The Issue The issues are whether Respondent, on or about October 2000, while employed by St. Joseph's Hospital, withdrew controlled substances (Demerol) from the Pysix system for patients and inaccurately and or incompletely documented the administration and or wastage of said medications, and, if so, what penalty is appropriate for Respondent's failure to conform to minimum standards of acceptable and prevailing nursing practice in violation of Subsection 464.018(1)(h), Florida Statutes.
Findings Of Fact Based upon observation of the witnesses and their demeanor while testifying, the documentary materials received in evidence, and the entire record complied therein, the following relevant and material facts are found. The Division of Administrative Hearings has jurisdiction over the parties and subject matter of this case. Subsections 120.57(1) and 464.018(1)(h), Florida Statutes. Respondent is, and has been at all times material hereto, a licensed registered nurse (RN) in the State of Florida, having been issued license number RN 3141652 by the Florida Board of Nursing. Respondent, at all times material hereto, was employed by St. Joseph's Hospital (St. Joe's), in Tampa, Florida. At all times material to this case, Respondent was working in the Intensive Care Unit (ICU), wherein is situated a Pysix medication dispensing machine. The Pysix medication dispensing system is comprised of a central control panel located in the office of the hospital's pharmacist. There are multiple outlets located in various units throughout the hospital. Access to medication contained in the several Pysix system outlets is similar in operation to access to money in an ATM machine, to wit: each authorized nurse is given by the hospital a personal password (like personal identification numbers for an ATM). A nurse enters the patient's name (for whom the medication is to be given and logged), then enters their personal password, and enters the desired medication number before the Pyxis machine will dispense the medication. All access entries to Pysix and dispensing of prepackaged medication by Pysix are recorded. The amount of medication administered to the patient is required to be recorded simultaneously on the patient care record (PCR) and on the hospital's Medication Administration Record (MAR). These records are required to be maintained and are reviewed periodically by doctors, nursing staff, and staff supervisors for accuracy and quality assurance purposes. It is the policy requirement of St. Joe's hospital that should a nurse not administer the entire amount of medication dispensed under his or her private password to the named patient, the acquiring nurse must retain the "waste" medication (unused medication). The accessing nurse shall then secure the presence of another nurse who shall witness the disposal of the "waste" medication. The nurse disposing of "waste" medication shall then enter into the Pyxis, his/her personal password and the amount of disposed "waste" medication. The witness nurse shall enter his/her personal password as having witnessed the actual "waste" medication disposal. At all times material and specifically in October and November 2001, Lynn Kelly, RN (Kelly), was the nursing manager for the ICU at St. Joe's and was Respondent's supervising nurse. In her capacity as nursing manager, Kelly's responsibilities included the following: hiring, firing, duty scheduling, performance evaluation, employee counseling, auditing medical records, quality control, risk management, management investigations, education and policy writing. In her capacity as a supervisor, Lynn Kelly received, reviewed and analyzed monthly reports that detailed controlled medication usage on her unit (ICU). The reports detailed the number of times a nurse accessed the Pysix system for narcotics as compared to the number of days that nurse worked a shift during the month. St. Joe's Hospital developed a standard deviation to be used when analyzing and reviewing records. Should a nurse's number of accesses to Pysix's narcotics fall outside the standard deviation, it was Kelly's duty to check that nurse's assignments to determine, if possible, a reasonable explanation for narcotic accesses beyond the standard deviation guidelines; a particular nurse could have been continually assigned to a particular patient who required more than normal narcotic medication for pain. A cross-check of the patient's medication records (PCR) and the hospital's MAR would be made upon discovery of assess outside standard deviation guidelines. After receiving a report on Respondent's narcotics (Demerol) withdrawals from the Pysix system that were outside the standard deviation, Kelly compared and analyzed Respondent's Pyxis access records to his assigned patients administration records with his narcotic waste records, for a two-month period, September 27 through November 2000. Kelly found instances where 25 milligrams and 50 milligrams units of Demerol were accessed by Respondent, but were not administered to the assigned patient. They were not entered as waste, and they were not documented in the MAR records. The discrepancies revealed that between October 2, 2001, and October 23, 2001, Respondent withdrew a total of 1,075 milligrams of Demerol from the Pysix narcotics dispensing system for administration to patients without documenting administering the medications or wasting the medications. Respondent suggested that "someone" could have or did look over his shoulder, observed and remembered his personal password as he typed it in, and later use his password to access the Pysix machine for Demerol. Respondent testified that on many occasions other nurses would come up behind him and instead of his logging out the Pysix machine, he would withdraw their narcotics for them and hand it to them. It was common practice for several nurses to be in the Pysix room at the same time. Respondent's responses and suggestions without other supporting evidence, are insufficient to account for the 1,075 milligrams of Demerol accessed by Respondent, not administered to the assigned patient, and not documented as waste medication as required. Proper and correct documentation of accessed medication is important and essential for the prevention of potential overmedication by a subsequent nurse due to the lack of proper and correct documentation by the preceding nurse in this case, Respondent. The record was left open from January 25, 2002, to March 4, 2002, for subsequent submission of evidence regarding theft of passwords by other employees at St. Joe's during the time material to the allegation in the Administrative complaint; the parties made no subsequent submissions.1 Petitioner has proven by clear and convincing evidence that in October 2001 while employed by St. Joe's Hospital, Respondent, using his personal password, withdrew controlled substances from the Pysix narcotics system and did not document, as required, administering the withdrawn controlled substances to the patients for whom the withdrawals were made, and did not document wasting the controlled substances withdrawn.
Recommendation Based on the foregone, it is
Findings Of Fact At all times relevant to the issues involved in this hearing, the Respondent was licensed as a registered nurse, having been licensed on September 1, 1967, by examination, with license number 41856-2. At all times pertinent to the issues involved in this hearing, Respondent was employed as a registered nurse at Gulf Coast Community Hospital (GCCH), Panama City, Florida. On August 4, 1983, Dr. David W. Scott, an orthopedic surgeon with practice privileges at GCCH, treated Arthur Collins in the emergency room of that hospital. After taking a history from the patient and examining him, he concluded that Mr. Collins was a drug addict who had the ability to manipulate physicians for the purpose of obtaining narcotics. As a part of his treatment of this individual, Dr. Scott prescribed 100 mg of Demerol four times a day which was obviously insufficient for Mr. Collins who had developed a drug tolerance. As a result, Dr. Scott added an additional drug, Vistoril, to augment the Demerol. Before leaving the hospital that night, and because Mr. Collins was obviously addicted to narcotics, Dr. Scott left an oral order with the nurse on duty at the nurses' station, subsequently identified as Ms. Habersham, not to increase the dosage prescribed for the patient, not to give additional narcotics, and not to call the on-call physician in the event Mr. Collins complained of pain. The reason for this last instruction concerning the physician was to prevent the on call physician, who might not know the patient's history and of his drug addiction, from prescribing additional narcotics. Ms. Habersham worked as a charge nurse on the day shift during this period and recalls patient Collins. When she was relieved by the Respondent at the end of her shift, she passed Dr. Scott's orders on to her. Consequently, it is clear that Respondent was aware of Dr. Scott's order not to increase Collins' dose and not to contact the on-duty physician in the event Collins asked for more medicine. Nonetheless, Respondent admits giving Mr. Collins an injection of 125 mg of Demerol even though the doctor's order called for a 100 mg dose. She justifies this on the basis that the patient had said he was in great pain and constantly kept coming to the nurses station begging for more medication. She observed him to be sweating and grabbing at his stomach. Based on her experience in the Army Nurse Corps and the Army Surgeon General's recommendation for a 125 mg dose of Demerol in situations such as this, and because she did not want to wake up Dr. Rohan, the on-call physician, she gave the additional dose on her own authority feeling she could get Dr. Rohan's approval later on. Dr. Rohan recalls only an incident in August of 1983 where he got a call from a nurse whose name he cannot remember for a "cover order" for a medication. As he recalls it, the nurse in question called to notify him that she had administered more of a drug than was called for in the doctor's order. It was his understanding, however, that the nurse had given too much by accident and was telling him about it after-the-fact, not in advance, to authorize a higher dose. It is clear from the above, therefore, that Respondent called Dr. Rohan after she had administered the higher dosage to Mr. Collins on her own authority. Respondent indicates, however, that Ms. Habersham had told her that if this particular patient needed more medication he was to get it and that the nurse should secure the authorization by phone. Respondent presented no evidence to support this, however, and though she contended she had a witness to this conversation, the witness was not presented. Respondent contends that she could change the amount of medication prescribed by the physician if it was necessary. She claims that nurse-practitioners can do this within the protocols set down by a physician. Respondent was not then nor is she now a nurse practitioner. During the month of February, 1984, Linda Marie Jones was unit coordinator for three units at GCCH, including Respondent's. Part of her job involved the monitoring of and investigation of drug discrepancies. During this time, Mr. Jones was conducting an audit of drug accountability in Respondent's unit. This audit, while not based on any suspicion of misconduct by any employee, resulted in a determination that one Nembutal tablet was missing from the unit. A check of the records reflected that this medicine had not been ordered for any patient on the unit that day. She then checked the patients' charts to see if a Demerol 100, a similar drug, had been used, and as a part of this procedure, she found that in the case of some patients, two different records dealing with a specific administration of medication did not agree. Her check of all records on the unit revealed that only the Respondent had any discrepancies. All other nurses' records were satisfactory. Her investigation included a comparison of the medication administration record (MAR) with the nurses notes on which the same administration was to be noted. In the course of her investigation, she checked six patient records, including those of patient Haire, patient Oakley, and patient Crosby. At the conclusion of her investigation, she prepared a summary of her findings which she presented to Ms. Flemister, the Director of Nursing. Ms. Flemister met with Respondent and showed her a copy of the report. At that point, Respondent denied having taken any of the medications and said that she could not figure out why the discrepancies existed. As to the Nembutal, which prompted the investigation initially, Respondent remembered cleaning out the narcotic box the first time, but did not identify a shortage at the time. As a result, the missing Nembutal was attributed to "wastage" and when that happens, the wastage must be recorded on the narcotics sheet. This Nembutal wastage was not recorded by Respondent or any other nurse. Ms. Jones admits, however, that there is no evidence to connect Respondent with the wastage of the Nembutal any more than any other nurse assigned to that floor. With regard to an administration of Morphine Sulfate to patient Haire at 9:00 P.M., on February 6, 1984, the narcotics control sheet fails to show that morphine sulfate was administered to this patient on that occasion. With regard to the 8:30 P.M. administration of Morphine Sulfate to patient Haire on February 5, 1984, the narcotics control sheet reflects that Respondent recorded the administration of this medicine but does not reflect the date in question. The entry made reflects the patient's room rather than the date. As a result, it is impossible to tell if the administration was done on February 4 or February 5. However, the Respondent did reflect this administration on the nurses' notes although in the wrong place. As to the issue of Respondent's signing out Morphine Sulfate for patient Haire at 7:00 A.M. on February 5, the evidence establishes that she did sign out both Morphine Sulfate 100 and Demerol 100 as alleged. The MAR reflects some entry but it is impossible to determine what the entry is or to what drug it refers and Respondent's nurse's notes for that date are silent. The medical records pertaining to patient Oakley for February 5, 1984, reflect that, as to the nurses' notes, the patient was given medication for pain but the notes fail to show what type of medication was administered. It could have been aspirin or tylenol and the note should have said what medicine was administered. This administration was not listed on either the narcotics control sheet or the MAR. If the substance given was not Demerol or Morphine Sulfate, it need not appear on the narcotics control sheet, but whatever it was, it should have been listed on the MAR and it was not. The records regarding patient Crosby reflect that on February 5, 1984, Respondent signed out 75 mg Demerol for the patient as alleged. The notes do not, however, reflect that she administered Demerol specifically. They reflect only that she administered some medication. As to the 9:30 P.M. dose of Demerol on February 5, 1984, Respondent did sign out Demerol at that time but the nurses' notes do not reflect what the substance administered was. Patient Haire's records reflect that on February 4, 1984, Respondent signed out Morphine Sulfate for the patient. The nurses' notes reflect that at 8:00 P.M. on that date, she administered a "pain medication" to the patient without defining what that medication was. The record does not indicate that Morphine Sulfate was administered. The narcotics control sheet for this period is not dated so it is impossible to determine whether Morphine Sulfate was listed on its document or not. However, the MAR reflects that Respondent administered Morphine Sulfate to this patient at 6:00 A.M. On February 4, 1984, Respondent signed out Demerol for patient Oakley and properly noted this on the narcotics control sheet but the nurses' notes fail to show that the substance was administered as required. Later on, at 8:30 P.M. the same day, Respondent again signed out Demerol for Patient Crosby listing on the narcotics control sheet the patient's room number but not the date. Other dates on the sheet lead to the conclusion that it was February 4, however Respondent thereafter failed to record the drug's administration on the nurses' notes. She also signed Demerol out for Patient Crosby at 7:30 P.M. on February 4 though the narcotics control sheet fails to reflect the date - only the room number. This administration is in the MAR at 8:30 P.M. rather than at 7:30 P.M. but is not in the nurses' notes at all. On February 3, 1984, Respondent recorded in her nurse's notes that she administered Demerol to patient Crosby at 8:00 P.M. The narcotics disposition record (narcotics control sheet) shows that she signed the medication out between 8:00 and 9:00 P.M., but it is impossible to tell with certainty the exact time. It is obvious that Respondent's handwriting is poor. This fact adds to the difficulties encountered from the way in which Respondent kept her records. In the opinion of Ms. Jones, who has been doing quality assurance checks for a number of years, Respondent's records are inaccurate, inconsistent, incomplete and totally insufficient for a nurse on the next shift to know what medications have been given and what must be done. In this area alone, Ms. Jones was of the opinion that Respondent's charts are below the minimum standards for nursing practice in the area and even though her own report was erroneous in some respects, there are still enough verified errors by the Respondent to support her opinion that Respondent's performance is less than acceptable. Respondent admits that some but not all of the charges against her are true. Though she may have mischarted her administration of drugs she never took the drugs herself. The patient always got the drug that he or she was supposed to get and her errors were errors only as to the recordation of time. They were administrative errors, not substantive errors. She contends that in February, 1984, because the floor on which she had been charge nurse since December, 1981 had been closed, she was forced into a staff nurse position. This was not a good situation and as a result of the closing of that floor, several nurses quit. This loss of nurses resulted in more patients per nurse to the point where Respondent felt that patient safety was in danger. She contends she tried to tell Ms. Jones about this but Ms. Jones would not see her. All of a sudden, she found herself called in front of Ms. Flemister and Ms. Jones and terminated based on the alleged inaccuracies in her records. Respondent contends she received no information about this other than that contained in Ms. Jones' summary and in that regard she says, Ms. Jones assured her that her summary was correct and in no way tried to explain the inaccuracy of the records. Respondent contends that she had frequently asked her supervisors for extra help but never got any. She contends she had as many as 18 patients to handle by herself and at the time involved in the records discrepancies here, she had 8 patients on the floor. She contends that the errors to which she admits were due to her hectic schedule. As a single parent, she was working, she says, between 60 to 80 hours per week on two jobs and had a sick child at home. Ms. Flemister, on the other hand, says that Respondent had plenty of help. At the time, Respondent was working the night shift from 7:00 P.M. to 7:00 A.M. The shift was staffed by 4 registered nurses, 2 licensed practical nurses, and a secretary, and in her opinion, this staff was well within the normal range of staff-patient ratio. Ms. Flemister contends that while Respondent was on duty, she had between 5 and 6 patients to take care of. She was the charge nurse for the shift and therefore had less patients than a regular floor nurse. She admits that Respondent did complain about being shorthanded, but these complaints were neither constant nor repeated and were never submitted through proper channels. Ms. Flemister contends that prior to this time Respondent had been counseled about her writing and documentation, but there has been no evidence of any discrepancies other than those involved in this case. There are certain procedures followed at GCCH and a part of Ms. Flemister's job is to oversee the standards of the hospital, the Board of Nursing, and the Joint Committee on Hospital Accreditation as they are applicable at this hospital. On the first day of duty, all new nurses are given an orientation which includes records management and how to use a medication cart. A medications test is given and a model cart is used in this training. On the cart, each patient has his or her own area. Narcotics and barbiturates are kept together. Medication administration records, including a page for every patient, are kept with the cart. Each administration of medication is supposed to be recorded and each use of narcotics is supposed to be listed on the narcotics sheet with the name of the patient, the date, the drug, and the nurse administering it. Medications are first called for in the doctor's orders and are checked by the secretary and the nurse who checks and signs it initially. The doctor's orders are then used to give medications. When a nurse gives a medication she checks the doctor's order against the medical records and then prepares the medicine, administers it, charts it and signs it off. The entry is recorded on the medical administration record and it and the charting register are both on the cart. The nurse goes back to the nurses' station to record the administration of the medicine in the nurses' notes which are kept in the patient record. This method of documentation is set out in the hospital policy and procedures which are given to all nurses. Accurate medication records are important so that nurses on subsequent shifts do not administer a drug too soon after the last dose was given and thereby create an overdose. Therefore, medications are logged in several different locations because state law requires it to promote agency oversight by the pharmacy and the Department of Nursing, and because the record is used at shift change to insure an accurate count of narcotics on hand on the medicine cart. Failure of employees to follow the hospital procedures results in the following sequence of events: reprimand; counseling; a written reprimand; and discharge; all depending, of course, on the seriousness of the offense. However, after the discussion with Ms. Flemister and Ms. Jones Respondent was terminated because of the discrepancies between the narcotic record and the poor and illegible documentation in the nurses' records and elsewhere. Respondent, on the other hand, claims that though she has been licensed in the State of Florida since 1967 and has worked at GCCH since 1981, there has never been any prior disciplinary action taken against her nor has she received any prior complaints about her method of charting or administration of drugs and she was doing it as she usually does in February, 1984. Notwithstanding her protestations of no prior disciplinary action, however, the records reveal that Respondent was given a two-day suspension for the incident involving the over administration of Demerol to Mr. Collins and advised that a repeat discrepancy would result in her discharge. It is important to note that as a part of the investigation into Respondent's alleged misconduct, she was requested to provide a urine sample for urinalysis. This routine drug screen revealed no use of controlled substances within the seven days prior to the test which was accomplished on February 20, 1984.
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 Whether the Respondent committed the offenses set forth in the Administrative Complaint filed in this case and, if so, what disciplinary action should be taken.
Findings Of Fact Respondent, Ruth Theresa Healey, was, at all times material hereto, licensed as a registered nurse in the State of Florida, having been issued license number 0983072 by the Board of Nursing. On May 20, 1988, Respondent was employed as a registered nurse at Broward Convalescent Home for the 11:00 p.m. to 7:00 a.m. shift. Included in Respondent's responsibilities were the assessment of each patient under her care; the administration of medication to her patients according to the physician's orders; and the correct documentation of each medication administration on each patient's medical chart. Under Respondent's care on May 20, 1988 was the patient, E.M. The physician's orders for E.M. during Respondent's shift indicated that she was to be fed with one-half strength Entrition at 60 cc's per hour with water flushes through the gastrostomy tube (G Tube) which had been inserted into her abdomen. One-half strength Entrition is a nutrition substitute which is supplied in a self-contained package. On May 20, 1988, the supply of one-half strength was on special order and would not be available for use at Broward Convalescent Home until the next morning during the 7:00 a.m. to 3:00 p.m. shift. E.M.'s G Tube was clearly marked on E.M.'s chart and easily observed upon patient assessment since it was protruding from her abdomen. Sometime during Respondent's shift, a naso-gastric tube, NG Tube, was also inserted into E.M. Without a physician's order, the insertion of a NG Tube into a patient with an existing G Tube could prove harmful to the patient and is contrary to the minimal standard of acceptable and prevailing nursing practice. It was Petitioner's contention that Respondent inserted the NG Tube into her patient. Petitioner's position was supported by the testimony of Geraldine Hamilton, a nurse who came on duty the morning of May 21, 1988. Ms. Hamilton recalled that Respondent admitted to Ms. Hamilton that Respondent was in trouble because she, "put an NG Tube in one of the patients who has already got a G Tube." However, Respondent, at the hearing, consistently denied having made the statement. She asserted, instead, that a co-worker, Bunster Martinez, inserted the NG Tube. During Respondent's shift, she had sought Mr. Martinez's advice concerning the procedure she should use to feed E.M. since the one-half strength Entrition was not available. Mr. Martinez was not present at the hearing. Respondent's speech pattern, as observed at the hearing and as noted through the testimony of others is not clear. Rather, it is cryptic and disjointed. Given Respondent's poor diction and syntax, Respondent's consistent denial that she inserted the NG Tube and the lack of corroborating evidence that Respondent did, in fact, insert the NG Tube, the literal meaning of Respondent's statement to Ms. Hamilton is unclear. Respondent did not perform an assessment of E.M. which would have revealed the G Tube. Instead, contrary to the physician's order, Respondent began the administration of full strength Entrition through the NG Tube. In an attempt to create one-half strength Entrition, Respondent knowingly administered full strength Entrition for one hour at 85 cc. per hour followed by water flushes. However, the quality of one-half strength Entrition can not be obtained by diluting full strength Entrition in this manner, and the administration of full strength Entrition could have harmed F.M. Respondent's failure to perform an assessment of her patient and her action with regard to this feeding were contrary to the minimal standards of acceptable and prevailing nursing practice and constituted unprofessional conduct on her part. Also, although Respondent administered to E.M. full strength Entrition through the NG Tube, she entered the feeding on E.M.'s chart as Entrition one- half strength at 60cc/hour via G tube. Accordingly, Respondent knowingly falsified the medication administration report. The following morning, May 21, 1988, when the presence of the NG Tube was questioned, Respondent abruptly and forcibly removed the NG Tube from E.M. The procedure Respondent used to remove the NG Tube was also contrary to the minimal standards of acceptable and prevailing nursing practice, constituting unprofessional conduct on her part and placing her patient in more jeopardy. Respondent acted somewhat incoherently on several occasions around the end of May, 1988. She was observed "talking to herself", was unresponsive to questions and appeared disoriented. No competent evidence was presented that such conduct resulted from a physical or mental condition or from medication. Respondent was previously suspended by the Board of Nursing and required to undergo psychiatric treatment. She was subsequently reinstated. No competent and substantial evidence was presented that Respondent disobeyed the previous order or any order of the Board of Nursing.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED the a final order be entered suspending Respondent's license for a period of one year, and thereafter, until she can demonstrate the ability to practice nursing in a safe and proficient manner. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 12 day of October 1989. JANE C. HAYMAN Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 12 day of October 1989. APPENDIX TO RECOMMENDED ORDER CASE NO. 89-3401 Petitioner's proposed findings of fact are addressed as follows: Addressed in paragraph 1. Addressed in paragraph 2. Addressed in paragraph 2. Subordinate to the result reached. In part, addressed in paragraph 3 ;in part, subordinate to the result reached. Not necessary to result reached. Not necessary to result reached. Not necessary to result reached. In part, subordinate to result reached; in part, addressed in paragraph 3. Addressed in paragraph 3. Subordinate to the result reached. Subordinate to the result reached. Subordinate to the result reached. Addressed in paragraphs 7 and 9. Addressed in paragraph 9. Addressed in paragraph 9. In part, addressed in paragraphs 5 and 6; in part, subordinate to result reached. Addressed in paragraph 8. Addressed in paragraph 3. Addressed in paragraph 7. In part, not supported by competent and substantial evidence, in part, subordinate to the result reached. Not supported by competent and substantial evidence. Not supported by competent and substantial evidence. Addressed in paragraphs 2 and 3. Addressed in paragraph 4. In part, addressed in paragraphs 10 and 11. In part, subordinate to the result reached, in part, not supported by competent and substantial evidence. Not supported by competent and substantial evidence. Subordinate to the result reached. Subordinate to the result reached. Subordinate to the result reached. Addressed in paragraph 7. Addressed in paragraphs 7 and 8. Addressed in paragraph 10. COPIES FURNISHED: Lisa M. Bassett, Esquire Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0729 Ruth Theresa Healey, R.N. 1075 N.E. 39th Street, Apartment 110 Fort Lauderdale, Florida 33308 Judie Ritter Executive Director Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, Florida 32201 Kenneth E. Easley General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0729
