Findings Of Fact Petitioner, Carolyn A. Keegan, is a licensed Practical nurse in the State of Maine and has been since October 10, 1947, when that State first began licensing nurses. Petitioner attended the Eastern Maine General School of Nursing between September, 1940, and June, 1942, but did not graduate. She has been employed as a nurse since that time. When the State of Maine began licensing nurses in 1947, Petitioner was grandfathered in as a licensed practical nurse without being required to take an examination or graduating from an accredited nursing program. On June 12, 1980, Petitioner applied for licensure as a licensed practical nurse in the State of Florida by endorsement. This application was denied by the Board of Nursing on July 11, 1980.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the application of Carolyn A. Keegan for licensure as a licensed practical nurse be denied. It is further RECOMMENDED that Petitioner be permitted to take the appropriate examination at the earliest practicable time. DONE and ENTERED this 8th day of January 8, 1981, in Tallahassee, Florida. DONALD R. ALEXANDER Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Ms. Carolyn A. Keegan 11839-108th Avenue, North Largo, Florida 33540 Linda A. Lawson, Esquire Assistant Attorney General The Capitol, LL04 Tallahassee, Florida 32301
Findings Of Fact At all times pertinent to this proceeding, Respondent was a licensed practical nurse licensed in the State of Florida and holding license number 0504051. The Petitioner is an agency of the State of Florida and is charged with enforcing the provisions of Chapter 464, Florida Statutes (1981), related to regulating and enforcing the licensure and professional practice standards for nurses of various categories enumerated therein in the State of Florida. During times pertinent to the allegations of the amended administrative complaint, the Respondent was employed as a licensed practical nurse at Ocala Geriatric Center, Inc. On September 16, 1982, the Respondent was the "float nurse" at Ocala Geriatric Center, meaning that she was a nurse assigned to various portions of the Geriatrics Center on an impromptu basis, which assignments to the various wings of the facility would be communicated to her by notations on her timecard which she would receive when she reported to duty for a particular shift. On September 16, 1982, she was previously scheduled by her supervisor to work on the north wing of the Ocala Geriatric Center. When Respondent reported to work for the 11:00 p.m. to 7:00 a.m. shift for September 16 - September 17, 1982, she was told by her supervisor, Deloris Jamison, to work instead on the east wing of the facility. Respondent, upon learning this, became engaged in a dispute with Mrs. Jamison regarding this assignment, refused to fulfill the assignment and indicated that she preferred to report herself as sick and return home rather than work at her assigned location on the east wing that evening. The Respondent was told to shift her duties from her customary station on the north wing to the east wing that evening due to a shortage of nurses on duty on that shift. The director of nurses of the Ocala Geriatric Center, Ellen Cain, had already arranged for nurse Phyllis Shepard to work half of the 11:00 to 7:00 shift on the north wing of the facility. When nurse Shepard duly reported for duty at the north wing she found the Respondent present at the north wing even though the Respondent had previously been informed that she was to work on the east wing. At this time the Respondent announced her intentions to nurse Shepard to remain on duty at the north wing and not to report to duty on the east wing, contrary to her supervisor's direction. At this point nurse Shepard went to the south wing of the facility and conferred with nurse Jamison regarding the Respondent's assignment and her own assignment, and had the instructions confirmed by supervisor Jamison. Upon nurse Shepard's return to the north wing, the Respondent indicated to her also that she intended to report herself sick and go home rather than work on the east wing. Only upon calling the Director of Nurses, Ellen Cain, at her home and again receiving instructions to work on the east wing that evening, did the Respondent ultimately elect to proceed to her assigned duty station. Patients Whitehurst and Rubright were classified on September 16, 1952 and September 17, 1982, "as critical geriatric patients" inasmuch as they were nasal-gastric or "tube-fed" patients and both had "indwelling" catheters for elimination of urine. On or about September 16, 1982, the Respondent charted a "dash" on the fluid intake and output record of patient Whitehurst, rather than specifying actual fluid, if any, taken in by the patient. This is an improper method of notation of fluid intake and output for such a patient, since this does not accurately reflect any information one way or the other regarding fluid intake or output for that patient for that shift. At best it might lead to a presumption that that patient had received no fluid, which is a potentially serious problem with such a patient since if a catheterized patient does not receive adequate fluid from time to time during the day, then the catheter is at risk of being blocked, with potentially serious health consequences to the patient. On that same date Respondent also failed to chart any information in her nurses' notes for patient Whitehurst. Both nurses Shepard and the Director of Nursing at Ocala Geriatric Center, Ellen Cain, were accepted as expert witnesses in the field of nursing and specifically with regard to minimal standards of professional nursing practice in Florida. It was thus established that the failure to chart in her nurses' notes any information for patient Whitehurst was conduct not comporting with minimal standards of nursing practice, especially in view of the fact that the patient Whitehurst was a naso-gastric tube patient who was also catheterized. It is imperative to note any reason why such a patient does not receive fluid during a single shift or alternatively, when a patient does receive fluid, to note on the chart the amount and type of fluids received. Further, the use of a dash on the nursing chart makes it even more imperative that the nursing notes explain what occurred on that shift regarding the patient's fluid intake, so that the nurse charged with the responsibility of that patient on the ensuing shift would be aware of the patient's fluid status and aware of any abnormality that may have occurred on the previous shift. Although the Respondent may have, in fact, administered the proper fluids to patient Whitehurst on that shift, she failed to record whether or not that duty was performed. On September 16, 1952, the Respondent also charted a for fluid intake on patient Rubright, but again failed to make any notation on the nurses' notes as to why this patient actually received no fluids. This failure to properly chart and make notes regarding the patient's fluid intake and failure to administer fluids without explanation does not comport with minimal standards of nursing practice, especially inasmuch as patient Rubright was also a naso- gastric tube-fed and catheterized patient. The Respondent also failed to chart or record any nurses' notes with regard to patient Lesimby on September 16, 1982. Failure to chart was established to be a violation of federal medicare regulations and a violation of this particular facility's policies with regard to such medicare patients. Although daily charting and notes from each shift for such critical care patients as patients Whitehurst and Rubright is required by minimal standards of professional nursing practice, failure to chart nurses notes for other patients, simply because they are medicare patients, does not necessarily depart from proper standards of nursing practice, although federal regulations require that medicare patients be the subject of daily charting, including recording of vital signs. Compliance with such federal standards is of course, not the subject of the administrative complaint in this proceeding, however. Respondent's failure to properly record fluid intake and output for patients Whitehurst and Rubright, and her failure to properly chart nursing notes for those patients on the above dates, as well as her failure to order medications for patients as required by her position at Ocala Geriatric Center, Inc., could have resulted in serious harm to the oat' ants. It was not established that the Respondent has committed acts or omissions that could have jeopardized safety in the past, however, and it was not shown that any other violations of the nursing practice act or failures to comport with minimal standards of nursing practice have ever been charged or proven with regard to the Respondent's licensure status and nursing practice in the past.
Recommendation Having considered the foregoing Findings of Fact and Conclusions of Law, the evidence of record, the candor and demeanor of the witnesses and the pleadings and arguments of the parties, it is, therefore RECOMMENDED that a Final Order be entered by the Board of Nursing finding the Respondent guilty of the violations charged with respect to Section 464.018(1)(f), Florida Statutes (1981), with the exception of the violation charged with regard to patient Lesimby, and that the penalty of a reprimand and 90-day suspension of her licensure be imposed. DONE and ENTERED this 19th May of July, 1984 in Tallahassee, Florida. P. MICHAEL RUFF Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904)488-9675 FILED with the Clerk of the Division of Administrative Hearings this 20th day of July, 1984. COPIES FURNISHED: Julia P. Forrester, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Linda Sears Gibson 2003 Southwest Seventh Street Ocala, Florida Helen P. Keefe, Executive Director Board of Nursing 111 East Coastline Drive, Room 504 Jacksonville, Florida 32202 Fred M. Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
Findings Of Fact The Respondent Mary Ambroz is a registered nurse having been issued license number 129 070-2. Her last known address is 3304 S.W. LeJeune Road, Coral Gables, Florida. At all material times, the Respondent Ambroz was employed as a nurse at Variety Children's Hospital (now known as Miami Children's Hospital), and Mount Sinai Hospital, in Miami, Florida. On or about June 14, 1981, the Respondent Ambroz was working at Mount Sinai Hospital under the supervision of Cindy Shoard, R.N. On that date, an emergency arose with a patient who suffered a lethal arrhythmia which required Shoard and another nurse to begin emergency procedures including starting an IV and placing vital sign monitors on the patient. The Respondent Ambroz entered the room after Shoard had begun emergency treatment and pushed her aside stating that the patient was hers and she would take over. Shoard asked the Respondent to leave the room. The Respondent did not leave and instead picked up drugs which had been placed by Shoard on a table for administration to the patient after the IV procedure, and attempted to administer the drugs herself. Shoard informed the Respondent that the drugs were to be administered in a different manner from the way which she was attempting, and again asked her to leave the room. The Respondent then left the room and the patient was stabilized. On or about July 7, 1981, while employed at Mount Sinai Hospital, the Respondent was absent without leave four days in a row. This incident resulted in her termination of employment from Mount Sinai. Additionally, while still employed at Mount Sinai, the Respondent failed to properly chart physicians' orders concerning medication on four separate occasions and reported to an oncoming nurse, that an IV bag of a patient in her care had been filled when the Respondent had in fact failed to fill the bag. In August of 1982, while employed at Miami Children's Hospital, the Respondent Ambroz was caring for an extremely ill premature infant, K. Kuehnart, who was being treated by endotracheal tube. The Respondent was aware that the infant was classified as "limited touch" due to her serious condition and the risk that movement could kink or dislodge the tube and cause a life-threatening situation. The Respondent handled this infant without adequate justification and after being repeatedly told not to do so by her supervisor, Mary Mulcahy. Moreover, in her care and treatment of baby Keuhnart, the Respondent Ambroz failed to observe basic aseptic techniques including insuring that the inside of the endotracheal tube remained sterile. On August 17, 1982, the Respondent Ambroz, while under the supervision of Andrea Prentiss, R.N., was caring for a premature infant with a tracheal problem which required that the infant be placed on a ventilator. It was extremely important that this infant be handled minimally and carefully so the tube in the infant's throat would not become dislodged. Despite Prentiss' instructions, the Respondent moved the infant in a manner which caused the tube to become dislodged. A neonatologist was present to reinsert the tube and no permanent damage occurred. However, even following this incident, the Respondent handled the infant contrary to Prentiss' instructions. Subsequently, the infant's mother arrived from out-of-town to visit her child. The mother was instructed to wash her hands and put on a surgical gown before entering her child's room. When the mother entered the room, the Respondent Ambroz refused to allow the mother to touch her baby, brushed her hand away from the child, and stated that the mother had an infected cuticle. Prentiss examined the mother's hands, saw no evidence of infection, and ordered the Respondent to allow the mother to touch her child. Also, during this visit, the Respondent requested that the mother change her child's socks since they were, in her opinion, an ugly shade of green. These incidents upset the baby's mother and resulted in her requesting that Prentiss prohibit the Respondent Ambroz from caring for her baby. The actions of the Respondent Ambroz, while employed at Mount Sinai and Miami Children's Hospital, departed from, or failed to conform to, acceptable and prevailing minimal standards of nursing practice.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED: That the Board of Nursing enter a Final Order revoking the nursing license of the Respondent Mary Ambroz. DONE and ENTERED this 17th day of October, 1983, in Tallahassee, Florida. SHARYN L. SMITH, 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 17th day of October, 1983.
The Issue The issue is whether Petitioner, Melvin Alston, is entitled to insurance coverage under the State of Florida Health Plan for services received at Miracle Hill Nursing Home.
Findings Of Fact Doris Alston, widow of Melvin Alston, is requesting payment for services rendered to Melvin Alston at Miracle Hill Nursing Home. Melvin Alston died on December 31, 1985. Melvin Alston, as a retired state employee, became eligible for coverage under the State Health Plan on July 1, 1985. He was a professor and dean at Florida A&M University from 1946 until 1969, when he retired. Thereafter he became a professor at Southern Illinois University, from which he retired in 1976. Alston was admitted to Tallahassee Memorial Regional Medical Center (TMRMC) in September, 1984, and was transferred to the extended care unit on September 20, 1984, because there were no available nursing home beds. On October 31, 1984, a bed became available at Goodwood Manor, a skilled nursing home facility, and Alston was admitted to Goodwood Manor from the TMRMC extended care unit. Alston remained at Goodwood Manor until August 22, 1985, when Mrs. Alston removed him and placed him at Miracle Hill Nursing Home. While at Goodwood Manor, Alston was receiving essentially custodial care. He had a routine diet and simply needed assistance with his activities of daily living, such as bathing and feeding. He was able to take his medications as they were given to him and he could leave the nursing home on a pass basis. While at Goodwood, Alston's medical orders were reviewed monthly and he was not seen daily by a physician. Alston received the same level of care at Miracle Hill Nursing Home. In skilled nursing facilities, the range of services needed and provided goes from skilled through intermediate levels to custodial. Skilled care includes such services as injections or intravenous medications on a daily basis which must be administered by a nurse. Dr. C. E. Richardson became Alston's physician at Miracle Hill Nursing Home. In the course of his deposition, Dr. Richardson testified that Alston received medical level care at Miracle Hill. However, Dr. Richardson stated several times that he did not know the level of care given to Alston under the definitions of the care levels available. He acknowledged that the levels of care ranged from skilled to custodial. Dr. Richardson also did not know the terms of the benefit document for the State Health Plan. Dr. Richardson only provided the medical care, which was the same no matter what level of nursing care he needed or received. According to Dr. Richardson, Alston was on a fairly routine diet, could engage in activities as tolerated, and could go out on a pass at will. One of Dr. Richardson's orders dated 11/27/85 shows that Dr. Richardson did not order a skilled level of care, but instead checked the level of care to be intermediate. Alston did not receive or need skilled nursing care at Miracle Hill. It is more appropriate to classify the level of care as custodial, as that term is defined in the State Health Plan Benefit Document. Alston's primary insurer was Blue Cross/Blue Shield of Illinois, based on coverage he had from his employment there. Blue Cross/Blue Shield of Illinois denied the claim for services at Miracle Hill because the services were custodial and were not covered by that plan. It also denied the claim because Miracle Hill's services did not fit its criteria for skilled nursing care. William Seaton is a State Benefits Analyst with the Department of Administration and his duties include assisting people who have a problem with the settlement of a claim with Blue Cross/Blue Shield of Florida, which administers the State Health Plan. After the claim was denied by Blue Cross/Blue Shield of Illinois, Mr. Seaton assisted Mrs. Alston by filing a claim under the State Health Plan. Blue Cross/Blue Shield of Florida concluded that no benefits were payable for facility charges at a nursing home and that an extended care or skilled nursing facilities would have limited coverage; however, because Alston was not transferred to Miracle Hill directly from an acute care hospital, no coverage existed. The pertinent provisions of the benefit document of the State Health Plan are as follows: I.G. "Custodial Care" means care which does not require skilled nursing care or rehabilitative services and is designed solely to assist the insured with the activities of daily living, such as: help in walking, getting in and out of bed, bathing, dressing, eating, and taking medications. * * * I.N. "Hospital", means a licensed institution engaged in providing medical care and treatment to a patient as a result of illness or accident on an inpatient/outpatient basis . . . and which fully meets all the tests set forth in ., 2., and 3. below: . . . In no event, however, shall such term include . . . an institution or part thereof which is used principally as a nursing home or rest for care and treatment of the aged. * * * I.AH. "Skilled Nursing Care" means care which is furnished . . . to achieve the medically desired result and to insure the insured's safety. Skilled nursing care may be the rendering of direct care, when the ability to provide the service requires specialized (professional) training; or observation and assessment of the insured's medical needs; or supervision of a medical treatment plan involving multiple services where specialized health care knowledge must be applied in order to attain the desired medical results. * * * I.AI. "Skilled Nursing Facility" means a licensed institution, or a distinct part of a hospital, primarily engaged in providing to inpatients: skilled nursing care . . . or rehabilitation services . . . and other medically necessary related health services. Such care or services shall not include: the type of care which is considered custodial . . . . * * * II.E. Covered Skilled Nursing Facility Services. On or after August 1, 1984, when an insured is transferred from a hospital to a skilled nursing facility, the Plan will pay 80% of the charge for skilled nursing care . . . subject to the following: The insured must have been hospital confined for three consecutive days prior to the day of discharge before being transferred to a skilled nursing facility; Transfer to a skilled nursing facility is because the insured requires skilled care for a condition . . . which was treated in the hospital; The insured must be admitted to the skilled nursing facility immediately following discharge from the hospital; A physician must certify the need for skilled nursing care . . . and the insured must receive such care or services on a daily basis; . . . 6. Payment of services and supplies is limited to sixty (60) days of confinement per calendar year. * * * VII. No payment shall be made under the Plan for the following: * * * L. Services and supplies provided by . . . a skilled nursing facility or an institution or part thereof which is used principally as a nursing home or rest facility for care and treatment of the aged. * * * N. any services in connection with custodial care . . . .
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Administration enter a Final Order denying the request for benefits for services rendered to Melvin Alston at Miracle Hill Nursing Home. DONE AND ENTERED this 24th day of May, 1988, in Tallahassee, Florida. DIANE K. KIESLING 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 24th day of May, 1988. APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 87-4674 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted by the parties in this case. Specific Rulings on Proposed Findings of Fact Submitted by Petitioner, Melvin Alston 1 . Proposed findings of fact 1-3 and 5 are rejected as being subordinate to the facts actually found in this Recommended Order. Additionally, proposed findings of fact 3 and 5 contain argument which is rejected. 2. Proposed finding of fact 4 is irrelevant to the resolution of this matter. Specific Rulings on Proposed Findings of Fact Submitted by Respondent, Department of Administration Each of the following proposed findings of fact are adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1(1); 4(2); 5(2); 6(11); 8(11); 9(12); 10(3 & 4); 11(5); 12(4); 14(5); 15(7); 19- 21(8 & 9) 23(13); and 24(13). Proposed findings of fact 2, 3, and 16 are unnecessary. Proposed findings of fact 7, 13, 18, 26, and 27 are rejected as being irrelevant. Proposed findings of fact 17 and 22 are subordinate to the facts actually found in the Recommended Order. 2. Proposed finding of fact 25 is unsupported by the competent, substantial evidence. COPIES FURNISHED: James C. Mahorner Attorney-at-Law P. O. Box 682 Tallahassee, Florida 32301 Andrea Bateman Attorney-at-Law Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550 Adis Villa, Secretary Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550
The Issue The issue in this proceeding was whether Respondent violated the Nurse Practice Act, Subsections 464.018(d) and (f), Florida Statutes, by making a false record and by abandoning the care of her patient and thereby departing from minimal standards of acceptable and prevailing nursing practice.
Findings Of Fact At all times relevant, Respondent was licensed as a practical nurse with license number 0797251. (Petitioner's Exhibit #1, T-22). Respondent, Sheri Ward, was employed by Bayshore Registry, a private-duty nursing service. (Petitioner's Exhibit #3). On August 3, 1985, Ms. Ward was assigned to Villa Maria Nursing Center, Bon Secours Hospital in Miami, to fill in for the regular LPN who was on leave. (T-26) Her only assigned patient was Estelle Crocoll. (T-10) The patient needed continual care because she remained either comatose or semi-conscious and had to be fed by a tube. She had to be watched to ensure that she didn't regurgitate the feeding. She also had bed sores and muscle contractures and had to be turned every couple of hours. (T-11, 26-28) When she checked in for her shift around 7:00 a.m., Ms. Ward learned that Cleo Bell, the nurse in charge of the unit, was the one who would sign her time sheet. She asked Ms. Bell if she could get off a little early, like around 2:00 p.m. Ms. Bell said okay and asked that she be notified when she (Ms. Ward) left. Ms. Ward's shift was supposed to end at 3:00 p.m. that day. (T-10, 42) Ms. Bell checked on the patient at 11:00 a.m. and around 12 noon but did not see Ms. Ward. (T-l1) Helen Bushey, R.N. is the head nurse on the wing where Ms. Ward was working on August 3, 1985. (T-23) She has thirty years of nursing experience and at the hearing was qualified as an expert to testify regarding nursing standards. (T-24, 26) Among her other duties, Ms. Bushey makes the rounds to check on the patients and to introduce herself to any new private duty nurse assigned to a patient. (T-29) On August 3, 1985, Ms. Bushey checked Estelle Crocoll's room at 8:30 a.m., between 11:00 and 11:30 a.m., and again around 12 noon, but at no time saw Sheri Ward. (T-29, 30) Ms. Ward failed to answer a page and members of the staff told Ms. Bushey they could not recall seeing her after 11:00 a.m. (T-31, 33) Ms. Bushey reviewed the notes on the patient's chart around 1:45 p.m., and found that notations for 3:00 p.m. had been written up already. (Petitioner's Exhibit #3, T-31) She notified Ms. Ward's employer and Ms. Ward was barred from practicing at Villa Marie. (Petitioner's Exhibit #3, T-32) Ms. Ward claimed that she left the patient's room only to help another nurse ("Virginia") move a patient and to get the nurse to come help her move Estelle Crocoll. (T-44) She claimed that the chair in which she sat was obscured from view by a person entering the room. (T-44) She admitted that she left the job no later than 1:25 p.m., and since she could not find Ms. Bell she told "Virginia" to tell Ms. Bell she was leaving. (T-51, 52) Sheri Ward also admitted that she pre-entered notes for 3:00 p.m., having learned that "little bad habit" (her characterization) from working and training in a county hospital where ". . . you are really pressed for time." (T-46, 53) The reason she left early was to go to a wedding. (T-13, 48) It is unnecessary to determine Ms. Ward's whereabouts during the day or the exact time she left her duty; clearly, by her own admissions, Sheri Ward falsified her patient's record and abandoned the care of that patient without proper notification. Ordinary common sense would conclude that, given the uncontroverted circumstances, these actions constitute extremely bad judgement. Competent expert opinion concluded that these actions constitute a departure from minimal standards of acceptable nursing practice. (T-36)
The Issue The issue for determination is whether Ferman Barrett committed unprofessional conduct and departed from minimal standards of acceptable nursing practice, in violation of Section 464.018(1)(f), Florida Statutes by abandoning his shift.
Findings Of Fact At all times material Ferman Barrett was licensed as a practical nurse, with State of Florida license number PN0628671. He was originally licensed by examination on December 14, 1981, and has regularly renewed' his license since then. Mr. Barrett was employed as a practical nurse at Westlake Hospital, in Longwood, Florida, from July 1987 until January 1988. Westlake is a psychiatric hospital serving individuals of all ages with complex psychiatric problems. On January 2, 1988, Mr. Barrett was assigned to the children's unit, consisting of 12-13 children with conduct disorders. He was given charge of three patients whose medication he was to maintain and whose activities he was to supervise. The children could have been combative and [illegible]. Barrett was scheduled to work a double shift on January 2, 1988 from 7:00 A.M. until 3:00 P.M., and from 3:00 P.M. until 11:00 P.M. At approximately 8:05 A.M., Barrett told Denise McCall, the charge nurse for that shift, that he "couldn't take it anymore" and was leaving. She asked him to wait until she could contact a supervisor to properly relieve him, but he left without permission. He was subsequently discharged by the hospital for abandoning his job. Diana Eftoda was qualified as an expert in the practice of nursing. She has been licensed as a registered nurse in Florida since 1978. She has 20 years experience in nursing, including beginning her nursing career as a licensed practical nurse. She has administered nursing staff of an entire hospital and has served in a policy making position with the Board of Nursing. Mrs. Eftoda established that abandonment of a shift without notice or permission is a breach of professional responsibility and constitutes misconduct. Ferman Barrett's action jeopardized the safety and well being of his patients and his license should be disciplined.
Findings Of Fact The Respondent, Joann Jensen, graduated from the University of Nebraska with the degree of Bachelor of Science in Nursing in 1972. She became licensed as a Registered Nurse in Florida, but upon moving back to the North she let the license lapse. When she returned to Florida in 1976 she was reinstated as a Registered Nurse, and she now holds license number 70429-2 issued by the Board of Nursing. Thereafter the Respondent became employed at Holy Cross Hospital in Fort Lauderdale on the 3:00 p.m. to 11:00 p.m. shift, and was assigned to the nursery where she became charge nurse in August of 1977. She held this position during the March-October, 1979, period which is involved in this proceeding. In October of 1979 the Respondent was transferred out of the nursery into a medical/surgical adult unit at Holy Cross Hospital, where she remained for about six months, when she left the hospital to work for a private nursing agency. Between March and October of 1979 the Respondent was observed by six nurses on several occasions when she continued to feed infants after they had begun to choke, gag and struggle for air. Specific occurrences were described with reference to infant's named Baby Mandell, Baby Saul, Baby Riccobono, Baby McDaniel, Baby Fast, Baby Davis, Baby Pierce, and Baby Fletch, although precise time frames were not uniformly established. Other instances were described generally without reference to any particular infant. The Respondent was further observed to have tube-fed an infant to the point where its abdomen became distended, to have forced liquid into an infant after it had been breast fed by the mother, and to have manipulated the nipple of a bottle in the mouth of an infant in a rough manner so as to increase the flow of fluid into the mouth. On at least one occasion an infant turned blue and required suction to clear its passages. This form of handling of infants by the Respondent continued from March of 1979 until October when she was transferred to an adult-care unit. The testimony of the six nurses presented by the Petitioner also establishes that the Respondent used what is known as the Crede Maneuver to induce newly circumcised infants to urinate. This is a procedure used by some nurses in which the bladder is massaged gently until urination occurs. However, the manner in which the Respondent performed this procedure was forceful and rough, resulting in painful screams from infants. On one occasion there was no stated medical reason for use of the Crede Maneuver on the infant except that the Respondent wanted to have the chart show that urination had occurred during her shift. The evidence further establishes that the Respondent cursed and used foul language in the nursery, and that in one instance this was directed at an infant when the mask used to protect its eyes under the bilirubin lights kept slipping off its face. Placing an infant under bilirubin lights with its eyes masked for protection is a procedure designed to break-down excessive bilirubin in the blood when this is a problem. Although the Complaint did not specifically allege that the Respondent's language in the nursery would be an issue, this evidence was received without objection, but has been accorded no weight by the Hearing Officer. The evidence presented by the Petitioner's expert witness establishes the fact that conduct such as described above, if true, is not acceptable nursing practice, and deviates from the minimum standards established for and prevailing in the nursing profession. Based upon the observed candor and demeanor of all the witnesses, the evidence presented by the Petitioner has been accorded sufficient weight to support the findings of fact set forth herein. No evidence was presented to show that these facts were in accordance with good nursing practice; thus, the evidence warrants a finding that the Respondent's conduct failed to conform to and departed from the standards of acceptable nursing practice. The testimony of the Respondent and her witnesses, and other evidence, amounted to a denial that the occurrences took place, that the Respondent was not working on at least one date when the conduct described was observed, that the charts and records do not corroborate the facts charged, and that the Petitioner's witnesses were engaged in a conspiracy against the Respondent. However, the testimony of the three nurses on behalf of the Respondent establishes no more than that they have not observed the conduct described by the other nurses. There was no corroborative testimony relative to a conspiracy among the Petitioner's witnesses. Further, the occurrences described took place over a prolonged time period, and involved numerous infants. There is no particular significance to the failure of the charts to contain notations confirming the observations of the nurses, or that the Respondent was not shown by the records to have been on duty the particular date of only one incident. The Respondent's former supervisor related one instance when a mother complained that the Respondent had been rough with her infant. An investigation resulted, from which she concluded that the Respondent might have been rough with the baby. This witness also thought there was some merit to the complaints that nurses made of the Respondent's treatment of infants, although she continued to give the Respondent good performance evaluations. In summary, there was not sufficient evidence presented by the Respondent to support her own self-serving denial and assertion of a conspiracy against her, or to effectively rebut the clear and convincing testimony presented in support of the allegations set forth in the Administrative Complaint.
Recommendation Based upon the foregoing findings of fact and conclusions of law, it is RECOMMENDED that license number 70429-2 authorizing the Respondent, Joann Jensen, to practice as a registered nurse, be revoked. THIS RECOMMENDED ORDER entered on this 25 day of September, 1981. WILLIAM B. THOMAS, 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 25 day of September, 1981. COPIES FURNISHED: William M. Furlow, Esquire 130 North Monroe Street Tallahassee, Florida 32301 Marie S. Hotaling, Esquire 1523 North East 4th Avenue Fort Lauderdale, Florida 33304
The Issue The issue is whether Ms. Battaglia is guilty of violations of the Nursing Practice Act by being unable to account for controlled substances at the close of her shift at a nursing home and by being under the influence of controlled substances during her shift.
Findings Of Fact All findings have been adopted except proposed findings 27 through 33, which are generally rejected as unnecessary. COPIES FURNISHED: Judith V. Battaglia 7819 Blairwood Circle North Lake Worth, Florida 38087 Lisa M. Bassett, Senior Attorney Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Kenneth E. Easley, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Judie Ritter, Executive Director Department of Professional Regulation Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202
Recommendation It is RECOMMENDED that: Ms. Battaglia be found guilty of the charges of unprofessional conduct in the delivery of nursing services, unlawful possession of controlled substances and impairment; She be fined $250, that she be required to participate in the treatment program for impaired nurses, that her licensure be suspended until she successfully completes that program, and demonstrates the ability to practice nursing with safety, and that she be placed on probation for a period of five years. DONE and ENTERED this 11 day of October, 1989, at Tallahassee, Florida. WILLIAM R. DORSEY, JR. 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 11 day of October, 1989.
Findings Of Fact Respondent, Barbara Jiminez, is a licensed practical nurse (LPN) in the State of Florida, having been issued license number PN 0812181. At the time of the incident involved in this case, Respondent was a LPN. In 1987, Respondent was employed as a licensed practical nurse by Holly Point Manor, a nursing home located in Orange Park, Florida. Respondent was also employed as a LPN by another nursing home in the area. She was scheduled to work the 3:00 p.m. to 11:00 p.m. shift at Holly Point Manor. Holly Point Manor was a new facility and had opened in November, 1987. Only one wing of the facility was open and in December, 1987, Holly Point Manor serviced approximately 50 patients. On December 21, 1987, Respondent presented a letter of resignation to Tom Burrell, Director of Nursing at Holly Point Manor. The resignation was effective December 20, 1987. The resignation was precipitated by a verbal altercation with Liz McClain, a certified nursing assistant (CNA) at Holly Point Manor. The verbal exchange occurred on December 20, 1987. However, difficulties between Respondent and Ms. McClain had been brewing for a period of time prior to the verbal exchange of the 20th. After discussing the letter with Burrell, Respondent agreed to work on an as-needed basis at the facility. Burrell indicated that he needed Respondent to work until the beginning of the year, and therefore scheduled the Respondent for the remainder of December. Respondent was scheduled to work her usual shift on December 23, 24, and 25, 1987. She was scheduled to work with Virginia Anderson. Ms. Anderson is also a LPN. On December 23, 1987, Respondent clocked in for work at approximately 2:40 p.m. EST and clocked out the same day at 3:40 p.m. EST. On December 23, 1987, the Respondent and Virginia Anderson began work before the 3:00 p.m. change-of-shift. At shift change, both nurses went into the medication room to "take report" from Nurse Jan Sturgeon, the LPN who had worked the previous shift. A "report" at the change of shift consists of the previous shift's nurse going down the list of each resident/patient and reporting each patient's respective condition to the on-coming nurse. Part of the report includes counting the medications on the medication cart to ensure a correct count in the narcotic drawer of each cart. In this case, there were two medication carts, one for each of the on-coming nurses. These carts are locked and the nurse responsible for the cart maintains possession of the keys to that cart. Ms. Sturgeon "reported off" first to Ms. Anderson, and then to Respondent. Ms. Anderson began her rounds after receiving a report and keys to her cart from Ms. Sturgeon. Subsequently, Respondent received a report and keys to her cart from Ms. Sturgeon. At some time during Respondent's clocking in and taking report, a problem arose over the staffing assignments of the C.N.A.'s. Respondent was the nurse responsible for making the CNA assignments. However, Nurse Anderson had already created patient-care assignments for the CNAs after one C.N.A. had failed to report for work.1/ The Respondent was not satisfied with the assignments created by Anderson and either requested that they be changed or changed them herself. The request or change immediately caused a bad atmosphere between the employees on the wing. Around 3:30 p.m., Respondent telephoned Tom Burrell. Respondent told Burre11 that she couldn't take it anymore and that she was leaving. Burrell told Respondent that she was scheduled to work and if she left she would be reported for what was, in his opinion, a violation of the Nurse Practice Act. Burrell did not give Respondent permission to leave. Either before or after the call to Burrell, Nurse Eppert, the Assistant Director of Nursing, told the Respondent that in her opinion there was nothing wrong with the C.N.A. assignments. Respondent stated, "Here's my keys - - I'm leaving." Eppert informed Respondent that she had no replacement nurse and did not want her to leave. Respondent pointed out that Ms. Sturgeon was still present. Eppert reminded Respondent that Sturgeon was off duty. Eppert then told Respondent to give a report to Nurse Anderson. She refused and told Ms. Anderson to get the report from Ms. Sturgeon who had just given the report to Respondent. Since Respondent had not begun her rounds, Ms. Sturgeon's report was still valid and the narcotic count had not changed. Respondent left Holly Point Manor. The Respondent did not positively know at the time she left whether Nurse Sturgeon would remain to assist. The Respondent did not stay to determine whether Sturgeon would, in fact, cover the shift. However, the evidence did show that Ms. Sturgeon tacitly agreed to stay before Respondent left the facility. Nurse Sturgeon was not the type of person to decline to help when the need arose. After the Respondent left, Jan Sturgeon formally agreed to stay to assist with the 5 p.m. medication pass. She agreed because Ms. Eppert could not find anyone to work due to the closeness of the holidays. After the medication pass, Ms. Sturgeon left for the evening and Ms. Anderson handled the shift by herself. One nurse working the night shift alone was not an unusual event at Holly Point and occurred frequently. In fact, Ms. Anderson had worked the previous evening's shift by herself. One nurse to 50 patients meets HRS staffing requirements for nursing home facilities. However, the hardest part of the evening shift for a solo nurse was the 5:00 p.m. medication pass. Later, the facility was able to retain a replacement nurse for the 24th and 25th. It is not an acceptable nursing practice for a nurse to leave his or her employment until that nurse is sure that somebody else is going to take care of the patients the nurse is responsible for. In this case, Respondent failed to positively ensure someone would replace her. Reliance on tacit agreement by either of the other two nurses is not enough. Likewise, past practice of the facility is not enough. Reliance on tacit agreement or past practice is too amorphous to insure protection and the safety of the patients the nurse is responsible for. However, tacit agreement and past practice do go towards mitigation of any disciplinary penalty in this case. Respondent's actions by not ensuring her replacement or at least the need for such a replacement constitutes unprofessional conduct in the practice of nursing Likewise, it is not an acceptable nursing practice for an LPN to leave without giving another nurse a report on patients that that nurse would be assuming and before counting the medications on the medication cart. However, in this case, the evidence demonstrated that a replacement was there whose earlier report was still accurate and valid. Therefore, formal patient reporting and narcotics counting was not necessary or required. 2/ Respondent is not subject to discipline under this standard.
Recommendation Based upon the foregoing Proposed Findings of Fact and Conclusions of Law, it is: RECOMMENDED that Petitioner enter a Final Order reprimanding the Respondent's license, and requiring her to take courses in the Legal Aspects of Nursing and in Stress Management within a 6 month time period. DONE and ENTERED this 19 day of October, 1989, at Tallahassee, Florida. DIANE CLEAVINGER 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 19 day of October, 1989.
