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
Recommendation Based upon the findings of fact and conclusions of law recited above, it is recommended that respondent's application for reinstatement of her practical nursing license be DENIED. Done and Entered this 10th day of January, 1978, in Tallahassee, Florida. DIANE D. TREMOR Hearing Officer Division of Administrative Hearings 530 Carlton Building Tallahassee, Florida 32304 COPIES FURNISHED: Julius Finegold, Esquire 1007 Blackstone Building Jacksonville, Florida 32202 Paul W. Ferrell, Esquire Legal Aid Society of St. Petersburg, Florida 440 Second Avenue North St. Petersburg, Florida 33701 Mrs. Geraldine Johnson, R.N. State Board of Nursing 6501 Arlington Expressway, Bldg B Jacksonville, Florida 32211
Findings Of Fact Joanne N. Dickey is licensed by Petitioner as a licensed practical nurse and holds license number 37835-1. During the period November 24 through November 28 Respondent was so licensed and was employed by Memorial Hospital, Hollywood, Florida on the 11:00 p.m. to 7:00 a.m. shift. Standard procedures established by Memorial Hospital regarding the accounting for controlled substances are for the nurse withdrawing medication for administering to a patient to record the withdrawal on the Narcotic Inventory Sheet on which a running inventory for a 24-hour period is kept, and, upon administering the medication to the patient, chart the medication on the medication administration record and in the nurses notes for the patient. Standard procedures established for accounting for excess drugs withdrawn (e.g., where doctor's orders call for 50 mg. and only 100 mg. ampules are available) prescribe that the excess drug withdrawn be disposed of in the presence of another witness and so recorded on the waste record. These procedures are presented to all nurses at Memorial Hospital during their compulsory training periods before they administer to patients at Memorial Hospital. On November 26, 1978, Respondent, at 1:15 a.m., signed out on the narcotic control record for 100 mg. meperidine for patient Cohen, but this medication was not entered on either the medication administration record or on the nurses notes for this patient. At 4:30 a.m., Respondent signed out for 75 mg. meperidine for patient Cohen and the administration of this medication was not entered on the patient's medication administration record or in the nurses notes. Doctor's orders for Cohen at this time authorized the administration of 50-75 mg. meperidine presumably not given to Cohen. No entry was made on the waste record. On November 27, 1978 at 12:30 a.m., Respondent signed out for 75 mg. meperidine and at 4:00 a.m. for 100 mg. meperidine for patient Cohen on the narcotic inventory sheet, but the entry of the administering of these medications to patient Cohen was not entered on the medication administration record or in the nurses notes. Again, no waste record was made for the excess over the 50-75 mg. authorized. Further, doctor's orders in effect on November 27, 1980 for patient Cohen did not authorize administration of meperidine. At 2:15 a.m. on November 27, 1978 Respondent signed out for 75 mg. meperidine and at 5:30 a.m. 50 mg. meperidine for patient Barkoski. No record of administering these medications was entered on the patient's medical administration record or in the nurses notes. Doctor's orders authorized administration of 50 mg. meperidine as necessary. No entry of disposal of the excess 25 mg. was entered in the waste record. At 4:20 a.m. November 24, 1978 Respondent signed out for 75 mg. Demerol for patient Giles. No entry was entered on the medical administration record or in nurses notes that this medication was administered to patient Giles. At 3:30 a.m. on November 24, 1978 Respondent signed out for 25 mg. Demerol for patient Evins but no entry was made on the patient's medical administration record or in the nurses notes that this medication was administered to the patient. At 12:50 a.m. on November 24, 1978 Respondent signed out for 100 mg. Demerol and at 4:30 a.m. signed out for 50 mg. Demerol for patient Demma. No entry was made in the medication administration record or nurses notes for Demma that this drug was administered. Doctor's orders in effect authorized administration of 50-75 mg. Demerol as needed. No entry was made on waste record for the overage withdrawn. On the 11-7 shift on November 27, 1978, Respondent's supervisor noticed Respondent acting strangely with dilated pupils and glassy eyes. She suggested Respondent go home repeatedly and sent her to the lounge but Respondent soon returned to the floor. Respondent was finally told if she didn't go home the supervisor would call Security. The supervisor had checked the narcotic inventory log at 4:50 and saw no entries thereon. By the time Respondent was finally sent home at 6:00 a.m., the entries on the Narcotic Control Record at 12:30, 1:15, 2:15, 4:30 and 5:30 were entered. Failure to chart the administration of narcotics to patients does not comply with acceptable and prevailing nursing practices. No evidence regarding the administering of hydromorphone was submitted.
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 =================================================================
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 Whether Respondent committed the offenses described in the administrative complaint? If so, what disciplinary action should be taken against her?
Findings Of Fact Based upon the record evidence, the following findings of fact are made: Respondent is now, and has been since August 17, 1987, licensed to practice practical nursing in the State of Florida. She holds license number 0876721. Respondent was employed for more than a year as a nurse at Martin Memorial Hospital (hereinafter referred to as the "hospital"), a private nonprofit community hospital located in Stuart, Florida. She was suspended from her position for three days on October 25, 1988, for suspected diversion of drugs and falsification of medical records. Upon the expiration of her suspension, she was terminated. At all times material to the instant case, Respondent was assigned to the hospital's sixth floor oncology unit and she worked the day shift (7:00 a.m. to 3:00 pm). Among the patients for whom Respondent cared was S.H. S.H., who is now deceased, had lung cancer. The first five days of S.H.'s stay at the hospital were spent in a room on the hospital's fifth floor. On October 15, 1988, she was moved to the sixth floor oncology unit, where she remained until her discharge at 3:35 p.m. on October 22, 1988. When a patient is admitted to the hospital, the admitting physician provides the nursing staff with written orders regarding the care that is to be given the patient. These written orders, which are updated on a daily basis, include instructions concerning any medications that are to be administered to the patient. The hospital's pharmacy department provides each patient with a twenty- four hour supply of the medications prescribed in the physician's written orders. The supply is replenished daily. In October, 1988, the medications that the pharmacy department dispensed were stored in unlocked drawers that were kept in designated "medication rooms" to which the nursing staff and other hospital personnel had ready access. The hospital's nursing staff is responsible for caring for the hospital's patients in accordance with the written orders given by the patients' physicians. Furthermore, if a nurse administers medication to a patient, (s)he must indicate that (s)he has done so by making an appropriate, initialed entry on the patient's MAR (Medication Administration Record). 1/ In addition, (s)he must note in the nursing chart kept on the patient that such medication was administered. Moreover, if the physician's written orders provide that the medication should be given to the patient on an "as needed" basis, the nursing chart must contain information reflecting that the patient's condition warranted the administration of the medication. The foregoing standards of practice that nurses at the hospital are expected to follow are the prevailing standards in the nursing profession. On October 13, 1988, S.H.'s physician indicated in his written orders that S.H. could be administered Darvocet N-100 for pain control on an "as needed" basis, but that in no event should she be given more than one tablet every six hours. S.H.'s MAR reflects that at 9:00 a.m. on October 18, 1988, the first day that Respondent was assigned to care for S.H., Respondent gave S.H. a Darvocet N-100 tablet. The entry was made by Respondent. Respondent did not indicate on S.H.'s nursing chart that she gave S.H. such medication on October 18, 1988. Moreover, there is no indication from the nursing chart that S.H. was experiencing any pain and that therefore she needed to take pain medication while she was under Respondent's care on that date. S.H.'s MAR reflects that at 10:00 a.m. on October 21, 1988, the day Respondent was next assigned to care for S.H., Respondent gave S.H. a Darvocet N-100 tablet. The entry was made by Respondent. Respondent did not indicate on S.H.'s nursing chart that she gave S.H. such medication on October 21, 1988. Moreover, there is no indication from the nursing chart that S.H. was experiencing any pain and that therefore she needed to take pain medication while she was under Respondent's care on that date. At some time toward the end of her stay in the hospital, S.H. told one of the charge nurses who worked in the sixth floor oncology unit that she had taken very few Darvocet N- 100 tablets during her stay at the hospital and that she had not taken any recently. S.H.'s physician did not prescribe Darvocet N-100 or any other similar pain medication for S.H. upon her discharge from the hospital. Notwithstanding the entries she made on S.H.'s MAR, Respondent did not give Darvocet N-100 to S.H. on either October 18, 1988, or October 21, 1988. Respondent made these entries knowing that they were false. She did so as part of a scheme to misappropriate and divert the medication to her own use.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Board of Nursing enter a final order finding Respondent guilty of the violations of Section 464.018(1), Florida Statutes, charged in the instant administrative complaint and disciplining Respondent by taking the action proposed by the Department, which is described in paragraph 9 of the foregoing Conclusions of Law. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 26th day of October, 1990. STUART M. LERNER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 26th day of October, 1990.
