The Issue The issue in this proceeding is whether Respondent committed the offences set forth in the Administrative Complaint and, if so, whether Respondent's nursing license should be disciplined accordingly.
Findings Of Fact The Agency for health Care Administration is the agency charged with the regulatory and prosecutorial duties related to nursing practice in the State of Florida. Respondent, Rachelle Chiaro Vaslowski, holds a nursing license number RN 2913542. Respondent's last known address is 240 Brookline Avenue, Daytona Beach, Florida 32118. Respondent was employed by the Coquina Center (the Center) from February 12, 1997, until her termination on January 7, 1998. On January 6 and 7, 1998, Respondent was working a day shift at the Center as a registered nurse, at 170 North Center Street, Ormond Beach, Florida. Respondent was under the supervision of Barbara Geyer, R.N., Unit Manager for the sub-acute care section of the nursing home. Respondent was assigned to care for patients which included the administration of their scheduled medications. Ms. Geyer testified regarding Respondent's performance of her duties. On Respondent's shift, patients, whom Respondent was caring for, had not received the medication that they were prescribed. Ms. Geyer also observed twenty to thirty cc' s of clear fluid on Respondent's medication cart when this was brought to her attention by Respondent. Respondent told Ms. Geyer, "I've just spilled a bottle of Roxanol, should I take the plunger and suck it back up again." Roxanol is a strong mixture of pain medication, consisting of Morphine and Demerol, used to medicate the terminally ill. Ms. Geyer advised Respondent that the medication had to be appropriately discarded and the correct documents completed regarding its wastage. Ms. Geyer, who has been an R.N. for many years, observed that Respondent had a very confused look on her face. Ms. Geyer went to her Director of Nursing, Kathy Johnson and advised her of the situation. Both women interviewed Respondent regarding the spilling of the narcotic. A hasty inventory also was conducted of Respondent's medication cart. Respondent was the only person on duty with a key to the cart. There were medications for which Respondent had received which were unaccounted for. Two and a half vials of Morphine and 14 Ambien were missing. They also found two vials marked as containing Roxanol. Since this was the medication that was supposed to have been spilled, Ms. Geyer questioned Respondent about it. Respondent replied, "What do you want, there is more than you need?" Ms. Geyer and Ms. Johnson both stuck their fingers in the supposed vials containing Roxanol. Both women testified that one had a bitter taste and the other had no taste at all. Ms. Geyer observed that, in addition to having a dazed look in her eyes, Respondent gave totally inappropriate responses to the questions she was asked when interviewed. Ms. Johnson, the head nurse, testified that she observed Respondent's nursing skills had declined. Respondent forgot to chart medications she administered. This became a pattern. Ms. Johnson identified Petitioner's Exhibit No. 5 as the complaint she had filed with the State against Respondent on February 20, 1998. Ms. Johnson was qualified as a nursing expert based on her education, training, and experience. She observed that Respondent, when interviewed following the spilling incident, was confused and dazed. Questions had to be repeated several times to her. Respondent appeared not to understand the questions. Ms. Johnson described that when Respondent was informed that they were going to do a narcotics count on Respondent's medication cart, Respondent grabbed her belongings and left the facility in haste. She did not clock out. She did not tell anybody she was leaving. She left the keys on the cart and she was out the door. Ms. Johnson opined that this was very unprofessional behavior. The Center's pharmacy policies and procedures were identified by Ms. Geyer. Ms. Geyer explained the policies and procedures regarding controlled substances. Respondent failed to follow the policy and procedure for disposing of controlled substances. As supervising nurse, Ms. Geyer, filled out a narcotics "wasting" report on Respondent spilling of Roxanol. The medication error report was signed by Barbara Geyer. Ms. Johnson also testified that it is a violation of nursing procedures to not account for narcotics properly when you administer or "waste" them. Further, she opined it was unprofessional conduct to work under the influence of narcotics, to take medications that are intended for patients, and not properly chart medications.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law set forth herein, it is RECOMMENDED: That the Board of Nursing enter a final order suspending the license of Respondent to practice until she has satisfactorily completed the IPN program, and, thereafter, place her on a five-year probation to follow her practice. DONE AND ENTERED this 6th day of April, 2001, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN 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 6th day of April, 2001. COPIES FURNISHED: Michael E. Duclos, Esquire Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Rachelle Chiaro Vaslowski 240 Brookline Avenue Daytona Beach, Florida 32118 Ruth R. Stiehl, 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 A02 Tallahassee, Florida 32399-1701 Dr. Robert G. Brooks, Secretary Department of Health 4052 Bald Cypress Way, Bin A00 Tallahassee, Florida 32399-1701
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.
