The Issue Whether the Respondent's license as a Licensed Practical Nurse should be suspended or revoked for alleged violation of Sections 464.21(1)(b) and (d), F.S., as set forth in Administrative Complaint, dated August 3, 1978. The Respondent did not appear at the hearing. Notice of Hearing was issued by the Hearing Officer under date of October 25, 1978, to the address provided by Petitioner, 7124 Bay Drive No. 1, Miami Beach, Florida 33141. This is the address reflected on the envelope which enclosed Respondent's request for hearing on the Administrative Complaint sent to Petitioner under postmark August 28, 1978. It being determined that adequate notice had been provided to Respondent, the hearing was conducted as a uncontested proceed, pursuant to Rule 28-5.25(5), Florida Administrative Code. (Exhibit 5)
Findings Of Fact Respondent Michaela Fives holds License No. 27554-1 as a Licensed Practical Nurse and was so licensed in November, 1977. (Testimony of Johnson) On November 5, 1977, Detective Kenneth Valentine, Hialeah Police Department, was acting in an undercover capacity on an investigation of narcotics. Pursuant to his investigation, he met with Respondent at her apartment located at 5960 NW 38th Street, Apartment 210, Virginia Gardens, Miami, Florida. Lynn Sampson and Danny Cundiff were also present in Respondent's apartment at the time. Cundiff and Sampson wrote out a prescription of 60 300 mg. Quaalude tablets on a printed prescription form. The top of the form showed the name Lacy, Adler, M.D., P.A., followed by "Andrew P. Adler, M.D., Ray C. Lacy, M.D., 221 West Flagler Street, Miami, Florida 33130, Telephone: 887-9339." The prescription was handed to Valentine and Respondent gave him $15.50 to have it filled at the My Pharmacy, 1550 West 84th Street, Hialeah-Miami Lakes, Florida. By pre-arrangement with the pharmacist, Valentine had the prescription filled there and took the pills back to the apartment. Sampson divided them among Respondent, Cundiff and herself, and each of them ingested one tablet. Valentine purchased ten tablets from Sampson and Cundiff for $35.50. (Testimony of Valentine) On November 9, 1977, Valentine again met with the three individuals at Respondent's apartment and was provided another prescription for the same amount of drugs. It reflected the patient's name as Robert Southern, and registration number 178855. It was purportedly signed by "S. Adler, M.D." Prior to this meeting, the Hialeah police had determined that Doctors Adler and Lacy were not listed in the telephone book nor were they located at the address shown on the prescription form. They also determined that the phone number shown on the prescription form was a pay telephone located in Hialeah, Florida. After the individuals at the apartment discussed the fact that the pharmacist would probably call the phone number listed on the prescription form to verify its authenticity, Valentine took the Prescription to the My Pharmacy and had it filled, using his own money for the purchase. At this time, another police officer present at the pharmacy called the phone number listed on the prescription form to ostensibly verify the prescription. Lieutenant Paul Gentesse of the Hialeah Police Department had previously placed himself in a position to observe the pay telephone. He saw the Respondent answer the telephone and then followed her back to her apartment. When Valentine returned with the filled prescription, he gave it to Cundiff who divided the tablets among Respondent, Sampson and Valentine Valentine paid $30.00 for ten tablets. Other police officers then arrived at the apartment and Respondent, Cundiff and Sampson were placed under arrest. (Testimony of Valentine, Gentesse, Exhibit 3) The tablets taken from the possession of Respondent and the others were analyzed by a chemist in the Crime Laboratory of the Dade County Public Safety Department and were found to contain Methaqualone, a controlled substance under Chapter 893, Florida Statutes. Quaalude is a common tradename for Methaqualone. (Testimony of Lynn, Exhibit 2, supplemented by Exhibit 1) On January 9, 1975, Petitioner had suspended the license of the Respondent for period of two years as a result of prostitution charges. The record of that proceeding contained the testimony of Respondent that she had been involved In the illegal use of controlled drugs and had been attending a drug rehabilitation program for the treatment of drug abuse as a result of court order. Respondent thereafter petitioned for reconsideration of the suspension and, on June 29, 1976, Petitioner stayed its order of suspension and placed Respondent on probation for the remainder of the period of suspension. (Testimony of Johnson, Exhibit 4)
Recommendation That Respondent's license as a Licensed Practical Nurse be revoked for violation of Section 464.21(1)(d) , Florida Statutes. DONE and ENTERED this 2nd day day of January, 1979, in Tallahassee, Florida. THOMAS C. OLDHAM Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1007 Blackstone Building Jacksonville, Florida 32202 Geraldine Johnson, R.N. Investigation and Licensing Coordinator 6501 Arlington Expressway, Bldg B Jacksonville, Florida 32211 Michaela Fives, L.P.N. 7124 Bay Drive No. 1 Miami Beach, Florida 33141
Findings Of Fact Mary Louise Rahming was a licensed practical nurse, who held a license issued by the Florida State Board of Nursing until March 31, 1977. Rahming failed to renew her license by March 31, 1977, and her license was automatically terminated effective April 1, 1977. Rahming continued in her employment as a licensed practical nurse from April 1, 1977, until July 28, 1978, when she sought to renew her license. Since July, 1978, Rahming has not practiced nursing. Rahming's request for reinstatement of her license was denied by the Board of Nursing on August 25, 1978, because Rahming had practiced without a license after her license was terminated.
Recommendation Whether the statute is construed to entitle an individual whose license has been terminated for failure to renew to a license pending a hearing, or construed to entitle the applicant to a hearing on the grounds for denial after notice of the Board's initial determination, the facts in this case reveal that Rahming applied for licensure on July 26, 1978, and has not practiced since that date when she became aware she was in violation of the law. The period of the denial of the right to practice between the applicant's request for reinstatement and the Board's final action must be considered in weighing the penalty. In the instant case, this period of defacto suspension has been nearly nine months. Although many delays have occurred in this case which have resulted from Rahming's failure to keep the Board advised of her current address, this period of suspension should be considered in any penalty ultimately assessed. Based upon the foregoing Findings of Fact and the Conclusions of Law, and considering the matters in mitigation, the Hearing Officer recommends that the Board reissue the license of Mary Louise Rahming, considering the period she has not been able to practice during the pendency of this case as sufficient penalty for her violation of Section 464.151(2). DONE and ORDERED this 16th day of March, 1979, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Mary Louise Rahming 5218 NW 5th Avenue Miami, Florida Julius Finegold, Esquire 1107 Blackstone Building 233 East Bay Street Jacksonville, Florida 32202 Geraldine B. Johnson, R. N. Board of Nursing 6501 Arlington Expressway, Bldg B Jacksonville, Florida 32211
The Issue By an Administrative Complaint executed May 27, 1986 and filed with the Division of Administrative Hearings on July 11, 1986, Respondent is charged, pursuant to Sections 464.018(1)(f) and/or (h) Florida Statutes (1985) with "unprofessional conduct which departs from minimal standards of acceptable and prevailing nursing practice; and/or being unable to practice nursing with reasonable skill and safety to patients by reason of use of alcohol or drugs." All charges are limited to events allegedly occurring May 6, 1985.
Findings Of Fact The Respondent is a licensed practical nurse. On May 5-6, 1986, Respondent was employed at the Orlando Health Care Center as a licensed practical nurse on the 11:00 p.m. to 7:00 a.m. shift. At that time, Jeanette Crandall, a 68 year-old female patient roomed with Lorene Johnson, another elderly female patient who has a history of "wandering." Mrs. Crandall testified that early on the morning of May 6, 1986 she observed Respondent alone attempt to place Lorene Johnson in bed and that when Respondent could not get Lorene Johnson into bed due to Johnson's resistance, Respondent struck Johnson with Johnson's shoe two or three times in her head resulting in a one and a half inch laceration causing Johnson to bleed. Although Ms. Crandall's testimony is somewhat disjointed as to precise time sequence, it is credible. In making the foregoing finding, the testimony of Linda Oram, nurse's aid, has not been overlooked. Ms. Oram testified upon behalf of the Respondent that when she first saw Lorene Johnson, witness Oram was with Respondent near the nurse's station and that patient Johnson came out of her room and was already bleeding. Ms. Oram stated she did not see how Ms. Johnson received her injuries nor did she see Respondent batter Ms. Johnson. Ms. Oram helped Respondent put Johnson back to bed but did not relate that Johnson had her shoes in her hand or that she resisted Oram and Respondent. Ms. Gram carefully explained that she was not present with Respondent all the time prior to putting Johnson back to bed and all the time afterwards. This evidence of Ms. Gram is not contradictory of Ms. Crandall's testimony. Moreover, there is the testimony of patient Lucille Diel that she subsequently heard Respondent telling Ms. Johnson "I didn't mean it," and the testimony of Pam Warner that Respondent told Warner that Lorene Johnson "just kept hitting me and hitting me. She was trying to kill me." Both Oram and Respondent confirm that Respondent applied a band-aid to Johnson's head injury when the two entered the room together despite profuse bleeding. Respondent's witness Oram is a recovering alcoholic and friend of Respondent who is also a recovering alcoholic. Her initial impression of Respondent's behavior was that Respondent was intoxicated and she stated this impression to a number of other witnesses on May 6, 1986. Her testimony at formal hearing did not contradict this initial impression but was expanded to include her belief that Respondent might also have been distressed on May 6 due a fight with Respondent's boyfriend. Oram felt Respondent was not in a condition to work. Jeanette Crandall was familiar with intoxicated people and testified that Respondent was drunk when she hit Johnson. Linda Ciekot, the licensed practical nurse who came on to relieve Respondent at 6:50 a.m. for the beginning of the 7:00 a.m. May 6, 1986 shift found Respondent with her head down on the desk, sweating profusely and responding to questions with slurred speech. She observed Respondent at that time to have glassy eyes, a staggering gait and to smell of alcohol. Ciekot formed the impression Respondent was very intoxicated. At this time several witnesses observed that the medicine cart and medicine Room in Respondent's charge were both unlocked and the cart was messy with doors turned out, all contrary to standard requirements. Respondent acknowledged that she frequently leaves the medicine cart unlocked and is reprimanded by her superiors for it. Pam Warner, a licensed practical nurse was summoned by Ciekot to attend patient Johnson. By that time, Johnson was in the atrium near the nurse's station and still bleeding from her wound. Pam Warner observed that Respondent had slurred speech and was loud and disheveled; she observed no alcohol odor on Respondent in the atrium. Arlene McClellan, a registered nurse coming on the new shift as charge nurse on Respondent's wing, described Respondent at this time as having glassy eyes, a wandering gaze, slurred speech and talking loudly. McClellan smelled alcohol on Respondent's person when she spoke with her privately in the small closed medicine room. These observations by persons familiar with the appearance and behavior of intoxicated persons are consistent with Respondent's being under the influence of alcohol while on duty and it is found that she was under the influence of alcohol while on duty. In making the immediately foregoing finding, Respondent's testimony has not been overlooked. She testified that her distraught condition was due to a violent fight she had had with her boyfriend just before coming to work at 11:00 p.m. May 5 and because of his telephoned threats against herself and her dog during the shift. Respondent maintained she was staggering due to skinned knees incurred May 5 when the boyfriend had dragged her across a parking lot. Her evidence of skinned knees and a series of phone calls and emotional upsets through the shift are corroborated by the observations of Leslie Martinez, another licensed practical nurse who saw Respondent approximately every two hours through the shift up until 4:00 a.m. However, Martinez stated that Respondent seemed herself until 4:00 a.m. when Martinez observed Respondent with a Betadine-stained uniform, messy nurse's station, unlocked medicine cart and medicine room, and slurred speech. Martinez' description is similar to that of other witnesses at approximately 6:30 a.m. It strains credulity to accept Respondent's version that so many medical personalities who are experienced with intoxicated persons could have confused the odors of imbibed apple juice and spilled Betadine (an iodine-based solution) with the odor of imbibed alcohol or confused the symptoms of acute emotional distress with the symptoms of being under the influence of alcohol. Her explanation is rejected. Despite elaborate speculation by Arlene McClellan based on uncorroborated hearsay, Petitioner did not establish by any competent direct evidence that any drugs were missing from the medicine cart or room or that any were ingested by Respondent.
Recommendation Based on the foregoing findings of fact and conclusions of law it is RECOMMENDED that the Respondent be suspended for a period of three years with leave to reapply after one year upon a showing to the Board of Nursing that her alcoholism is under control, that she is rehabilitated, and that she is fit to practice nursing. DONE and Ordered this 26th day of January, 1987 in Tallahassee, Florida. ELLA JANE P. DAVIS 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 26th day of January, 1987. APPENDIX TO RECOMMENDED ORDER Rulings pursuant to Section 120.59(2) F.S. upon Petitioner's proposed findings of fact (FOF): Accepted FOF 1. Accepted FOF 2. Accepted but not adopted as subordinate and unnecessary. Accepted but not adopted as subordinate and unnecessary. Accepted FOF 3. Accepted FOF 3. Accepted but not adopted as subordinate and unnecessary. Accepted FOF 5. Those portions supported by the record as a whole are accepted in FOF What is rejected is rejected as speculative, without predicate, and as not supported by the record as a whole. Accepted as FOF 5. Accepted that Respondent testified to this but rejected as a finding of fact as not supported by the record as a whole. Rejected as irrelevant what anyone observed concerning Respondent 10 hours after the incident at a time when she was off duty. Accepted but irrelevant for the reasons stated above. Accepted but irrelevant for the reasons stated above. Accepted FOF 5. Accepted FOF 5. Accepted FOF 5. Accepted FOF 3. Rulings pursuant to Section 120.59(2) F.S. upon Respondent's proposed findings of fact (FOF): 1. Respondent has presented no additional argument as to why Petitioner should not have been permitted to reopen its case to present evidence of licensure. The reopening of the Petitioner's case was permitted upon authority of Dees v. State 357 So.2d 491 and Jones v. State 392 So 2d 18. Since Respondent has not availed herself of further argument on that issue in her post hearing proposals, that ruling on the record is reiterated here and the record therefore contains evidence to support licensure of Respondent by Petitioner. Rulings pursuant to Section 120.59(2) F.S. upon Respondent's alternative proposed findings of fact (FOF): Accepted FOF 1. Accepted but not adopted as not determinative of any issue at bar (See FOF 5). Accepted but not adopted as not determinative of any issue at bar (See FOF 5). Accepted but not adopted as not determinative of any issue at bar (See FOF 5). Rejected as not supported by the record. Rejected as not supported by the record. Mrs. Crandall is unclear about whether Mrs. Oram was present or came in later from behind her. Mrs. Oram was not with Respondent at all times prior to going into the room with her. It would appear Ms. Johnson wandered on several occasions that night and Mrs. Crandall is clear Mrs. Oram was not assisting Respondent when the blow was struck. Accepted FOF 3. Accepted FOF 3. Accepted FOF 3. Rejected as not supported by the record as a whole and upon the lack of credibility of the Respondent. Rejected as not supported by the record as a whole and upon the lack of credibility of the Respondent. Rejected. Observation of Petitioner's Exhibits 1 and 2 suggests this type of injury is consistent with the sandal used. Rejected as not supported by the record as a whole. Accepted but not adopted as not determinative of any issue at bar. (See FOF 5) Accepted FOF 6. COPIES FURNISHED: John Namey, Esquire 22 East Pine Street Orlando, Florida 32801 Francisco Colon, Jr., Esquire 1 North Orange Avenue Suite 500 Orlando, Florida 32801
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 matters presented for consideration in this instance concern an Administrative Complaint brought by the Petitioner against the Respondent seeking to suspend, revoke or take other disciplinary action against the Respondent's license, in particular, against her license as a Registered Nurse. The substance of the Administrative Complaint is contained in five (5) counts. Count I to the Administrative Complaint alleges that on or about March 10, 1981, Respondent signed out a controlled substance, to wit: two (2) ampules of Demerol, between the approximate hours of 7:00 P.M. to 7:15 P.M. for a patient, DeFrisco [sic]. DeFrisco [sic], reputedly states that she did not receive the Demerol. Based upon the foregoing alleged facts, Respondent has purportedly violated Subsection 464.018 (1)(d), Florida Statutes (1979), by making a false report of record which she knew was false and in addition has violated Subsection 464.018(1)(f), Florida Statutes (1979), by failing to conform with the minimal standards of acceptable and prevailing nursing practice. 1/ Count II to the Administrative Complaint alleges that on or about March 5, 1981, the Respondent administered a controlled substance, to wit: Demerol, in excess of that ordered by the attending physician and for that reason violated Subsection 464.018(1)(f), Florida Statutes (1979), in that she failed to conform with the minimal standards of acceptable and prevailing nursing practice. 2/ Count III alleges that the Respondent wasted, without a witness, certain controlled substances, in violation of hospital policy, as follows: On 2/28/81 Dilaudid, 1 mg On 2/23/81 Demerol, 100 mg. On 2/22/81 Demerol, 50 mg. On 2/16/81 Demerol, 100 mg. On 2/22/81 Morphene Sulphate 3 mg. On 1/28/81 Demerol, 25 mg. On 1/22/81 Demerol, 100 mg. Based upon these alleged facts, the Respondent purportedly violated Subsection 464.018(1)(f), Florida Statutes (1979), by failing to conform with minimal standards of acceptable and prevailing nursing practice. Count IV to the Administrative Complaint alleges that on or about March 5, 1981, Respondent signed out a controlled substance, to wit: Demerol, at approximately 9: 02 A.M., and at 12:15 P.M., for the use of patient Theodora Durham. It is further alleged that patient Durham states that she did not receive the above mentioned Demerol. Based upon those alleged facts Respondent purportedly violated Subsection 464.018(1)(d), Florida Statutes (1979), in that she made a false report of record which she knew was false. Further, Respondent, based upon those facts, has allegedly violated Subsection 464018(1)(f), Florida Statutes (1919), by failing to conform with minimal standards of acceptable and prevailing nursing practice Count V alleges that on or about April 12, 1981, the Respondent reported to her place of employment, Beaches Hospital, under the influence of alcohol to the extent that it affected her body coordination Further, it is contended that Respondent's supervisor; Joyce Strarnes, did not allow her to complete her work shift because she, Respondent was unable to function safely and to conform with minimal standards of acceptable nursing practice Based upon these allegations, the Respondent has purportedly violated Subsection 464018(1)(f), Florida Statutes (1979), for failure to conform to the minimal standards of acceptable and prevailing nursing practice, in which case actual injury need not be established. 3/
Findings Of Fact This case is presented for consideration based upon the aforementioned Administrative Complaint filed by the Petitioner, State of Florida, Department of Professional Regulation, Board of Nursing, against the Respondent, Rebecca Lael Calhoun. The Petitioner, agency, is a regulatory body which has been granted the authority by the State of Florida to license, regulate and discipline those persons who practice nursing in the State of Florida. The Respondent Rebecca Lael Calhoun has been issued a license to practice as a Registered Nurse in the State of' Florida and at all times pertinent to this Administrative Complaint, has held that license issued by the Petitioner. Calhoun was employed at St. Luke's Hospital, in Jacksonville, Florida, between the months of December, 1980, and March 10, 1981. Her position with that institution was that of Registered Nurse. On March 10, 1981, the Respondent worked at the St. Luke's Hospital on Ward 1-C. In that capacity, she had responsibility for the medication cart where controlled substances and other medications were kept for patient use. One of the patients who was on Ward 1-C on March 10,1981, and for whom controlled substances and other medications were made available by physician's orders was one Barbara L. DiFrancesco. On that date, DiFrancesco had an operative procedure known as dilatation and curettage performed and after the procedure, was brought to room 161, which was a room on the ward where the Respondent was on duty. It was 4:30 P.M. when the patient was placed in that room. After DiFrancesco returned to her room, between the hours of 4:30 P.M. and 8:00 P.M. on March 10, 1981, she did not receive any form of controlled substance, in particular, Demerol. The Demerol was in fact removed from the hospital inventory in DiFrancesco's name and Respondent knew that the patient did not receive the Demerol. Nonetheless, the Respondent documented that the patient DiFrancesco had the substance withdrawn for the patient's benefit and had received such a controlled substance. The false documentation was discovered by Kathleen Lawson, Assistant Director of Nursing at St. Luke's Hospital who was investigating possible "discrepancies" on the part of the Respondent in the recordation of entries on the controlled substance forms kept by the hospital. On the evening of March 10, 1981, Lawson checked the controlled substance form at approximately 7:00 P.M., which pertained to Ward 1-C where the Respondent was working. This controlled substance form may be found as a part of the Petitioner's Composite Exhibit No. 1, admitted into evidence. (The entries on that form pertain to the time of the sign-out, name of patient, room number, nurse's signature, dosage amount, amount of wastage, if any, and signature of a witness to wastage, and the description of the medication or controlled substance signed out by the practitioner) Lawson's review of the controlled substance form on March 10, 1981, at around `1:00 P.M. did not indicate that Demerol had been signed out for the benefit of DiFrancesco; however, when Lawson returned to Ward 1-C at approximately 7:15 P.M. on that same evening, she observed an entry on the controlled substance form which had been made by the Respondent. This entry indicated that Demerol in the amount of 50 mg. had been signed out for the benefit of DiFrancesco at approximately 5:30 P.M. When confronted with the discrepancy of having failed to make a timely entry of the sign-out of the controlled substance, Demerol, for the benefit of the patient DiFrancesco, that is to say the fact that the 7:00 P.M. check revealed no sign-out and a 7:15 P.M. check revealed a sign-out post-timed to 5:30 P.M.; the Respondent was than asked to perfect all necessary documentation to conform all records on the question of the administration of a controlled substance for the benefit of the patient DiFrancesco. In response to this request, the Respondent made an entry on the nurse's notes portion of the patient DiFrancesco's medical chart, to the effect that at 5:00 P.M. Demerol in the amount of 50 mg., IM, intramuscular, was administered to the patient DiFrancesco for "cramping." A copy of those nurse's notes may be found in Petitioner's Composite Exhibit No. 3, admitted into evidence. Some of the aforementioned "discrepancies' that officials at St. Luke's Hospital had been concerned about in terms of the Respondent's reporting procedures pertained to the controlled substance form, related to wastage of Schedule II controlled substances. St. Luke's Hospital had a written policy dealing with this subject as may be found in Petitioner's Exhibit No. 6, which is a copy of that policy related to unit doe drug distribution. That written policy was to the effect that when Schedule II controlled substances are wasted, or partially administered to the patient, the wastage or partial administration is recorded on the controlled substance form through the name of the patient; room number; the nurse who wasted material; the material; the amount injected and/or the amount wasted. The substance is shown to a witness in the process of recording the incident description as set forth herein. Pursuant to the written policy, there is also a line on the controlled substance form for the placement of . Off initials of that person who witnessed the accountability of the wasted Schedule II controlled substance, when the substance is only partially administered. In addition, the Respondent and other nurse practitioners in the hospital underwent an orientation which apprised the Respondent and others of the matters pertaining to wastage of Schedule II controlled substances as set forth in the written procedures and the utilization of the controlled substance form. Also, a customary practice within the hospital was established in which totally wasted narcotics were witnessed by initials placed by the witness on the controlled substance form, in the same fashion as partially wasted substances. Having been made aware of the requirements of that drug distribution handout, the utilization of the controlled substance form and custom, the Respondent did, in fact, on occasion have wastage which was recorded on the controlled substance form and initialed by another nurse practitioner as may be seen in a review of Petitioner's Composite Exhibit No. 1, which is a series of controlled substance forms for various dates. Notwithstanding her knowledge of procedures and customs within the hospital, there were a number of dates in which the Respondent failed to have a witness initial the wastage of Schedule II controlled substances Those occasions were as follows: Date: January 28, 1981 Patient: Pinkney Dose: 50 mg. Demerol Waste: 25 mg. Demerol Witness: No entry Date: February 16, 1981 Patient: Gression Dose: 100 mg Demerol Waste: 100 mg. Demerol Witness: No entry Date: February 22, 1981 Patient: Perry Dose: 50 mg. Demerol Waste: 50 mg. Demerol Witness: No entry Date: February 23, 1981 Patient: Fraser Dose: 100 mg. Demerol Waste: 100 mg. Demerol Witness: An entry made to the effect that a witness was unavailable Date: February 28, 1981 Patient: Bergdorf Dose: 1 mg. Dilaudid Waste: 1 mg. Dilaudid Witness: No entry There were no facts presented other than those related to the patient Fraser on the presence of a witness to the events of wastage and destruction of the Schedule II controlled substances. In addition to the incident with DiFrancesco, there were two other occasions in which the Respondent had signed out a controlled substance and indicated giving that controlled substance to a patient, when in fact the patient did not receive the controlled substance. This pertained to incidents on March 5, 1981, involving a patient on Ward 1-C, where the Respondent was employed as a Registered Nurse at St. Luke's Hospital. On the aforementioned date, i.e., March 5, 1981, the patient Theodora Durham was in the hospital for procedures related to curettage and packing of the uterus. She was assigned to Room 158 on Ward 1-C as her patient's room. The controlled substance sign-out form for March 5, 1981, which is found as part of Petitioner's Composite Exhibit No. 1, indicates that at 9:02 A.M. and 12:15 P.M., Demerol in the amount of 50 mg. on each occasion was signed out for the benefit of the patient Durham. The sign-out and other entries were made by the Respondent. The Demerol was in fact removed from the hospital inventory. The patient's chart, a copy of which may be found as Petitioner's Composite Exhibit No. 2, admitted into evidence, also indicates nurses notes authored by the Respondent stating that the 50 mg. amounts of Demerol were administered intramuscular to the patient Durham at 9:00 A.M. and 12:00 Noon. In fact, the patient Durham never received the Demerol on either of the occasions referred to herein. The Respondent knew the patient had not received the Demerol. Following her employment at St. Luke's Hospital, the Respondent received employment at Beaches Hospital in Jacksonville Beach, Florida. On April 12, 1981, she reported work as a Registered Nurse at Beaches Hospital for the 11:00 P.M. to 7:00 A.M. shift. During the transition from the prior shift into the shift of the Respondent, two (2) fellow employees noticed the aroma of what they felt to be alcohol on the breath of the Respondent. The employees having reported their observation to the nurse supervisor, the Respondent was summoned into the office of the nurse supervisor and under questioning admitted that she had been "drinking." This response was related to the issue of whether the Respondent had been consuming an alcoholic beverage. The nurse supervisor detected an unkempt appearance about the person of the Respondent and the fact that the Respondent's eyes were bloodshot Following this discussion, the Respondent was asked to leave the hospital because she could not afford patient care to those patients on her ward, due to the fact that she had been consuming an alcoholic beverage before coming on duty which was contrary to the policy of the hospital.
The Issue The issues are whether Respondent violated Section 464.018(1)(h), Florida Statutes, and Rules 64B9-8.005(2) and 64B9-8.005(12), Florida Administrative Code, and if so, what penalty should be imposed.
Findings Of Fact Petitioner is the agency charged with the regulatory and prosecutorial duties related to nursing practice in Florida. Respondent is a licensed practical nurse in Florida, holding license no. PN 0481631. From May 13, 1992, to April 11, 1997, she was employed by Southlake Nursing and Rehabilitation Center (Southlake). On April 9, 1997, Respondent worked as a nurse on the 3:00 p.m. to 11:00 p.m. shift on Southlake's A wing. T.C. was a patient of another nurse on that wing. Around 7:00 p.m., Respondent began administering medications to her patients. Melody Perez, the ward clerk, informed Respondent that T.C. needed assistance because he was in respiratory distress. T.C. was sitting in the hall, six to eight feet from Respondent. Respondent went over to T.C., checked to make sure that there was oxygen in his tank and that his nasal cannula was in place. Respondent saw no outward symptoms of T.C. being in acute respiratory distress such as rapid breathing or anxiety. Respondent told Ms. Perez that she could not help T.C. because he was not her patient. She told T.C. that his nurse, who was on break and had the keys to the other medication cart, would be back in a few minutes. Respondent thought that T.C. just wanted his medications. She did not perform a nursing assessment, as that term is commonly understood in the practice of nursing. She did not take T.C.'s vital signs, count his respirations, or listen to his chest. After telling him to wait for his nurse, she just walked away. On April 10, 1997, T.C. and another resident complained to Southlake's administrative staff about Respondent's failure to help T.C. Southlake initiated an investigation based on these complaints. Conchita Griffin, Southlake's Assistant Director of Nursing, conducted the investigation. As was the custom and procedure at Southlake, Ms. Griffin interviewed T.C., the second complaining resident, Ms. Perez, and two certified nursing assistants (CNAs) who were on duty during the incident. Ms. Griffin then compiled a written report of the incident and submitted it to Southlake's administration. Based on her investigation, and after considering Respondent's disciplinary history at Southlake, Ms. Griffin recommended that Southlake terminate Respondent. Southlake had written policies requiring a nurse to attend to any resident who needed help. The policies require a nurse to assess a patient complaining of respiratory distress by taking the patient's vital signs, listening to respirations and to the chest for congestion. According to the policies, a nurse should attend to any patient in distress, calling the patient's assigned nurse, facility management, or 911 if needed. There are no circumstances where the nurse should do nothing. On April 11, 1997, Respondent was called in and asked about her side of the incident. She admitted that she looked at T.C. and that he did not appear to be in distress. She acknowledged that she did nothing except tell T.C. that his nurse would be back soon. When informed that she was being terminated, Respondent refused to sign the disciplinary form. She was asked to leave the premises immediately. Sharon Wards-Brown, Southlake's nursing supervisor for the evening shift in question, accompanied Respondent to A wing to retrieve her belongings. When Respondent arrived on the A wing, she went into the medication room, picked up T.C.'s chart, removed some pages from the chart, and went to the fax machine just outside the medication room. Ms. Wards-Brown and Beverly Burstell, the nurse manager who was on the floor checking some charts, saw Respondent remove the pages from T.C.'s chart and go to the fax machine. Both of them told Respondent that she could not remove or copy anything from the resident's chart. Respondent told Ms. Wards-Brown and Ms. Burstell not to touch her. Each page of nurses' notes in the patients' charts have a front and back side. Respondent stood at the fax machine for only a couple of seconds, not long enough to copy both sides of one page of nurses' notes. She certainly did not have time to copy both sides of all of the pages that she had removed from T.C.'s chart. Respondent's testimony that she had time to copy some of the nurses' notes from T.C.'s chart is not persuasive. Her testimony that she left all of the original pages in the fax machine is not credible. After being prevented from copying all of the pages that she had removed from T.C.'s chart, Respondent ran into the bathroom. A few seconds later she came out of the bathroom with papers and her purse in her hand. Ms. Wards-Brown called Clara Corcoran, Southlake's administrator, and Ms. Griffen for assistance. All three of them followed Respondent out of the building, demanding that she return the documents that she had removed from T.C.'s chart. Respondent repeatedly told them not to touch her. Ms. Corcoran and Ms. Griffen followed Respondent into the parking lot. Respondent got in her car but Ms. Corcoran and Ms. Griffen blocked Respondent from closing the car door and continued to demand the return of the papers. Respondent finally drove forward over the cement bumper and the grass in order to leave with the papers. Meanwhile, Ms. Wards-Brown returned to the A wing to examine T.C.'s chart. Ms. Griffen also examined the chart within two to three minutes after Respondent left the floor. The chart was still open on the desk. Ms. Wards-Brown and Ms. Griffen discovered that T.C.'s nurses' notes for April 9, 1997, were missing. They knew the notes were missing because both of them had seen the notes in the chart the day before when they reviewed the chart as part of the investigation. Respondent's Exhibit 2 is a copy of the front and back of one page of T.C.'s nurses' notes. The last note is dated March 27, 1997. It is not plausible that T.C.'s chart had no nurses' notes from that time until after April 10, 1997. Even if Respondent did not remove any of T.C.'s original nurses' notes from the premises, she violated the acceptable standards of nursing care by copying the front and back of one page and removing the copies from the facility.
Recommendation Based on the foregoing Findings of Facts and Conclusions of Law, it is RECOMMENDED: That Petitioner enter a final order fining Respondent $1,000 and suspending her license for one year, followed by two years of probation with appropriate conditions. DONE AND ENTERED this 10th day of October, 2000, in Tallahassee, Leon County, Florida. SUZANNE F. HOOD 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 10th day of October, 2000. COPIES FURNISHED: Diane K. Kiesling, Esquire Agency for Health Care Administration 2727 Mahan Drive Building 3, Room 3231A Tallahassee, Florida 32308 Thomas A. Delegal, III, Esquire Randy Rogers, Esquire Delegal & Merritt, P.A. 424 East Monroe Street Jacksonville, Florida 32202-2837 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 A00 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4042 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
Findings Of Fact On March 27, 1979, at 3:30 or 4:00 o'clock in the afternoon, respondent entered Ashton Pharmacy in Kissimmee, Florida, and asked Keith W. Lawhorne, the pharmacist on duty, to fill a prescription for 40 tablets of Demerol 50 mg. The prescription was on a Community Hospital form, purportedly signed by A. N. Feir, M.D. Mr. Lawhorne filled the prescription and respondent left with the pills. Later, Mr. Lawhorne telephoned Dr. Feir who said he had not prescribed anything for respondent. Mr. Lawhorne then telephoned Geraldine Francis, Director of Nursing Services at the Community Hospital in Kissimmee, where respondent was employed as a licensed practical nurse. Ms. Francis arranged a meeting the following day, March 28, 1979, with Mr. Lawhorne, respondent and herself. At this meeting, respondent admitted forging Dr. Feir's signature on the prescription form with which he had obtained Demerol the day before. He made the same admission to Mary L. Willis, a nursing practice consultant in petitioner's employ, on April 2, 1979. On April 4, 1979, respondent signed a written confession to the same effect, after talking to Lt. Charles Lee Cecil of the Kissimmee Police Department. In his written statement respondent said, "I realize that I have a drug problem and am seeking help for it, and will never make a mistake like this again." Petitioner's exhibit No. 2. He also stated that the forgery occurred "while under the influence of a Class II Narcotic (Percocet-5) . . ." Petitioner's exhibit No. 2. Demerol, a trade name for meperidine, is also a class II controlled substance. On April 3, 1979, respondent "began voluntary participation in Thee Door's (out-patient) drug abuse program . . . [and, by April 16, 1979] had successfully withdrawn . . ." Letter of Muse/Pollack dated September 10, 1979.
Recommendation Upon consideration of the foregoing, it is RECOMMENDED: That petitioner suspend respondent's license for six (6) months. DONE and ENTERED this 23rd day of October, 1979, in Tallahassee, Florida. ROBERT T. BENTON, II Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1107 Blackstone Building Jacksonville, Florida 32202 Mr. James E. Davis 6331 Spanish Oak Drive Orlando, Florida 32309
Findings Of Fact Having reviewed the entire record before it, the Board finds that the Findings of Fact as contained in the Hearing Officer's Recommended Order are adequately supported by competent, substantial evidence and hereby adopts those Findings of Fact as its own.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Petitioner's application for licensure by examination be GRANTED and that Ann Mary McKay be authorized to take the licensed practical nurse examination. DONE and ENTERED this 9th day of March, 1982, in Tallahassee, Florida. DONALD R. ALEXANDER 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 9th day of March, 1982.
Findings Of Fact Margie Leverson, petitioner, was registered with the Florida State Board of Nursing in 1978 as a licensed practical nurse holding license number 13107-1. On the evening of March 9, 1978, petitioner was assigned to work the 11 p.m. through 7 a.m. shift in the critical care unit of Palm Springs General Hospital, Homestead, Florida. An audit of administration records at the Hospital disclosed that petitioner failed to properly chart medications administered to a number of patients, that she failed to complete the nurses' notes of patients under her care, and that she did not sign the medication administration profile sheets or nurses' notes for any of the patients under her care during the time at issue. The importance of conforming to these requirements is to assure that all medications have been given when scheduled and to assure continuity in evaluating a patient's illness. With critically ill patients, it is necessary to be able to ascertain when a condition or problem was noted and how it was treated. Otherwise, continuity is lost, and it is possible that decisions as to treatment may not be accurately made, and the nurse in charge cannot in every case be identified unless her signature appears on the documents. Failure to chart medications administered to patients. On two occasions, petitioner failed to chart medications administered to patients. Specifically, Juan Pinera was to receive 2 million units of penicillin intravenously every four hours, including twice during the time he was in petitioner's care. However, the prescribed medication was not charted as having been given to the patient during this time. Another patient, Peter L. Garcia, was scheduled to receive ampycillin 500 mg. at midnight and 6 a.m., and garamycin 40 mg. at midnight. Such administrations, if given, were not charted by petitioner. Failure to adequately and properly chart the nurses' notes of patients in the nurse's care. In the case of four patients under the care of petitioner, no nurses' notes were kept. (Exhibit Nos. 1, 2, 5, & 6). For the other three patients, the notes were of minimal, if any, value because they did not provide any evaluation or explanation of the problems noted. (Exhibit Nos. 3, 4 & 7). Petitioner herself acknowledged that the words were written in her hand writing and were of no value to anyone attempting to determine the patient's condition. Failure to sign medication administration profile sheets and nurses' notes. The petitioner failed to sign the medication administration profile sheets and nurses' notes for any of the patients under her care during the time at Issue. In mitigation, petitioner had earlier completed a 3 p.m. through 11 p.m. shift at another hospital on the same date. She arrived on duty at the Hospital around 11:30 p.m. Because of an argument with a co-worker, she was transferred by her supervisor to another unit around 1:00 a.m. and claims she cannot be held accountable for the failures as to the seven patients who were under her care. Petitioner stated she ultimately left the hospital on leave around 3:00 a.m. due to a pinched nerve in her back.
Recommendation Based upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED the application of Margie Leverson for reinstatement of her license as a licensed practical nurse be granted subject to the conditions set forth in conclusion 14 above. DONALD R. ALEXANDER Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Ms. Margie Leverson 4030 Northwest 190th Street Opa Locka, Florida 33055 Frank A. Vickory, Esquire Assistant Attorney General The Capitol Tallahassee, Florida 32301
