The Issue Whether Respondent's license to practice nursing in the state of Florida should be revoked, suspended or otherwise disciplined under the facts and circumstances of this case.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made: At all times material to this proceeding, Respondent Teresa Iva Smith Lobato (Lobato) was licensed as a Registered Nurse in the state of Florida, holding license number RN-1655102, and was employed by the Bayfront Medical Center (Bayfront) located in St. Petersburg, Florida as a Registered Nurse. On May 13, 1990 Lobato was to work the 7:00 a.m. to 3:00 p.m. shift, and upon arriving for work was told that she was being "floated" from the Coronary Care Unit (CCU) where she regularly worked to the Progressive Care Unit (PCU) where she had never worked. Bayfront had a policy whereby nurses were "floated" from one unit to another, and at the time Lobato was employed by Bayfront she was made aware of this "floating" policy. Floating means that a nurse is assigned temporarily to a unit other than the nurse's regularly assigned unit. On May 12, 1990 Lobato was aware that she was to be "floated" on May 13, 1990, but had informed the Acting Director of CCU that she would rather cancel her work assignment than be "floated". However, upon arriving for work on May 13, 1990, and being told that she was being "floated" to PCU she accepted the assignment on PCU although she was not pleased about the situation. Bayfront has a policy that requires the outgoing nurse to audiotape a report for the oncoming nurse regarding the condition of the patients and any events occurring during the outgoing nurse's shift or if no tape is made to give report verbally to oncoming nurse. Upon arriving at PCU Lobato, along with PCU Charge Nurse (CN), listened to the audiotaped reports from the outgoing nurse on the following patients D. L. L., A. S., E. H., C. L. S., and H. K. As the morning progressed, Lobato became more and more displeased with her assignment, and let her displeasure be known to the PCU Charge Nurse. However, Lobato did not ask to be relieved from her assignment, although there was testimony that she indicated to the CN that she wanted to go home. Although the record is not clear as to the time the following events occurred, the sequence of those events are as follows: Around 9:00 a.m. Lobato was offered help by the CN but declined; Around 9:30 Lobato went on break, and again was offered help but declined; While on break Lobato talked to the Assis- tant Director of Nursing (ADON) about her under- standing of not being required to "float", and became upset with the ADON's response; After returning from break Lobato was again offered help by the CN which she accepted. The CN brought Michelle Nance, Medical Surgical Technician, and two RNs whose first names were Jessica and Melinda to the unit to assist Lobato. Around 10:30 a.m. Lobato and the CN dis- cussed Lobato's patient assignments, and Lobato advised the CN that everything was done, in- cluding all a.m. medication, other than the missing vasotec doses, and that she had some charting to do. Also, the patient's baths had been completed. Shortly after Lobato and the CN discussed her patients' assignments, the ADON came to the unit to determine what was troubling Lobato. The ADON and Lobato met and there was a confrontation wherein Lobato advised the ADON that she was quitting and the ADON advised Lobato that she was fired. After Lobato's confrontation with the ADON, Lobato left the unit and Bayfront without completing the balance of charting her patients' notes, and without giving the CN a report of the patients even though the CN requested her to do so. Lobato's reasons for not giving the CN a report was that she had discussed the patients with the CN throughout the morning, and that the CN knew as much about the patients as did Lobato at that time, and therefore, she had made a verbal report. Lobato's reasons for not completing the charting of her patients' notes was that when the ADON fired her on the spot the ADON accepted full responsibility for the patients, and Lobato's responsibility to both Bayfront and to the patients assigned to her ceased at that time, notwithstanding her understanding of the importance of charting so that appropriate care could be given to the patients on the next shift. By her own admission, Lobato left Bayfront around 10:30 a.m. on May 13, 1991 before the end of her shift without completing the balance of charting her patients' notes and without giving a report to the CN, other than the ongoing report given during the morning. Earlier while Lobato was still on the unit working the CN had obtained two registered nurses (RN) and a medical surgical technician to assist Lobato. One of the nurses whose first name was Jessica (last name not given) was the RN assigned to Lobato's patients by the ADON when Lobato left and she received a report on the patients from Janice Ritchie, CN. (See Respondent's exhibit 1, and Petitioner's exhibit 1 and Janice Ritchies' rebuttal testimony.) Although Lobato's failure to chart the balance of her patients' notes and make a report to the CN before she left may have caused some problems, there was no showing that any patient failed to receive proper care or suffered any harm as a result of Lobato leaving. While some of the patients may not have received all their medication before Lobato left, the record is not clear as to whether the medication was made available to Lobato to administer or that she was shown where the medication was located in the floor stock. The patient is the nurse's primary responsibility, and the minimal standards of acceptable and prevailing nursing practice requires the nurse, even if fired (unless prevented by the employer from performing her duties), to perform those duties that will assure the patient adequate care provided for after her absence. In this case, the failure of Lobato to compete the charting of her patients' notes and the failure to make a report to the CN, notwithstanding her comments to the CN upon leaving, was unprofessional conduct in that such conduct was a departure from and a failure to conform to minimal standards of acceptable and prevailing nursing practice.
Recommendation Based upon the foregoing, it is recommended that the Respondent be found guilty of violating Section 464.018(1)(h), Florida Statutes, and that she be given a reprimand. RECOMMENDED this 31st day of May, 1991, in Tallahassee, Florida. WILLIAM R. CAVE 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 31st day of May, 1991. APPENDIX TO RECOMMENDED ORDER, CASE NO. 90-7828 The following contributes my specific rulings pursuant to Section 120- 59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties in this case. Rulings on Proposed Finding of Fact Submitted by the Petitioner 1. Adopted in Finding of Fact 1. 2. Adopted in Findings of Fact 1 and 2. 3.-4. Adopted in Findings of Fact 3 and 4, respectively. 5.-6. Adopted in Finding of Fact 4 and 5. 7.-8. Adopted in Finding of Fact 5. 9. Adopted in Findings of Fact 6 and 7. 10. Adopted in Finding of Fact 7. 11.-12. Rejected as not being supported by substantial competent evidence in the record, but even if this testimony was credible it is not material or relevant to the conclusion reached. Adopted in Finding of Fact 8, as modified. Rejected as not being supported by substantial competent evidence in the record, but even if this testimony was credible it is not material or relevant to the conclusion reached. Rejected as not being supported by substantial competent evidence in the record. Adopted in Finding of Fact 8, as modified. Rejected as not being supported by substantial competent evidence in the record. 18.-20. Adopted in Finding of Fact 9 and 12, as modified. Adopted in substance in Findings of Fact 9 and 12. Rejected as not being supported by substantial competent evidence in the record. See Findings of Fact 10, 11, 13 and 14. Adopted in Finding of Fact 11. Rejected as not being supported by substantial competent evidence in the record. 25.-27. Adopted in Findings of Fact 3, 15 and 15, respectively. Paragraph 28 is ambiguous and, therefore, no response. Rejected as not being Finding of Fact but what weight is to be given to that testimony. Rulings on Proposed Findings of Fact Submitted by the Respondent 1.-2. Rejected as being argument rather than a Finding of Fact, but if considered a Finding of Fact since there was other evidence presented by other witnesses. The first sentence is rejected as not being supported by substantial competent evidence. The balance of paragraph 3 is neither material nor relevant. Neither material nor relevant, but see Findings of Fact 6, 7, and 8. Rejected as not being supported by substantial competent evidence in the record, but see Findings of Fact 6, 7, and 8. Neither material nor relevant since the Respondent assisted in selecting those items to be included in Respondent's exhibit 1. First sentence adopted in Finding of Fact 8. The balance of paragraph 7 is argument more so than a Finding of Fact, but see Findings of Fact 12 and 14. More of an argument than a Finding of Fact, but see Findings of Fact 7(c), 12 and 14. 9.-11. More of an argument as to the credibility of a witness rather than a Finding of Fact. More of an argument than a Finding of Fact but see Findings of Fact 7(d) and 13. More of a restatement of testimony than a Finding of Fact, but see Findings of Fact 8 and 9. More of an argument than a Finding of Fact, but see Finding of Fact 10. More of an argument than a Finding of Fact, but see Findings of Fact 7(e) and 9. Not necessary to the conclusions reached in the Recommended Order. 17.-19. Rejected as not being supported by substantial competent evidence in the record, but see Findings of Fact 9 and 12. 20. More of an argument as to the credibility of a witness rather than a Finding of Fact. 21.-23. More of an argument than a Finding of Fact. COPIES FURNISHED: Lois B. Lepp, Esquire Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, FL 32399 Teresa Iva Smith Lobato 6870 38th Avenue North St. Petersburg, FL 33710 Judie Ritter, Executive Director Board of Nursing 504 Daniel Building 111 East Coastliinne Drive Jacksonville, FL 32202 Jack McRay, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792
Findings Of Fact The Respondent, Bonnie Jean Hutcheson, is a licensed practical nurse, who holds License No. 19002-1. In June and July of 1978, the Respondent was employed at The Abbey Nursing Home in St. Petersburg, Florida. On July 4, 1978, the Respondent was terminated from her employment at The Abbey Nursing Home by the Director of Nursing. Respondent Hutcheson was employed as a licensed practical nurse at North Horizon Convalorium in St. Petersburg, Florida in April, 1979. On February 16, 1979, an Administrative Complaint was filed alleging that Respondent Hutcheson was guilty of unprofessional conduct. The Respondent requested an administrative hearing in May of 1979, and a hearing was scheduled for July 25, 1979, but was continued by Motion of the Petitioner. Thereafter, the Administrative Complaint was amended on August 12, 1979, to add additional charges. On June 17, 23 and 24, 1978, while employed at The Abbey, Respondent Hutcheson signed out for Dalmane, a controlled substance, for a patient, Josephine Miracky, and failed to chart the administration of same on the patient's medication record. On July 2, 1978, Respondent reported to work at The Abbey for the 3:00 p.m. to 11:00 p.m. shift. Alice Henderson, a registered nurse who was going off duty at 3:00 p.m., noticed the Respondent and reported to the nursing office that Respondent's speech seemed slurred, that she seemed unsteady on her feet and slow to respond, and that she had counted medications very slowly. On July 4, 1978, the Director of Nursing terminated the employment of Respondent Hutcheson for the reason that she felt the Respondent's performance was unsafe as a practitioner. In April of 1979, while employed at North Horizon Convalarium, Respondent Hutcheson signed out for Tylenol No. 3, a narcotic and controlled substance, at an interval of one hour for a patient, Emma Jackson, when the physician's order for this medication was that it be administered no more frequently than every four (4) hours. On three (3) or four (4) occasions during the month of April, 1979, the Respondent took from the patients' medication stock three (3) or four (4) Tylenol No. 3 tablets and left the facility with them to give to her son at home. Respondent Hutcheson did not deny the allegations in the Administrative Complaint. In defense of her actions she testified that she knew Alice Anderson, the witness for Petitioner, but that she had not worked with her and did not work with her on the same shift. (Ms. Anderson's report is contained in Paragraph 2) Respondent Hutcheson acknowledged that she knew Eris J. Frye, the Director of Nursing at The Abbey Nursing Home, and admitted that she might have made a "common error" by failing in June of 1978, to chart medication on a patient's medication record. She did not know she had been terminated as "an unsafe practitioner." Respondent Hutcheson recalled the day of July 2, 1978, when she came to work, and she stated she had developed a back problem, having a chronic type of arthritis. She stated that she had taken a pain medication prescribed for her by her physician, Dr. Spatapora, which was a medication called Anexsia-D. Respondent stated that at that time she had just learned that her daughter, who was fifteen (15) years of age and unmarried, was pregnant, and that she in fact was exceedingly disturbed over her daughter's condition and could not sleep, and had taken the medication prescribed for her by her physician. She said she had not taken any of the medication at work, but that she was so over-whelmed by her problems she was ready to resign her position at The Abbey at the time she was terminated on July 4, 1978. Respondent Hutcheson stated that in April of 1979, while working at North Horizon Convalarium, she took several tablets of Tylenol No. 3 from the medication supplies to give to her son, who had recently come out of the hospital after having been seriously injured in an automobile accident. She testified that her son was in a great deal of pain, that she had to leave him alone in the house, and that she used the tablets to help him get to sleep for a few nights because she could not get in touch with his physician and could not afford to take him to another physician. She said her son used the nine (9) to eleven (11) tablets only, and was not and is not addicted to drugs. Respondent Hutcheson is not addicted to drugs. Witnesses for the Petitioner Board stated that it was contrary to acceptable and prevailing nursing practice for the Respondent to fail to accurately chart all medications signed out by her, and that it is contrary to acceptable and prevailing nursing practice to take Tylenol No. 3 tablets from the patients' medication supplies. Witnesses for the Respondent testified that she is a good neighbor and a hard-working, conscientious nurse, and that she is a devoted mother to her son and daughter. They stated Respondent is divorced and has the responsibility for her children. Petitioner and Respondent submitted proposed findings of fact and recommended orders. These instruments were considered in the writing of this Order. To the extent the proposed findings of fact have not been adopted in, or are inconsistent with, factual findings in this Order they have been specifically rejected as being irrelevant or not having been supported by the evidence.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer recommends that the Respondent, Bonnie Jean Hutcheson, be placed on probation for a period of two (2) years from the date hereof. DONE and ORDERED this 7th day of November, 1979, in Tallahassee, Leon County, Florida. DELPHENE C. STRICKLAND Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1107 Blackstone Building 233 East Bay Street Jacksonville, Florida 32202 Jean M. Flanagan, Esquire Gulfcoast Legal Services, Inc. 641 First Street, South Post Office Box 358 St. Petersburg, Florida 33731 Geraldine B. Johnson, R. N. Board of Nursing 111 Coastline Drive East, Suite 504 Jacksonville, Florida 32202
The Issue The issue posed for decision herein is whether or not the Respondent, based on conduct which will he set forth hereinafter in detail, engaged in acts and/conduct violative of Subsection 464.21(1)(d) and (g), Florida Statutes.
Findings Of Fact Based on my observation of the witnesses and their demeanor while testifying, the arguments of counsel, the documentary evidence received and the entire record compiled herein, the following relevant facts are found. Michael Ray Hernicz, R.N., is a licensed registered nurse who holds license No. 0985972. Additionally, the Respondent has been certified as a Certified Registered Nurse Anesthetist (CRNA) and an Advanced Registered Nurse Practitioner (APNP). By its eight-count Administrative Complaint filed March 14, 1979, the Petitioner, Florida State Board of Nursing, seeks to place on probation, suspend or revoke the Respondent's license to practice nursing based on allegations that: During the week of January 15, 1979, Respondent caused to be advertised in the DeLand Sun News, a newspaper of general circulation the opening of an office in the 4 Towns Shopping Center, Orange City, Florida, for the general practice of medicine and used in connection with his name designation, "M.D." to imply or designate himself as a medical practitioner while not licensed, in violation of Florida Statutes Sec. 458.152(a), (b) and (c). On or about February 9, 1979, in Orange City, Florida, Respondent administered medical treatment to Steven H. Gaffney which action was not within the purview of the Nurse Practice Act, Florida Statutes Chapter 464. On or about February 9, 1979, Respondent practiced medicine as defined by Florida Statutes Sec. 458.13, in that he diagnosed, treated and prescribed medication for Steven Gaffney although not licensed to practice medicine in Florida and without the responsible supervisory control of a licensed physician, in violation of Chapter 453 and the Nurse Practices Act, Chapter 464, Florida Statutes. On or about February 16, 1979, Respondent was arrested by law enforcement officers of the Volusia County Narcotics Task Force at his office in Orange City, Florida, and was found to be in unlawful possession of controlled substances as set forth in Florida Statutes Chapter 893. On or about February, 1979, Respondent, for a fee, treated and prescribed medication for patient, Gladys M. Mossman, which treatments and medications were not prescribed or authorized by a person licensed to practice medicine in Florida. Respondent, for a fee, also treated and administered medications to cardiac patient, Nils Ljunberg, which treatment and medications were not prescribed or authorized by a person licensed in the State to prescribe medications or treatment, in violations of Florida Statutes Chapters 458 and 464. On numerous occasions from January 15, 1979, through February 9, 1979, Respondent unlawfully practiced medicine in violation of Chapter 458 by prescribing medications for various patients and treating said patients when he was not licensed to do so and while he was not acting under the responsible supervisory control of a licensed physician or without the purview of the Nurse Practices Act, Florida Statutes Chapter 464. In conclusory fashion, it is alleged that the Respondent is therefore guilty of engaging in the possession of controlled substances as set forth in Chapter 893, Florida Statutes, in violation of Florida Statutes 464.21(1)(d) and (g). The facts surrounding the allegations in the Administrative Complaint filed herein are not in dispute. What is in dispute, however, is the nature and scope of treatment authorized by nurse practitioners, such as Respondent, in view of the additional acts apparently approved by the Joint Advisory Committee on Advanced Nursing Practices. Section 464.021, Florida Statutes. Respecting the allegations that the Respondent caused to be advertised in the DeLand Sun News, an advertisement to the effect that he was opening an office for the general practice of medicine, Steve Blais, an advertising official of the Deland Sun News, appeared and testified that the day following the advertisement which appeared in the local paper, Respondent telephoned his office to alert the paper's advertising staff that a mistake had been made and that the initials "M.D." should not have followed the designation in his ad as he was not a licensed medical doctor in Florida. Mr. Steve Blais offered Respondent a letter of correction such that he could show to customers or anyone who needed documentation. Mr. Blais testified that the ad with the M.D. format ran on January 13, 14 and 17, and that the change was made on or about January 24 to delete the designation "M.D." from the ad. As stated, the facts surrounding the treatment aspect of the allegations are undisputed. However, Respondent contends that based on the supervisory arrangements and the written protocol that he had with Dr. Randal Whitney, M.D., and the working relationship that he had with Dr. Jeffrey Rudell, he was authorized to do the acts which he is here charged with as being violative of the Nurse Practice Act and Chapters 458 and 893, Florida Statutes. As originally conceived, the Respondent planned to practice with Dr. Jeffrey Rudell, who was then licensed in Alabama and who had applied for licensure by endorsement in Florida. This application by Dr. Rudell for licensure by endorsement was denied and Respondent entered into a supervisory relationship with Dr. Randal Whitney of Daytona Beach, Florida. Dr. Whitney appeared and testified that he had in fact entered into a supervisory relationship with Respondent and that he was consulted by Respondent on the treatment of several patients. Dr. Whitney's testimony is that of these patients about when Respondent consulted with him, he concurred with the method of treatment outlined and/or prescribed by Respondent. Respondent testified that he reached a decision that he could properly treat patients while working under the supervision and control of a licensed medical doctor or other specialized practitioner after considerable reflection on the latitude granted Advanced Registered Nurse Practitioners. In support of this decision, Respondent points to the fact that the Joint Committee, by its official Minutes, pointed out in Section 210-11.03, acts which were proper to be performed by an Advanced Registered Nurse Practitioner. Therein, the Board authorized various categories of functions that Advanced Registered Nurse Practitioners may perform at advanced and special levels which are recognized by the nursing profession and which are currently included in the curricula of advanced nursing education programs by the Board (Petitioner). Additionally, the Board authorized Advanced Registered Nurse Practitioners to perform such additional acts as was recognized by the Advisory Committee created by Florida Statutes Subsection 464.021(2)(a)(4) as proper to be performed by an Advanced Registered Nurse Practitioner. Petitioner requested the minutes from numerous meetings of the Board from 1977 through 1978 and noted that Board Member Charles D. MacIntosh during a meeting with the Board of Nursing advised that the Board of Medical Examiners had met on April 2, 1978, and ratified a new appendix D regarding Advanced Registered Nurse Practitioners. Dr. MacIntosh urged the Board that in light of the ratification by the Board of Medical Examiners, the Joint Advisory Committee should jointly meet to work out a proposed formulary of drugs that would he available to Advanced Registered Nurse Practitioners. The Board thanked Dr. MacIntosh for apprising them of the medical board's actions and Petitioner's counsel stated his opinion that, based upon the interpretations of subject Section 465.031, no conflict would result if the Joint Advisory Committee agreed that prescriptions and medications would be an additional act defined by Florida Statutes 464.021. Page 4 of the minutes indicate that with respect to Advanced Registered Nurse Practitioners, they are authorized to perform those additional acts which are performed within protocols which are jointly established by the Advanced Registered Nurse Practitioner and the M.D., D.O., or D.D.S., or the appropriate medical staff of a healthcare facility. Respondent entered into an arrangement with Dr. Whitney and explained to him the manner in which he expected to treat patients coming to his office and Dr. Whitney agreed to allow him the latitude he envisioned. (TR 259 through 261.) Accordingly, Respondent perceived his actions as falling within the purview of the regulation authorized by the joint committee. (TR 263 through 264.) Additionally, Respondent denied that he represented to anyone in this State that he was a licensed medical doctor. Respondent reiterated his position that he immediately notified the paper and asked them to change the designation to reflect that he was not a medical doctor. (Respondent's Exhibit 17.) On February 16, 1979, Respondent's office was searched by the law enforcement officers of Volusia County Narcotics Task Force in Orange City, Florida, and Respondent was given a list of drugs taken from his office by the law enforcement officers. (Petitioner's Exhibit 5.) No evidence was offered to establish that the Respondent has been found guilty of the unlawful possession of controlled substances as set forth and defined in Florida Statutes Chapter 893.
Conclusions In summation, the Respondent established that he, in addition to being a Registered Nurse, has been further certified as an Advanced Registered Nurse Anesthetist. Dr. Randal Whitney established that he entered a relationship with Respondent under the laws of the State of Florida to be his supervisory or sponsoring physician, to consult with him in the practice, and to call or talk personally with Respondent about problems or cases that might be a potential problem or possibly outside his field of expertise as to what to do about them. A similar arrangement was shown to exist between the Respondent and Dr. Paul Andrews, Additionally, Dr. Rene Almiron, M.D., testified that he agreed to read and interpret EKG's for Respondent. Subsection 464.021(2)(a), Florida Statutes, provides that performance of assessment, diagnosis, counselling and health teaching of the ill are within the definition of professional nursing. It thus appears that all of the acts and/or conduct engaged in by Respondent were permissible acts within the responsible supervisory control of Dr. Randal Whitney or were for medications within the approved formulary for Advanced Registered Nurse Practitioners. Respondent credibly testified that he consulted with Dr. Whitney, who supervised him in the treatment of all of his patients. (TR 261.) Finally, although it was alleged in Count IV of the Administrative Complaint that Respondent was found to be in the unlawful possession of controlled substances in violation of Florida Statutes Chapter 893, the Respondent denies this, and no evidence was offered by Petitioner to counter Respondent's assertion. The record herein reflects that while some of Respondent's acts and/or practices may have been questionable based on the conflicting directions embarked upon by the various joint committees, in view of the latitude granted to Advanced Registered Nurse Practitioners by the Nurse Practices Act and the established working relationship entered into between Respondent and Dr. Randal Whitney, the undersigned concludes that Respondent acted within his authority in his treatment of patients referred to herein. I shall so recommend.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is hereby, RECOMMENDED: That the Administrative Complaint filed herein be DISMISSED IN ITS ENTIRETY. RECOMMENDED this 4th day of December, 1979, in Tallahassee, Florida. JAMES E. BRADWELL, Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675
The Issue The issue is whether Respondent's license to practice nursing should be revoked, suspended, or otherwise disciplined under the facts and circumstances of this case.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made: At all times material to this proceeding, Respondent Rita Flint (Flint) was a licensed practical nurse in the State of Florida, holding license number PN0655201. Flint's last known address is 6494 South West 8th Place, North Lauderdale, Florida 33068. At all times material to this proceeding Flint was employed by North Broward Medical Center (NBMC) located in Pompano Beach, Florida, as a practical nurse. On August 3, 1990, Flint was assigned to care for patients J. C. and J. K. including administering their medications and charting same on their Medication Administration Record (MAR). On August 3, 1990, J. C.'s physician prescribed one (1) nitroglycerine patch each day. Flint failed to administer the patch on this date. On August 3, 1990, J. C.'s physician prescribed 100 mg. of Norpace every six (6) hours. Flint failed to administer the 2:00 p.m. dosage of Norpace to J. C. On August 3, 1990, J. C.'s physician prescribed 120 mg. of Inderal each day. Flint failed to administer the 9:00 a.m. dosage of Inderal until 1:30 p.m. without noting any explanation on J. C.'s MAR. On August 3, 1990, Flint failed to document the administration of J. K's own medications on the MAR. On August 3, 1990, Flint failed to sign the MARs for J. C. and J. K. as required by hospital policy. On August 15, 1990, Flint left an intravenous bag with an exposed needle hanging at the bedside of a patient. On August 29, 1990, Flint was assigned to care for patient R. R. including administering his medications. Flint failed to administer the following medications leaving all of them at R. R.'s bedside: (a) Timolo (9:00 a.m. and 2:00 p.m. doses); (b) Mixide (9:00 a.m. dose); (c) Zantac (9:00 a.m. and 4:00 p.m. doses); (d) Lasix (9:00 a.m. dose); and, (e) Entozyme (8:00 a.m. and 12:00 noon doses). On August 30, 1990, NBMC terminated Flint's employment as a result of the aforementioned conduct. There is no evidence that any patient suffered any actual harm as a result of Flint's errors. In September of 1990, NBMC referred Flint to the Intervention Project for Nurses. At all times relevant to this proceeding, Flint's job performance was adversely affected by long work schedules necessitated by severe financial problems. During the week of August 3, 1990, Flint worked a ninety-two-hour week. The acute financial stress was due to domestic problems including the breakup of her twenty-two-year-old marriage. Flint had no problems involving substance abuse. Flint attended individual therapy sessions with a clinical psychologist, Priscilla Marotta, Ph.D., and participated in group therapy designed primarily for persons with substance abuse problems. Flint attended weekly therapy sessions for approximately one month after which she could no longer afford treatment. Even though Flint was financially unable to continue treatment with Dr. Marotta or any other counseling program recommended by the Intervention Program for Nurses, she diligently undertook a self-help program to educate herself on stress management techniques, to develop self-reliance, and to improve self-esteem. Flint's effort to participate in therapy, to the extent financially possible, and to rehabilitate herself shows a strong commitment to her profession. Flint has been licensed to practice nursing since May 31, 1982. There is no evidence of any disciplinary action against her license prior to or after the incidents herein described. Flint is currently employed as a nurse in a hospice. Her recent performance appraisal reports indicate that, on an average, she fully meets all job requirements.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore recommended that the Board of Nursing enter a Final Order finding Respondent guilty of violating Section 464.018(h), Florida Statutes (1989), as defined in Rule 210-10.005(1)(e)1 and Rule 210-10.005(1)(e)2, Florida Administrative Code, and not guilty of violating Section 464.018(1)(j), Florida Statutes. It is further recommended that the Board's final order: (1) place the Respondent on probation for one year subject to such requirements as the Board may require; and (2) require the Respondent to pay an administrative fine in the amount of two hundred fifty dollars ($250). DONE AND ENTERED in Tallahassee, Leon County, Florida, this 21st day of November 1994. SUZANNE F. HOOD, Hearing Officer Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 21st day of November 1994. APPENDIX TO RECOMMENDED ORDER IN CASE NO. 93-2715 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case. FOR THE PETITIONER: Incorporated into Findings of Fact 1. Incorporated into Findings of Fact 2 and 11. Incorporated into Findings of Fact 4. Incorporated into Findings of Fact 5. Incorporated into Findings of Fact 6. Incorporated into Findings of Fact 7. Incorporated into Findings of Fact 8. Incorporated into Findings of Fact 9. Incorporated into Findings of Fact 10. The first sentence is incorporated into Findings of Fact 13. The remaining portion of this proposed fact is not supported by competent substantial evidence. Furthermore, Respondent's Exhibit 3, as it relates to a diagnosis of a mental condition, is hearsay which does not supplement or explain any other psychological or medical evidence. Thus, any reference in Exhibit R3 to a generalized anxiety disorder is insufficient to support Petitioner's proposed finding. Unsupported by competent substantial evidence. Unsupported by competent substantial evidence. See number 10 above. FOR THE RESPONDENT: 1. Respondent did file proposed findings of fact or conclusions of law. COPIES FURNISHED: Laura Gaffney, Esquire Natalie Duguid, Esquire Agency for Health Care Administration 1940 North Monroe Street Tallahassee, Florida 32399-0792 Rita Flint 3313 South East Second Street Pompano, Florida 33063 Judie Ritter Executive Director Board of Nursing AHCA 504 Daniel Building 111 East Coastline Drive Jacksonville, Florida 32202 Harold D. Lewis General Counsel The Atrium, Suite 301 325 John Knox Road Tallahassee, Florida 32303
Findings Of Fact Petitioner became a Registered Nurse in 1965 and has been engaged in the nursing profession since that time. She was awarded a Bachelor of Science in nursing in 1975 from Florida International University and is presently enrolled in the masters of nursing degree program at the University of Miami. In 1973 Petitioner enrolled in the Primary Care Nurse Practitioner program at the University of Miami and successfully completed the six months program in December 1973. During this program she received 1,000 hours training. Upon completion of this training, Petitioner was eligible for licensure as an Advanced Nurse Practitioner but did not apply for registration at that time although she worked as a Nurse Practitioner immediately upon completion of the training. From January 1974 to March 1977 Petitioner worked at Jackson Memorial Hospital at Miami as an Advanced Family Nurse Practitioner. During this period she received actual instruction of approximately one hour per day for a total of some 710 hours in duties of Nurse Practitioner in addition to the daily experience gained working as a Nurse Practitioner. In 1977 Petitioner moved to Colorado where she worked as a Nurse Practitioner from October 1977 until April 1978 for the Rocky Mountain Planned Parenthood organization and the Mountain Community Medical Clinic. In the latter position she manned a clinic that was some 30 to 40 miles from the nearest doctor and communicated with the doctor by telephone in diagnosing and treating patients. She worked some 348 hours in this position. Additionally, Petitioner taught in the Nurse Practitioner program at the University of Colorado one to three days per week from January until May 1978. Upon Petitioner's return to Florida in May 1978 she applied for licensure as an Advanced Nurse Practitioner and was denied licensure because the regulations were changed effective March 31, 1978, to require a one-year educational training program in lieu of the six months program completed by Petitioner. The current approved program at the University of Miami provides some 1,105 hours of training similar to the training Petitioner obtained at the earlier course.
Findings Of Fact At all times pertinent to the issues herein, Respondent, Thelma L. Jones, was licensed as a Licensed Practical Nurse in Florida, holding license number PN 0704471, and Petitioner was the agency responsible for licensing nurses in Florida. On June 2, 1986, Respondent was employed as a LPN by the Glades Health Care Center in Pahokee, Florida, as nurse on the 3-11 p.m. shift. She was assigned to the West Wing of the facility, and was assisted by at least two nursing assistants. Kathy Davis, another LPN, was assigned to the East Wing of the facility with her assistants, and in that location, though not officially identified as such, was the charge nurse for the entire facility. Though licensed as a 120 bed skilled nursing home, GHCC somewhat resembles an acute care facility, since the least seriously ill patient is normally more severely affected than those in most nursing homes. The patient census at that facility at the time was between 45-60 patients, total, in both wings. The facility is a one-story building with the two parallel nursing wings separated by a corridor. While possible, it would be extremely difficult for one nurse to service both wings. At approximately 3:50 p.m., on June 2, 1986, Respondent clocked in for work at the facility, approximately 50 minutes late. She immediately went to the West Wing, where she told Ms. Davis she was quitting and delivered to her the letter of resignation she had prepared that same day. Ms. Jones then returned to her duty station and attempted to contact the Director of Nursing, Mr. Gooley by phone, but was unable to do so. She then went out on the floor and spoke with some of the patients with whom she was most friendly, telling them she was leaving, but assuring them they would be taken care of. She returned to her station and again tried to contact Mr. Gooley by phone without success. After passing out some medications and making the required entries on some medical records, and after making a count of the narcotics as required, but without making an official record of it, she went back to Ms. Davis and told her she could not reach Mr. Gooley. Ms. Jones states that Ms. Davis replied, "Don't worry about it. I'll call him." After going back to the West Wing to collect her belongings, Ms. Jones then went to the front exit, where, over the television security monitor, she again spoke to Ms. Davis, who, for the second time, allegedly said she'd call Mr. Gooley. At this point, Ms. Jones saw a wandering resident trying to run away from the facility. She caught him and turned him over to a nursing assistant and for the third time, called Ms. Davis, who advised her she had reached Mr. Gooley and he was on his way in. Ms. Davis reportedly told Ms. Jones there was no reason she should stay. According to her time clock records, Ms. Jones punched out at approximately 5:40 p.m. She contends, however, she did not leave immediately, but stayed at least an hour after punching out. Mr. Gooley, on the other hand, indicated he arrived at the facility, pursuant to Ms. Davis' call, at approximately 5:50, and though he walked through the whole facility, failed to see Ms. Jones. It is found, therefore, that Ms. Jones left prior to the arrival of Mr. Gooley. After his walk through the facility, Mr. Gooley asked Ms. Davis where Respondent was, at which point, Ms. Davis handed him Respondent's letter of resignation and the key to the narcotics cart on the East Wing. Mr. Gooley immediately went to that wing, where he counted the narcotics with Ms. Davis present. He checked other records and determined that certain medications due to be dispensed at 5:00 p.m. by the Respondent, had apparently not been dispensed. Ms. Jones strongly contends that no patient due medicines failed to receive them prior to her departure and that she noted this in at least one record in each file. She admits, however, and it is so found, that she did not complete all records necessary prior to her departure. To ensure the East Wing was properly covered after Respondent's departure, Mr. Gooley remained on duty until relieved at the 11:00 p.m. shift change. Ms. Jones asserts her departure was justified and was not without authority. She had had some previous discussion with Mr. Gooley about the proposed change in working hours to require 12 hour, 8:00 a.m. to 8:00 p.m., shifts. Since her husband went to work at 4:00 a.m. and she had two children to care for, she advised him she could not work those hours. He insisted that she do so, however. On the day before she left, when she came to work, she again spoke with Mr. Gooley about the problem and he is reported to have advised her that her family was of no importance to him and she had to work the new hours. Mr. Gooley denies this. That same day, Respondent's husband told her he was being transferred to Leesburg and she could go up there with him to work. Whether or not the aforementioned colloquy took place is immaterial. Investigation by DPR reveals Ms. Jones did not leave Clewiston right away after she left her position with GHCC, but remained in town for several days. She returned to Clewiston after staying in Leesburg for only a week or so. When hired, each employee of GHCC is given a handbook which contains the facility's policy on resignation. This policy calls for two weeks notice to be given, in the case of nurses, to the Director of Nursing. Ms. Jones failed to give two weeks notice either orally or in writing. Respondent also contends that since Ms. Davis was the nurse in charge, she had authority to release Ms. Jones when Ms. Jones decided to quit. Mr. Gooley contends, and his contention is well taken, that though the East Wing nurse held the more senior position of the two, and had authority to answer the phone, call for fire support, and perform other routine tasks, her authority did not include receiving and approving letters of resignation. Ms. Jones also contends that by notifying Ms. Davis of her intent to leave at least an hour before delivering the letter of resignation, she gave ample notice. She asserts that because the State's staffing rules were not violated by her departure, and because Ms. Davis had her own aides as well as Respondent's after she left, no harm was done by her leaving. She had previously handled the whole facility by herself with only aides, even to the extent of passing medications. When she left, though it was during a shift, she was satisfied that everything that needed to be done was done and that Ms. Davis could handle anything that came up. Mr. Gooley, on the other hand, is of the opinion that her leaving without authority; her departure without dispensing medications; and her failure to sign off on the narcotics register, itself a violation, is not consistent with the fundamental standards of proper nursing practice in Florida. Though one nurse, plus aides, may meet the State staffing requirements, in his opinion, one nurse cannot, in light of the physical layout of this facility, handle all patients in both wings. To leave only one licensed nurse in charge of the whole facility could endanger the patients. For the past two years or so, Respondent has served as the nurse in charge of the medical facility at the Palm Beach County Jail, where she has been observed on a daily basis by Lieutenant William Arthur, under whose administrative supervision she falls. He is most pleased with her work and believes that due to her efforts, the facility has received clean inspection reports since she began working there. This is unusual for jail medical facilities. He has found her to be very conscientious in her work, and an employee who anticipates problems, solving them before they grow out of hand.
