Recommendation Based upon the forgoing facts presented in mitigation, the Hearing Officer would recommend that the State Board of Nursing revoke the license of Paul Bryce as a Licensed Practical Nurse with consideration of his reapplication upon the expiration of his probation in the absence of any adverse information obtained from Bryce's counselor. DONE and ORDERED this 30th day of October, 1978, in Tallahassee, Florida. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Paul J. Bryce 1010 North 25th Avenue Hollywood, Florida 33020 Julius Finegold, Esquire 1005 Blackstone Building Jacksonville, Florida 32201 Geraldine Johnson, R.N. State Board of Nursing 6501 Arlington Expressway - Bldg. B Jacksonville, Florida 32211
The Issue The issue is whether Respondent violated the Florida Civil Rights Act of 1992, as alleged in the Petition for Relief filed by Petitioner in May 1998.
Findings Of Fact Based upon all of the evidence, the following findings of fact are determined: In this proceeding, Petitioner, Jerrylene Barr, who is an African-American, contends that in May 1994, Respondent, Columbia Ocala Regional Medical Center (Respondent), unlawfully terminated her from employment as a registered nurse on account of her race. Respondent has denied the charges and contends instead that Petitioner was terminated after she negligently overmedicated a patient, in addition to her prior performance of medication errors over a two-year period. After a preliminary investigation was conducted by the Commission on Human Relations (Commission), which took some three years to complete, the Commission issued a Notice of Determination: No Cause on April 27, 1998. Although not specifically established at hearing, it can be reasonably inferred from the evidence that Respondent employed at least fifteen employees for each working day in each of twenty or more calendar weeks in the current or preceding year and thus is an employer within the meaning of the law. Petitioner began working for Respondent as a nurse in January 1992. Between September 1992 and May 1994, a period of seventeen months, Petitioner had twelve documented errors in giving medications to patients under her supervision. This was more than any other employee at Respondent's facility. During Petitioner's tenure at Respondent's facility, Respondent had a Medication Error Policy in effect. This policy outlined the procedures and penalties for medication errors. For each error, points were assigned according to the severity and frequency of errors. The policy provided, however, that management had the right to terminate an employee at any time for a serious medication error regardless of whether the employee had accumulated any points under the policy. Petitioner was aware of, and understood, this policy. On May 2, 1994, Petitioner was working the night shift at Respondent's facility and was in charge of six patients on the third floor. One of her patients was a 78-year-old male who was scheduled to have surgery for a life-threatening abdominal aortic aneurysm. The attending physician had written on his orders that day that the patient was to be given "Halcion 0.125 milligrams PO noon." This meant that he was to receive one-half of a .25 milligrams tablet of Halcion, a narcotic-type drug, by mouth at noon on May 3, the following day. The order was attached to the patient's chart. Around 6:30 p.m. on May 2, 1994, Petitioner mistakenly gave the patient five Halcion 0.25 milligrams tablets by mouth, or ten times the prescribed dosage. Although Petitioner did not initially disclose this fact to other personnel, she eventually conceded that she had made an error. When the patient was found in a comatose state a few hours later, three physicians were called to check on his condition, including his primary physician, a critical care physician, and a neurologist. Not knowing that Petitioner had overmedicated the patient, the primary physician initially believed the patient had suffered a stroke. The patient was admitted to the intensive care unit (ICU), a catheter was inserted, and he was placed on a respirator. After reading the medication record, the ICU nurses discovered that the patient had been overmedicated. The patient eventually recovered, but his surgery had to be postponed, which might have resulted in a burst aorta. His family later sued the hospital for Petitioner's negligence. Because of the serious nature of the error, and given Petitioner's past history of medication errors, Respondent terminated Petitioner on May 3, 1994. The employment decision was not based on Petitioner's race, but rather was based on "her poor work performance overall." There is no evidence as to whom, if anyone, was hired to replace Petitioner. The termination was wholly consistent with Respondent's Medication Error Policy. At hearing, Petitioner contended that the hospital did not terminate other nurses for similar offenses. However, during the same period of time that Petitioner was employed by Respondent, another nurse, M. C., a Caucasian female, was also terminated for making a serious medication error with a narcotic- type drug. Although M. C. had an otherwise "very good" record at the hospital, and did not have a history of medication errors, Respondent nonetheless terminated her since her conduct, like that of Petitioner, constituted a "life-threatening nurse practice error." Petitioner also contended that another nurse on duty that evening assisted her in calculating the Halcion dosage and this should relieve her of any responsibility. Although there was no independent testimony to corroborate this claim, even if true, the patient was under the direct supervision of Petitioner, and it would not diminish Petitioner's responsibility for placing the patient in a life-threatening situation.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that the Commission on Human Relations enter a final order dismissing, with prejudice, the Petition for Relief. DONE AND ENTERED this 14th day of April, 1999, in Tallahassee, Leon County, Florida. DONALD R. ALEXANDER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (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 14th day of April, 1999. COPIES FURNISHED: Jerrylene Barr Post Office Box 289 Reddick, Florida 32686 Kip P. Roth, Esquire 2501 Park Plaza Nashville, Tennessee 37203 Sharon Moultry, Clerk Florida Commission on Human Relations Building F, Suite 240 325 John Knox Road Tallahassee, Florida 32303-4149 Dana A. Baird, General Counsel Florida Commission on Human Relations Building F, Suite 240 325 John Knox Road Tallahassee, Florida 32303-4149
The Issue Whether Respondent's license to practice medicine should be disciplined for alleged violations of Chapter 458, Florida Statutes.
Findings Of Fact At all times material to this proceeding, Respondent was licensed as a physician in the State of Florida having been issued licensed number ME 0025012. On January 1, 1990 Respondent's license to practice medicine in the State of Florida became inactive. Respondent was not aware that his license had become inactive because he had not received the usual notice from the Board that his license was due to be renewed. The notice had been mailed to Respondent's last known address. At Respondent's own admission, Respondent continued to practice medicine in the State of Florida after his license had become inactive. However, Respondent immediately ceased such practice when he learned that his license was inactive. Respondent's license has never been reactivated. Given these facts, Respondent's practice of medicine after his license had become inactive constitutes only a minor violation of Section 458.331(1)(x), Florida Statutes. The penalty for such a violation should be minor. Therefore, a letter of reprimand would be appropriate in this case. In 1984, Dr. Cooper was employed as a staff physician in the emergency room of Tallahassee Memorial Regional Medical Center. On March 30, 1984, Patient D.J.D., a nineteen year old male, ingested an unknown quantity of the drug Asendin. Asendin is a tricycline antidepressant drug. Patient D.J.D. told his roommate what he had done. His roommate called an ambulance. The ambulance transported Patient D.J.D. to Tallahassee Memorial Regional Medical Center (TMRMC) While D.J.D. was being transported to TMRMC, the Respondent, who was on duty in the TMRMC emergency room, gave the paramedics who were treating Patient D.J.D. en route orders by phone to give patient D.J.D. 30 cc's of Ipecac with water to induce vomiting. The Ipecac was administered but Patient D.J.D. did not vomit. When the paramedics arrived at the hospital at 8:16 p.m., Patient D.J.D. was coherent and responded appropriately to questions. He was conscious and was sitting up with his eyes open. Approximately twenty minutes after D.J.D. arrived at the hospital, he had a grand mal seizure. Respondent was made aware of the seizure. Respondent performed an initial evaluation of Patient D.J.D. and wrote orders for an intravenous line, blood and urine analysis. The emergency room nurse did not inform Respondent that D.J.D. was an overdose patient. However, Respondent did not question the ER nurse about Patient D.J.D.'s history. At approximately 9:00 p.m., Patient D.J.D. had a second grand mal seizure. Following Patient D.J.D.'s second grand mal seizure, the Respondent administered Valium, Phenobarbital and Dilantin. After the drugs were administered Respondent asked the ER nurse about D.J.D.'s history. Although Respondent was made aware that Patient D.J.D. had overdosed on Asendin, at no time did he pump or lavage Patient D.J.D.'s stomach or administer charcoal. Charcoal is used with Asendin overdose patients to absorb the drug from the patient's system. It is usually diluted with sorbitor and pushed into the stomach. Gastric lavage involves washing the stomach contents out with saline solution. Dr. Jack F. Kareff, M.D., who has completed a three year residency in emergency medicine and who has been with Humana Hospital Bennett Emergency Department in Plantation, Florida, testified as an expert in emergency medicine. Dr. Kareff was of the opinion that Respondent should have lavaged or pumped Patient D.J.D.'s stomach and/or administered charcoal and that by not doing so, Dr. Cooper failed to practice medicine with that level of care, skill and treatment that is recognized as being acceptable in his treatment of Patient D.J.D.'s overdose. Respondent stated that he did not lavage Patient D.J.D.'s stomach or administer charcoal since it was not appropriate treatment for a patient who is seizing. Respondent stated that this is difficult to do as the teeth are clenched and it is difficult to force a tube in. However, the evidence showed that Patient D.J.D. had an oral air tube placed by either Respondent or the nurse after his first seizure. In fact, at one point during the treatment of Patient D.J.D., Respondent replaced the patient's airway tube. Such evidence indicates that Respondent's reasoning is not well founded. Respondent also states that he did not lavage patient D.J.D.'s stomach or administer charcoal because Asendin is absorbed very rapidly. However, the better evidence demonstrated that in the case of an overdose of the tricyclic antidepressants, like Asendin, gastric stasis is accomplished. Therefore, the stomach does not empty as fast as it usually does and the drug may still be in the stomach up to 12 hours after ingestion. The failure of Dr. Cooper to administer such treatment and immediately inquire about the patient's history constitutes a violation of Section 458.331(1)(t), Florida Statutes by falling below the standards of practice of medicine recognized in the community. Dr. Kareff testified that the Respondent failed to keep written medical records justifying the course of treatment of Patient D.J.D. in that the records did not justify Respondent's failure to pump or lavage his stomach and administer charcoal. However, in 1984, a doctor was not required to keep records justifying a course of treatment not given and it is questionable whether practicably speaking such records can be kept. Therefore, Respondent is not guilty of violating Section 458.331(1)(m), Florida Statutes, and Count II of the Administrative Complaint should be dismissed.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is: RECOMMENDED: That the Board of Medicine enter a Final Order finding Respondent guilty of violating Sections 458.331(1)(t) and (x), Florida Statutes, and that Respondent be: 1) reprimanded, 2) fined $4,000.00, and 3) placed on probation for a period of two years. If is further recommended that Count II of the Administrative Complaint be dismissed. DONE and ORDERED this 1st d ay of October, 1991, in Tallahassee, Florida. DIANE CLEAVINGER Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 1st day of October, 1991. APPENDIX TO CASE NO. 90-2212 The facts contained in paragraphs 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 and 23 of Petitioner's Proposed Findings of Fact are adopted, in substance insofar as material. The facts contained in paragraph 24 of Petitioner's Proposed Findings of Fact were not shown by the evidence. COPIES FURNISHED TO: Francesca Small Senior Attorney Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Gerald Cooper 2114 Owens Street Tallahassee, Florida 32301 Dorothy Faircloth Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 Jack McRay General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0792 =================================================================
The Issue The question presented is whether Respondent violated Section 456.072(1)(bb), Florida Statutes (2006), or Section 458.331(1)(nn), Florida Statutes (2006), by means of violating Florida Administrative Code Rule 64B8-9.007(2)(b), and if so, what penalty should be imposed?
Findings Of Fact Petitioner is the state agency charged with the licensing and regulation of medical doctors pursuant to Section 20.43 and Chapters 456 and 458, Florida Statutes. At all times material to the Administrative Complaint, Respondent was a medical doctor licensed by the State of Florida, having been issued license number ME 70981. Respondent is also certified by the American Board of Internal Medicine with a subspecialty in interventional cardiology. No evidence was presented to indicate that Respondent has ever been disciplined by the Florida Board of Medicine. On March 12, 2007, Dr. Elsakr was caring for two patients at Halifax Medical Center (Halifax). Patient M.D. was an 84-year-old Caucasian female born on March 22, 1922. F.E. was an 82-year-old Caucasian female born on February 5, 1925. Both women were scheduled for cardiac procedures to be performed on March 12, 2007, but only F.E. was scheduled for a cardiac catheterization. M.D. and F.E. shared the same semi-private room at Halifax. During the night before the scheduled procedures, one of the patients asked to be moved away from the window, and as a result, the two patients' bed locations were reversed. Halifax had procedures in place related to the transport of patients from one area of the hospital to another. The policy required that a staff member referred to as a transporter was required to check at least two patient identifiers on the patient's arm band to confirm a patient's identity. The arm band contains four identifiers: the patient's name, date of birth, a medical record number and a visit number. While any of the four may be used, the patient's name and date of birth are preferred. Patient M.D. was supposed to be transported for a heart catheterization the morning of March 12. However, the hospital policy regarding patient identification was not followed, and the wrong patient, M.D. as opposed to F.E., was transported to the catheterization lab (cath lab). Apparently, the transporter relied on the room and bed placement of the patient as opposed to following the protocol for affirmatively checking the patient identifiers. Once a patient was transported to the cath lab for a procedure, Halifax had a separate "pause" or "time out" protocol designed to ensure that the correct patient was present and the correct procedure was performed. The procedure was designed to be consistent with standards provided by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission for Accreditation of Hospitals, and the practices used by other hospitals. After transport and before a sterile field was created, the patient would be prepared for the procedure. As part of that preparation, a nurse was supposed to verify the patient's identity and confirm with another staff member that the patient's chart was the appropriate chart. The chart would then be provided to the person referred to as the recorder located in the adjacent control room outside the sterile field. The control room is separated from the sterile field by a plexi-glass wall, through which the recorder can observe everything taking place in the cath lab. The recorder would create a chronological log of the procedure, documenting the exact time when events took place. The physician performing the procedure would not necessarily be in the cath lab at the time the nurse verified the patient's identity. The chronological log for M.D. does not indicate that the patient's identity was confirmed or if it was confirmed, who confirmed it. Once a patient was prepped and draped, and the sterile field created, the recorder would call out the patient's name, procedure, procedure equipment, site and side of the procedure to be performed. The accuracy of the information was to be confirmed by a staff member saying "yes" or nodding his or her head. This procedure was considered by the hospital to be its "time out" procedure. The physician would be present but not actually participate in the time out, and would observe the time- out taking place. In this case, although the recorder called out F.E.'s name and the procedure she was scheduled to have, M.D. was actually present. Notwithstanding this error, an unidentified staff member either nodded or verbally confirmed that the information recited by the recorder was correct. Dr. Elsakr arrived at the cath lab after the patient was prepped but before the time out called by the recorder. He was present, but did not verbally participate, in the time out process. Before it took place, he met with the recorder in the control room to review the medical chart prior to the procedure. The medical chart reviewed was for F.E. After the time out, Dr. Elsakr approached the patient and stood near her head. By this time, the patient was fully draped, with blankets and surgical drapes covering all of her body except the surgical entry area (in this case her groin) and a portion of her face. Dr. Elsakr spoke to the patient, calling her by the first name of the patient F.E., and telling her, "[F.], this is Dr. Elsakr. I'm going to get started with your heart cath. Okay?" This interaction was consistent with his standard practice before he began a procedure, in order to give patients a level of comfort. M.D. did not initially respond to the name F., but said "yes" in response to Dr. Elsakr's question. He then moved down to the groin area, again called her by name (F.E.'s first name), and told her what she would feel as he started the procedure. She nodded her head and the procedure was begun. A catheterization was completed on the right side of the heart and begun on the left side. At that point, staff reported to Dr. Elsakr that the patient was the wrong patient. The procedure was immediately stopped. Dr. Elsakr immediately informed the patient, the patient's daughter, and the patient's primary care physician. He also noted the mistake on M.D.'s medical chart. Halifax Hospital undertook an investigation of the events leading to the procedure. The purpose of its investigation was to determine whether there was a breach in hospital safety protocols and to prevent any recurrence of the error. Dr. Donald Stoner, Halifax's Chief Medical Officer, testified that the fault lay with hospital staff, and not with Dr. Elsakr, and that if he had been the doctor involved, he likely would have done the same things as Dr. Elsakr. Halifax accepted full responsibility for the incident and independently compensated the patient for the incident. The hospital also determined that it would be inappropriate for Dr. Elsakr to be subject to any discipline for the incident by Halifax with respect to his privileges. Immediately after discovering that the wrong patient had the heart cath, Dr. Elsakr instructed that the patient should not be charged in any way for the procedure. While patient M.D. clearly could have been harmed by having to undergo the procedure, information about her condition was obtained that was actually a benefit to her.
Recommendation Upon consideration of the facts found and conclusions of law reached, it is RECOMMENDED: That the Florida Board of Medicine enter a Final Order finding that Respondent, Ashraf Elsakr, M.D., violated Section 456.072(1)(bb), Florida Statutes, and Section 458.331(nn), Florida Statutes by means of violating Florida Administrative Code Rule 64B8-9.007(2)(b). As a penalty, it is recommended that the Board issue a letter of concern, and impose a $5,000 fine. In addition, Respondent should be required to obtain five hours in continuing medical education in the area of risk management, perform 25 hours of community service, and give a one-hour lecture on performing procedures on the wrong patient. DONE AND ENTERED this 30th day of June, 2010, in Tallahassee, Leon County, Florida. S LISA SHEARER NELSON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of June, 2010.
