The Issue The issue in the case is whether the allegations of the Administrative Complaint filed by Petitioner are correct and, if so, what penalty should be imposed against Respondent.
Findings Of Fact Petitioner is the state agency charged with regulation of the practice of nursing in State of Florida. At all times material to this case, Respondent has been licensed as a registered nurse in the State of Florida, holding license no. 2003552, with a last known address of 1407 Wekewa Nene, Tallahassee, Florida 32301. Respondent was employed at all times material to this case by Tallahassee Memorial Hospital (TMH) until December 1, 2000, when her employment was terminated. On November 23, 1999, Respondent was working a day shift at TMH as a nurse at 1300 Miccosukee Road, Tallahassee, Florida. On November 23, 1999, Sharissa Holloway was a student nurse from the Florida State University (FSU) School of Nursing and happened to be doing a clinical rotation on the TMH orthopedic/neurological floor. Respondent was the primary nurse for the patients on that floor who were under the care of the student nurse. The student nurse received the patient assessment sheets from Respondent prior to 8:00 a.m. with entries already charted by Respondent for estimating Patient N.C.'s pain, and a sedation scale already charted by Respondent covering the period of time that stretched all the way to 12 o'clock noon. When handing the patient assessment sheets to the student nurse at approximately 7:30 a.m., Respondent stated "I have already started the notes." The note entries had Respondent's initials next to them in the appropriate column. Narrative notes on Patient N.C. had already been written indicating that a dressing change of a surgical wound had been done at 8:00 a.m. These notes bore Respondent's signature. The student nurse also got these notes from Respondent before 8:00 a.m. Concerned with the advanced notations that she discovered, the student nurse took the patient assessment sheets which bore Respondent's entries for future times up to 12 o'clock noon to her FSU clinical nursing instructor who was on the premises at the time. Proceeding to Patient N.C., the instructor verified that the patient's wound dressing had not been changed. The student nurse did the dressing change at approximately 8:30 a.m. The nursing instructor took the documents to the head nurse for the orthopedic/neurological floor, Kay Keeton. Keeton requested that both the student nurse and the nursing instructor submit independent written statements. They complied with Keeton's request. Contemporaneously with the drafting of statements by the clinical nurse instructor and the student nurse, photocopies of the patient assessment sheets were made at least two hours prior to 12 o'clock noon. Keeton made notes on the sheets to show entries charted by Respondent as opposed to entries charted by the student nurse. Keeton is familiar with Respondent's signature. After determining that Respondent had charted something that had not been done yet, Keeton made her report to the TMH administration. When questioned about the entries on December 1, 1999, Respondent denied making the entries. She was given a disciplinary form entitled "Notice of Corrective Action." Upon her refusal to sign the form, Respondent was terminated from her employment. Respondent has experienced employment problems at TMH for which Notices of Corrective Action were issued which date back to 1996. This history, in conjunction with Respondent's demeanor while testifying and her lack of candor, dictate that her denial of improper action in this case, cannot be credited. Minimal acceptable standards of prevailing nursing practice require that documentation of care provided to patients be recorded contemporaneously with the provision of the care. Respondent's "before the fact" documentation of care provided to the patients identified herein fails to meet minimally acceptable standards of prevailing nursing practice. The placing of a care provider's initials on a medication administration record indicates that medication has been administered to patients. "Pre-initialing" or signatures on medication administration records poses a risk of confusion to other care providers working in the facility and is not an acceptable practice.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Petitioner enter a final order against Respondent, imposing a fine of $250, requiring completion of appropriate continuing education in nursing records documentation in addition to any existing continuing education requirement, and placing the Respondent on probation for a period of one year under such conditions as the Board of Nursing determines are warranted. DONE AND ENTERED this 24th day of October, 2000, in Tallahassee, Leon County, Florida. DON W. DAVIS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 24th day of October, 2000. COPIES FURNISHED: Michael E. Duclos, Esquire Agency for Health Care Administration 2727 Mahan Drive Building 3, Room 3240 Tallahassee, Florida 32308 Donna H. Stinson, Esquire Broad & Cassel 215 South Monroe Street, Suite 400 Post Office Box 11300 Tallahassee, Florida 32302 Ruth R. Stiehl, Ph.D., R.N. Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A00 Tallahassee, Florida 32399-1701
The Issue The issue in the case is whether the allegations of the Administrative Complaint filed by the Petitioner are correct and, if so, what penalty should be imposed against the Respondent.
Findings Of Fact The Petitioner is the state agency charged with regulation of the practice of nursing in State of Florida. At all times material to this case, the Respondent has been licensed as a practical nurse in the State of Florida, holding license number PN 0741801. At all times material to this case, the Respondent was employed as a practical nurse at the Harborside Health Care facility in Naples, Florida. At all times material to this case, Patient F. D. was a resident of Harborside Health Care. On or about August 17, 1998, at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to F. D. According to the medication administration record, F. D. was to receive the nutritional supplement at approximately 2:00 p.m. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to F. D. At all times material to this case, Patient L. G. was a resident of Harborside Health Care. On or about August 17, 1998, at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to L. G. According to the medication administration record, L. G. was to receive the nutritional supplement at approximately 2:00 p.m. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to L. G. At all times material to this case, Patient R. T. was a resident of Harborside Health Care. On or about August 17, 1998, at approximately 11:00 a.m., the Respondent initialed a medication administration record indicating that the Respondent had provided a nutritional supplement to R. T. According to the medication administration record, R. T. was to receive the nutritional supplement at approximately 2:00 p.m. At the time the Respondent placed her initials on the medication administration record, she had not provided the nutritional supplement to R. T. Minimal acceptable standards of prevailing nursing practice require that nurses accurately document the provision of supplements and nourishment to nursing home patients. Minimal acceptable standards of prevailing nursing practice require that documentation of care provided to patients be recorded contemporaneously with the provision of the care. The Respondent's documentation of care provided to the patients identified herein fails to meet minimally acceptable standards of prevailing nursing practice. The placing of a care provider's initials on a medication administration record indicates that medication has been administered to patients. "Pre-initialing" of medication administration records poses a risk of confusion to other care providers working in the facility and is not an acceptable practice. The Respondent acknowledges that she initialed each medication administration record at about 11:00 a.m., several hours prior to the actual administration of the supplement's to the patients. She asserts that she did not record the amounts of supplement each patient consumed (100 percent in all three cases assuming the records are accurate) until after the patient had consumed the supplement. The rationale for the Respondent's practice is unclear. The Respondent suggests that she had "a few moments" at about 11:00 a.m. and so she went ahead and initialed the documents, knowing that she could complete the charting at a later time. The Respondent's suggestion is the intent of the practice is to save time; however, any time saved is at best minimal. If the Respondent's testimony regarding post- administration record completion is credited, the practice requires that each record be handled twice to complete a single task. The Respondent suggests that she returns to each individual record after administering the supplement and charts the amount of supplement consumed by writing in a space approximately one-quarter inch beneath the "pre-initialed" space. In reality, "pre-initialization" doubles the time required to complete the documentation and increases the potential for confusing other care providers involved in patient care and charting. The Respondent continues to assert that the "pre- initialization" practice is acceptable. The assertion is clearly contrary to minimally acceptable standards of nursing practice, and to common sense.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Petitioner enter a final order against the Respondent, imposing a fine of $500, requiring completion of appropriate continuing education in nursing records documentation in addition to any existing continuing education requirement, and placing the Respondent on probation for a period of one year under such conditions as the Board of Nursing determines are warranted. DONE AND ENTERED this 30th day of August, 2000, in Tallahassee, Leon County, Florida. WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of August, 2000. COPIES FURNISHED: Reginald D. Dixon, Esquire Agency for Health Care Administration 2727 Mahan Drive Post Office Box 14229 Tallahassee, Florida 32317-4229 Harry A. Blair, Esquire Harry A. Blair, P.A. 2180 West First Street, Suite 401 Ft. Myers, Florida 33901 Ruth R. Stiehl, Ph.D., R.N., Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Angela T. Hall, Agency Clerk Department of Health 4052 Bald Cypress Way Bin A02 Tallahassee, Florida 32399-1703 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way Bin A02 Tallahassee, Florida 32399-1703
Findings Of Fact The Respondent is a registered nurse holding License No. 0936792 issued by the Florida State Board of Nursing. The Respondent was employed as a registered nurse at Shands Teaching Hospital in Gainesville, Florida, from August of 1978, until April, 1979. Her duties were as a nursing team leader and medication nurse on the fourth floor. The fourth floor unit to which the Respondent was assigned was a 52-to-56- bed unit. Staff on this floor consisted of a charge nurse in charge of the floor and two to four registered nurses. Patient census on this unit ran from 40 to 56 patients. This was a general medical ward whose patients included the chronically ill. (a) Regarding the allegations of Count 1 of the Administrative Complaint related to the patient Gussie Sims Gardner, the hospital records reveal the patient was not admitted to the hospital until 2225 hours on March 24, 1979. The individual responsible for initial preparation of the medication administration record (MAR) did not cross through the times prior to the administration of the patient's first medications as required by the hospital's protocols. See Exhibit 1, Medication Record (Form No. 15-02-41-2), page 2, paragraph 5. Because of this failure, the initial entries for medication administered to the patient on March 25 were transposed to the date of March 24, and the entries for March 26 were placed in the column far March 25. After two days this error was apparently discovered, and no entries were made in the column for March 26. The Respondent cannot be held responsible for this error, because she was not on duty when the patient was admitted. Under the hospital's standard operating procedures (SOP), the first individual administering medication should have crossed out the dates and times in such a manner that this error could not occur. (b) Regarding Counts 1 and 2 of the Administrative Complaint, the Control Substance Form (CSF) does reflect that the Respondent withdrew two Darvon 65, a Class IV controlled substance, on March 25, 1979. The Respondent recorded the administration of the Darvon at the appropriate time but under the date of March 24, 1979. Only the administration of this medication at 0830 hours on March 25 was noted by the Respondent in the nurses' notes. (c) Regarding the allegations of Count 4, recording of the entries for March 25 and 26 under the dates of March 24 and 25 resulted in no entries being made on the MAR on March 26 by any of the nursing staff. (d) Regarding the allegations of Counts 6 and 8 that the physician's order entered March 24 for Oarvom 65 was no longer effective on March 28, Exhibit 1, the Formulary, page VIII, provides that stop orders occur automatically at the end of 48 hours for narcotics and at the end of seven days for all other drugs unless renewed. The Formulary differentiates on page IX between narcotics and other controlled substances. Darvon, while a controlled substance, is not a narcotic and therefore would not be terminated at the end of 48 hours, but at the end of seven days. The administration of this drug by the Respondent on March 28 was not precluded by the hospital's regulations. (e) Regarding the allegations contained in Counts 3, 5, 7 and 9, there is no substantial evidence that the Respondent possessed any controlled substance for any purpose other than the administration of the substance to the patient. No substantial and competent evidence was presented that the medications were not administered to the patient as recorded in the written records of the hospital. (a) Regarding the allegations concerning the patient Mary Lee Love Graham contained in Count 10 of the administrative Complaint, the CSF reflects two doses of Codeine were signed out by the Respondent for this patient on March 25, 1979. The appropriate entries were made on the MAR by the Respondent. Although the 1200 hour administration of medication was charted in the nurses' notes, the administration of the medication at 0830 hours was not charted by the Respondent. Similarly, the administration of Codeine 60 to this patient at 2200 hours was not charted by Nurse Wigginton on March 24, 1979. (b) Regarding Count 12 of the Administrative Complaint, the MAR reflects that Graham received Codeine 60 at 0400 hours from Wigginton and at 0800 hours from the Respondent on march 26, 1979. The nursing notes do not reflect the administration of Codeine 60 at either time. On March 27, 1979, the Respondent apparently administered no medications to this patient; however, the administration of Codeine 60 to this patient at 1600 hours on March 27, 1979, was not charted in the nursing notes. (c) Regarding the allegations of Count 14 in the Administrative Complaint, the MAR and CSF agree regarding the administration of Codeine 60 to Graham on March 26, 1979, at 0800 and 1400 hours by the Respondent. The administration of the medication at 0800 hours was not charted in the nursing notes, as was the administration of the same medication at 2300 hours on the same date by another nurse. Although the physician's orders were not renewed and therefore terminated at the end of 48 hours as discussed above, the MAR was not changed to reflect discontinuation of this medication, and all staff nurses, to include the Respondent, continued to administer Codeine 60 to this patient after the physician's orders ceased. (d) Regarding the allegations contained in Counts 11, 13 and 15, there is no substantial and competent evidence that the Respondent possessed any controlled substance for any purpose other than its administration to a patient. There is no substantial and competent evidence that the medications were not administered as charted. (a) Regarding the allegations contained in Count 16 concerning the patient Marshal Rex Burk, the MAR and CSF records reflect administration of Darvon 65 by the Respondent to this patient at 1000 hours on March 24, 1979. This was not charted by the Respondent in the nursing notes. As stated above, the drug Darvon 65 is not a narcotic drug and not subject to automatic termination at the end of 48 hours. Thee administration of Darvon 65 on March 24, 1979, was pursuant to a physician's order entered on March 19, 1979. (b) Regarding the allegations of Count 18, the CSF and MAR reflect administration of Darvon 65 to Burk at 1000 hours on March 25, 1979, by the Respondent. The Respondent did not chart this in the nurses notes. The physician's order for Darvon remained valid on March 25, 1979. (c) Regarding the patient Burk, the MAR reflects that Dalmane, a Class IV controlled substance, was administered March 21, 22, 23 arid 25 by a staff nurse. The administration of this medication was not charted in the nursing notes, and a review of the physician's orders for this patient does not reflect an order for Dalmane being entered until March 29, 1979. A review of the nursing notes for this patient reveals no charting for March 27, 1979. The SOP for charting provides a minimum of one charting for each patient per shift. (d) The allegations contained in Counts 17 and 19 are not proven. The records reflect the Respondent signed out for Darvon 65 and administered it to the patient. (a) Regarding the allegations contained in Count 20 of the Administrative Complaint concerning the patient Willie Mae Bender Tison, the CSF shows the Respondent signed out for two doses of Darvon 65 on March 24, 1979, for this patient. The MAR reflects administration at 0330 hours on March 24, 1979. The nursing notes do not reflect administration of Darvon 65 to his patient on March 24, 1979. One Darvon 65 was not accounted for in the records. (b) Regarding this patient, his MAR indicates the patient started receiving drugs on March 17, 1979; however, the admitting data and nursing notes reflect that this patient was not admitted until 1450 hours on March 21, 1979. The data contained in the MAR from March 17 until March 24 is clearly in error. (c) Regarding Count 21, although the facts indicate the Respondent did not chart the administration of one Darvon 65 to the patient Tison, no evidence was introduced that the Respondent took the medication herself or retained the medication for sale or distribution. (a) Regarding the allegations in the Administrative Complaint contained in Count 22 relating to the patient Frances Louise Blocker Medina, the MAR reveals that Percodan was administered to this patient on March 24, 1979, at 0530 hours, 0930 hours by the Respondent, 1300 hours by the Respondent and 2200 hours. The CSF reflects that the Respondent withdrew two doses of Percodan for the Respondent on March 24, 1979. The Respondent recorded the administration of the medication to this patient at 1300 hours in the nursing notes. No entries were made in the nursing notes for March 24, 1979, reflecting the administration of Percodan at 0530 hours, 0930 hours and 2200 hours by the Respondent and others. (b) Regarding the allegations of Count 24, the MAR reflects that the Respondent administered Percodan to this patient at 0700 hours and 1100 hours on March 25, 1979. The Respondent charted the administration of this medication to this patient in the nursing notes at 0730 hours and 1030 hours. The CSF shows the Respondent signed out for two Percodan for this patient on March 25, 1979. The MAR also reveals that this patient received Percodan at 1830 hours on March 25, 1979, from another nurse. The nursing notes do not reflect charting of this medication. (c) Regarding the allegations in Count 26, the CSF reflects that the Respondent signed out for two doses of Percodan for this patient on March 26, 1979. The MAR reflects administration of Percodan to this patient at 0200 hours, 0800 hours by the Respondent, 1400 hours by the Respondent and 2000 hours on March 26, 1979. The nursing notes reflect only the administration of this medication for 2000 hours. (d) Regarding the allegations of Count 28, the medical records of this patient reflect that staff nurses, to include the Respondent, continued to give the patient Percodan, a narcotic, although the physician's order for this medication automatically terminated. (e) Regarding the allegations of Count 30, the MAR and CSF reflect that the Respondent administered one Percodan to this patient on March 28, 1979. The Respondent failed to chart the administration of this medication to this patient in the nursing notes. (f) Regarding Counts 23, 25, 27, 29 and 31, no substantial and competent evidence was presented that the Respondent maintained possession of any drug. The records reflect that all drugs signed out by the Respondent were administered to the patient. (a) Regarding allegations contained in Count 32 of the Administrative Complaint concerning the patient Ruby Lee Denson Standback Woodburne, the times on the exhibit copies of the CSF are illegible. However, the MAR and CSF do reflect that the Darvon 65 checked out for this patient by the Respondent on Marcy 24, 1979, was administered to the patient. The nursing notes reflect administration of the medication to the patient. (b) Regarding the allegations in Count 34, the CSF shows the Respondent signed out for Darvon 65 two times on March 25, 1979, for this patient. The MAR reflects the Respondent administered Darvon 65 to the patient at 0830 hours and 1200 hours. The nursing notes reflect that Darvon 65 was administered at 1200 hours but not at 0830 hours. (c) Regarding the allegations of Count 36, the MAR and CSF records show the Respondent medicated the patient at 0800 hours and 1200 hours on March 26, 1979, with Darvon 65. The Respondent charted the administration at 1200 hours in the nursing notes but failed to chart the administration at 0800 hours. (d) Regarding the allegations of Count 38, the CSF reflects the Respondent withdraw one Darvon 65 for this patient on March 27, 1979. The MAR does not reflect administration of this medication; however, the nursing notes reflect the administration of Darvon at 0830 hours on March 27, 1979. (e) The medical service orders for this patient were renewed March 22, 1979, after Use patient's surgery. Presumably, this would have renewed the Darvon 65 order of March 17, 1979, and it would have been effective through March 29, 1970. (f) Regarding Counts 33, 35, 37 and 39, there is no evidence that any medication was net administered to the patient as reflected in the records. Although the MAR entry was not made on March 27, 1979, a nursing note does reflect administration of Darvon 65 on that date by the Respondent. (a) Regarding the allegation contained In Count 40 of the Administrative Complaint concerning the patient Willie Mae Hair, the CSF and MAR records reflect the Respondent administered Darvon 65 to this patient at 0830 hours on March 24, 1979. No entry was made in the nursing notes by the Respondent for this date. Although the patient was discharged on March 24, she was medicated for pain in the evening of March 23, and the nursing note for 0145 hours of March 24 reflects that the nursing staff apparently expected her to experience pain. (b) There is no substantial and competent evidence to support the allegation of Count 41. All medications checked out by the Respondent for this patient were administered according to the records. Regarding Count 42 of the Administrative Complaint, Exhibit 11 reveals that on several occasions the Respondent wasted medications without the required countersignatures of another staff member. There was no substantial and competent evidence presented that the Respondent converted any of the drugs wasted to her own use. To the contrary, although improperly witnessed, the records reflect that the medications were wasted. Review of Exhibit 1, containing extracts of the hospital's SOP's for controlled substances and charting, does not reveal any requirement that the specific time of withdrawal of a controlled substance be entered on the CSF. Exhibit 1 does reflect that medication may be prepared and placed upon a lockable medicine cart. The nature of the entries on the MAR reflect that medications were drawn at one time from the controlled substance container for administration to patients during a shift. The SOP for charting nursing notes does not require that the administration of medication be noted. However, the SOP for administration of medication would require noting the patient's complaint and the patient's response to medication in the nursing notes if a prn medication were administered. Gross departures from the hospital's SOP's regarding controlled substances and charting of nursing notes occurred among staff nurses employed on the fourth floor at the time in question due to staffing shortages.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer would recommend that no action be taken against the Respondent. DONE and ORDERED this day of January, 1980, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Michael I. Schwartz, Esquire Suite 201, Ellis Building 1311 Executive Center Drive Tallahassee, Florida 32301 Irving J. Whitman, Esquire 9595 North Kendall Drive, Suite 103 Miami, Florida 33176 Geraldine B. Johnson, R. N. State Board of Nursing 111 Coastline Drive East, Suite 504 Jacksonville, Florida 32202
Findings Of Fact At all times pertinent to the issues herein, Respondent, Anthony Salzano, was a registered nurse licensed as such in Florida. On November 1, 1983, Ms. Fabian was acting as head nurse of the cardiac care unit at James Archer Smith Hospital in Homestead, Florida, where Respondent, Salzano, along with another male nurse, Blakemore, was working as a registered nurse, though on different shifts. At that particular time, Ms. Fabian had no complaints about Respondent's skills or drug control until on this date, she received a call from another nurse to come check the narcotic records on the unit. When she did so, what she saw disturbed her and she immediately contacted Mr. Ellis, the Director of the Pharmacy requesting that he look at the ward narcotic records. Mr. Ellis did so and immediately determined they were not correct. He gathered them together and, along with Ms. Fabian, started to take them to the pharmacy to check them against the pharmacy records. As Fabian and Ellis were getting on the elevator, they saw and were seen by Salzano and Blakemore who immediately left the hospital without signing out. Neither has returned. Hospital records for November 1, 1983, indicate that Salzano checked in at 2:45 p.m. for the 3 to 11 shift, but did not go to the floor or at any time report for duty. Examination of the records in question, which include drug sign-out sheets, medical administration records, and nurses' notes revealed that there were numerous discrepancies thereon as to times, patients' names, nurses' names, and the quantities of demerol and demerol 100 used on the cardiac care unit. Cardiac patients rarely receive doses of demerol or demerol 100. Ms. Fabian compared the Respondent's signatures on the drug sign-out sheets with other documents on which his signature appears and concluded that they were the same and that he had signed the control records. As a part of her job, she was required to be familiar with all of her nurses' signatures and was satisfied that the records in question had been made by the Respondent. Specifically, on the dates set out in the Administrative Complaint, times of drug administration were out of sequence, dates were out of sequence, and fictitious names as administering official, the signatures for which appeared to be by Respondent, appeared on the records. Blakemore's name only appeared a few times and there was indication that the Respondent and Blakemore did not work on the same shift. The erroneous record keeping by the Respondent could not have been because of his lack of knowledge of procedures. He had received the entire indoctrination program on the hospital's drug policies and procedures administered by not only Ms. Fabian but also the Director of Nursing and the Chief Pharmacist as well. The records show that Respondent did not properly follow the procedures which include not only accounting for the medication but also reflecting it was administered and the effect it had on the patient. Accounting for the medication would be accomplished on the drug sign-out sheet. Administration of the medication would be shown on the medicine administration record, and the effect on the patient would be shown in the nurse's notes. The failure of the Respondent to keep the required records, in the uncontradicted opinion of Ms. Fabian, constitutes the practice of nursing in a manner far below minimum standards of acceptable and prevailing nursing practice and it is so found.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that Respondent's license as a registered nurse in Florida be suspended for two years or until he appears before the Board of Nursing to demonstrate he continues to be qualified to practice nursing safely to the satisfaction of the Board, whichever comes first. RECOMMENDED this 19th day of December 1986, at Tallahassee, Florida. ARNOLD H. POLLOCK Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 FILED with the Clerk of the Division of Administrative Hearings this 19th day of December 1986. COPIES FURNISHED: Judie Ritter, Executive Director Board of Nursing 111 East Coastline Drive, Room 504 Jacksonville, Florida 32201 William T. Furlow, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Michael L. Cohen, Esquire 1615 Forum Place Barister's Building, Suite 4-E West Palm Beach, Florida 33401 Fred Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Wings S. Benton, General Counsel Department of Professional Regulation =================================================================
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.
