she did not do on March 18 and 21, 1997. In June 1997, Respondent was also working as an agency nurse for Maxim Healthcare Services (Maxim). On June 8, 1997, Respondent submitted a time ticket to Maxim and to Beaches indicating that she had worked eight-hour shifts at Beaches on June 2, 3, 4, and 5, 1997. All four days were on the same time ticket and purported to bear the initials and signature of Carol Lee. This time ticket was brought to Ms. Hollander's attention because Beaches had a strict policy that only one shift could appear on each time slip. Even if a nurse worked a double shift, she would have to complete two separate time tickets, one for each shift. Under Beaches policy, no time ticket would ever have more than one shift on it. The time tickets are submitted to Ms. Hollander's office daily with the staffing schedules that correspond. Therefore, a time ticket for a person who is not on the staffing schedule would immediately stand out. When Ms. Hollander was given the time ticket for June 2-5, 1997, she investigated and reviewed the staffing sheets for those days. Respondent was not listed on any of the staffing schedules. Ms. Hollander then showed the time ticket to Erlinda Serna, who was the nursing supervisor on the 3 to 11 shift. Nurse Serna verified that Respondent had not worked on the shift any of those days. Ms. Hollander then showed the time-slip to Carol Lee, the 11 to 7 nursing supervisor. Carol Lee verified that she had not initialed or signed the time ticket and that the initials and signature were a forgery. Nurse Lee would not have signed a time ticket with more than one shift per time ticket because she was well aware of the policy prohibiting more than one shift per time ticket. Nurse Lee verified that Respondent had not been scheduled to work any of those days and that Respondent had not worked on June 3, 4, or 5, 1997. These inquiries to Nurse Serna and Nurse Lee took place within a few days after the dates for which Respondent had submitted this time ticket. Therefore, the matter was fresh in the minds of both nursing supervisors. Both are certain that Respondent was neither scheduled nor worked on June 2-5, 1997. Only nursing supervisors at Beaches are authorized to sign time tickets. Maxim Healthcare has a policy of never working a nurse in excess of 40 hours in one week. The same policy was in effect in 1997. Susan Ranson, the records custodian who also staffs for Maxim on the weekends and assists in their billing, indicated that Respondent was paid by Maxim for working at another facility the same week as June 2-5, 1997. June 2-5, 1997, are a Monday through Thursday. Specifically, Respondent submitted a time ticket to Maxim for another facility showing that she worked 12 hours on Saturday, June 7, 1997, and 13 hours on Sunday, June 8, 1997. Maxim pays from Monday through Sunday. If Respondent had worked 32 hours at Beaches on Monday through Thursday and then 25 hours at another facility on Saturday and Sunday, she would have worked more than 40 hours in one week, which would have violated their policy and would have required Maxim to pay overtime. When Maxim gets a request for a nurse and has no one to send who would not exceed 40 hours in one week, rather than exceed 40 hours, the agency does not staff the job. In the disciplinary document from Health Force dated June 18, 1997, Health Force advised Respondent that it would not be scheduling her based on the complaints they received regarding false billing, the missing drugs at Cathedral, and another incident at Beaches that occurred during this same time. Taken in its totality, the testimony of Respondent is not credible. Respondent's explanation of the discrepancy in the count of drugs and corresponding cards is that during her shift "there was [sic] one or two cards that only had one or two pills on them, so you just throw them away. And that's what made it back to 16." This explanation is unpersuasive. If there had been any pills left in the drawer from cards that Respondent threw away, the count would have been off at the change of shift. Moreover, several witnesses testified as to the care that is taken to carefully account for all narcotics. Respondent's assertion that narcotic pills were simply thrown away is not credible. Nurse Schiesser clearly remembered that there were no cards for the medications in question and there were no medications from this delivery in the medication cart. Respondent has been previously disciplined by the Board of Nursing in the Board's case No. 98-20122.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law set forth herein, it is RECOMMENDED: That the Respondent be found guilty of one count of violating Section 464.018(1)(h), Florida Statutes, by failing to secure and document receipt of the drugs at Cathedral Gerontology Center; That the Respondent be found guilty of one count of violating Section 464.018(1)(h), Florida Statutes, and of violating Rule 64B9-8.005(1), Florida Administrative Code, by falsifying employment and time records on multiple occasions; and That a penalty be imposed consisting of a fine of $1000 and payment of costs associated with probation, together with a reprimand and a three-year suspension of license to be followed by a two-year probation with conditions as deemed appropriate by the Board of Nursing. Reinstatement of Respondent's license after the term of the suspension shall require compliance with all terms and conditions of the previous Board Order and her appearance before the Board to demonstrate her present ability to engage in the safe practice of nursing, which shall include a demonstration of at least three years of documented compliance with the Intervention Project for Nurses. DONE AND ENTERED this 29th day of December, 2000, in Tallahassee, Leon County, Florida. BARBARA J. STAROS 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 29th day of December, 2000.
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.
