Findings Of Fact At all times pertinent to the issues herein, the Petitioner, Board of Nursing, was the state agency in Florida responsible for the licensing of registered nurses and the regulation of the nursing profession in this state. Respondent, Maria S. Melegrito was licensed as a registered nurse under license number RN 1138222. During the month of March, 1992, L.B. was a patient at HCA New Port Richey Hospital suffering from congestive heart failure and a decubitus ulcer on his coccyx. He was in and out of the hospital frequently during the month. During this period, Respondent called Mrs. B. on the phone and solicited being hired to care for him at home when he was released from the hospital. Respondent is alleged to have indicated she was L.B.'s favorite nurse. At first Mrs. B. declined, but on or about March 12, 1992, K.B., the patient's wife, after checking on Respondent's credentials with her husband's physician, contracted with the Respondent to provide home health care to L.B. upon his discharge from the hospital. The arrangements were made through Maximum Care, Inc., a home health nursing agency of which Respondent was a cofounder. In a telephone conversation with K.B. on March 12, 1992, the day prior to L.B.'s discharge from the hospital, Respondent assured K.B. that Respondent would supply cardiac trained registered nurses around the clock to care for L.B. K.B. understood from this conversation that a cardiac trained registered nurse would be waiting at the patient's home when he arrived there after discharge. No contract was signed between Respondent and L.B., his wife, or their daughters. That same day, March 12, 1992, Respondent, in a conversation with B.C., one of L.B.'s daughters, indicated that Respondent would be taking care of the patient; that she would relieve the family members of their responsibilities in caring for him. Respondent indicated she was a cardiac care specialist and that she would be present at the patient's home the following days, with all necessary medical equipment, when the patient arrived from the hospital. B.C. also understood Respondent to represent that she would provide certified nursing assistants, (CNA's), and that she was familiar with the patient's condition because she had been his personal nurse while he was in the hospital. In a conversation with G.P., the patient's other daughter, Respondent said she would provide private nurses around the clock; that home health aides and CNA's would be present to assist the family in caring for the patient; and that Respondent would personally be present at the home with the necessary oxygen equipment to greet the patient upon his arrival from the hospital. According to hospital records, L.B. was discharged to the care of his wife, K.B., and his daughter, B.C., at 10:20 AM on March 13, 1992, and the evidence indicates that the discharge form was signed by K.B. The party arrived at the home shortly thereafter, but Respondent was not present there when the party, including the patient, arrived. By the same token, the oxygen ordered by the patient's physician also was not there. Shortly after the patient and his family arrived home, Ms. B and one daughter went to the drug store. When they came back, they were met outside by K.B.'s grandson who kept K.B. outside while the daughter went in. It appears that while they were gone, L.B. suffered a cardiac episode. His daughter, B.C., laid him on the floor so that he would not aspirate his vomitus, but he appeared to have no pulse, no audible heartbeat, was not breathing, and appeared to turn blue from lack of oxygen. One of the family members attempted to contact the Respondent but was unable to do so. Finally, the family called the patient's physician who in turn called the oxygen supply house and directed that oxygen be delivered to the patient's home. Though the discharge form reflects the physician ordered oxygen for the patient, no evidence was presented as to who was to arrange for it. At approximately 1:00 PM the same day, Respondent contacted the family indicating she would "be right there." When family members told Respondent the patient had suffered a cardiac episode, she instructed them to leave him on the floor. Notwithstanding her promise to be right there, Respondent, according to the family, did not arrive at the patient's home until sometime after 3:00 PM. When she arrived she did not have with her oxygen, a stethoscope or a blood pressure cuff. Using the equipment owned by C.P., the patient's other daughter, also a nurse, Respondent took the patient's blood pressure while he was laying prone on the floor. She found it to be 60 over 40. Respondent tells a different story. While not disputing the allegation of her pre-need solicitation of the patient's family for her services, she contends that she was not advised of the immediate need for them until she received a call from one of the daughters at approximately 12:30 PM on March 13, 1992, indicating that the patient was to be discharged. She claims she immediately asked if there was anything needed for the patient's care and was told all was taken care of. She also claims she was told the patient would be at his home within 10 to 15 minutes. On cross examination, Respondent indicated the verbal agreement she had with the patient's wife called for her to be called when the patient got home and she would come, assess the patient and then decide if she or her firm could provide the services required. It is her contention that her initial visit to the patient's home on March 13, 1992 was for the purpose of rendering a patient assessment, and she ended up staying for five hours until she could arrange for follow-on nursing care to be present. This assertion is rejected, however. She had already indicated she knew the patient and was his favorite nurse in the hospital. She would have already been familiar with his condition. Ms. Melegrito further claims she arrived at the patient's house at 1:25 PM to find the patient on the floor with a blood pressure cuff on his arm and oxygen being supplied. Respondent claims it is usually the discharge nurse or the social worker who makes the arrangements for oxygen to be delivered to the patient's home, and it was not her responsibility to do so. There was no direct evidence to contradict this assertion, but it was the physician who ultimately arranged for the delivery of the oxygen. 11 Notwithstanding the allegation that the Respondent did not arrive until after 3:00 PM, the initial visit nursing notes, dated March 13, 1992, reflect in one place she arrived at 2:00 PM; in another place, that she arrived at 1:24 PM; and in a third place that she arrived at 3:00 PM. In its totality, the best evidence suggests that Respondent arrived sometime between 1:00 and 3:00 PM, neither as late as the family claims nor as early as she claims. There is some substantial question as to whether Respondent performed a proper initial assessment of the patient or devised a care plan for him when she arrived. An initial visit nursing note, prepared by the Respondent and bearing date of March 13, 1992, lists the patient's temperature, his pulse rate and his blood pressure. It also discusses a history of the patient's condition and certain initial observations of him. The second page of the form indicates that certain items were covered including a description of the patient's grip, his cardio-pulmonary status, the condition of his skin, his abdomen, ENT status and comments regarding his diet and genito-urinary status. The third page of the form described the patient as being fearful, anxious, restless, confused and disoriented, suffering from headaches, vertigo and blackout spells. He is described as having irregular breath with pale, dry, pallid skin, dry mouth and several difficulties in the cardio-vascular area. The body drawing on the form reflects he has an open bed sore at the base of the spine, and the intervention portion of the form indicates that the patient was found on the floor upon the Respondent's arrival, unconscious. His pressure was down and there was no palpable pulse. Patient was cyanotic and had appeared to have suffered another syncope syndrome. Nonetheless, Respondent noted that the patient's vital signs came back enough for him to regain consciousness, but notwithstanding, he was in the terminal stage of a cardiac condition and the instructions given by the family were not to resuscitate him in the event he should again reach the stage of unconsciousness. The parties agree that the Respondent gave the patient a sponge bath even though, at the time, he may not have been soiled. The family claims he was clean, but Respondent contends she bathed the patient to clean fecal material, urine and sweat from him and the bed clothes. Notwithstanding the Respondent's notation that the patient was confused or disoriented, neither his wife nor his two daughters considered him to be so, and after the patient was placed back in bed and cleaned up, according to the family members, Respondent spent the remainder of the afternoon at the patient's home on the telephone, trying to find a nurse to cover the next shift. Initially, she was unable to do so, and B.C. claims Respondent approached her to work as an aide and deliver patient care to her father. B.C. refused to do so. Respondent admits to a discussion with B.C. about hiring her to care for the patient but claims the discussion was in response to a question by the daughter, not a solicitation by Respondent. Respondent was apparently successful in securing a relief nurse because she was relieved at 5:00 PM by Dorothy Reisebeck, a licensed practical nurse, (LPN), who was not a trained cardiac nurse. According to Ms. Riesebeck she had been told by Respondent that the patient had been discharged from the hospital after minor surgery, and that she, Riesebeck, need only monitor him, check his oxygen, and make him comfortable. Notwithstanding Respondent's claim that she prepared an assessment of the patient and gave an adequate report to her relief, Ms. Riesebeck claims that Respondent failed to provide her with a care plan, an assessment sheet for the patient, or a list of the patient's medications and proper dosages. She also indicates Respondent did not inform her that the patient was suffering from congestive heart failure and was terminally ill. When fully advised of the patient's true condition, Ms. Riesebeck did not feel adequately prepared to care for him. Nonetheless, she remained on the scene until she was relieved at 7:30 the following morning. In this regard, Ms. Riesebeck claims she had been led to believe by Respondent that she would be relieved at 10:00 PM the prior evening, March 13. When she was relieved it was by another LPN, Ms. Holloway, who also had no cardiac care experience. When Ms. Holloway arrived, she also looked for the assessment sheet on the patient which should have been there, but was told by Ms. Riesebeck that one did not exist. They tried without success to contact Respondent and while Ms. Riesebeck and Ms. Holloway were on the scene, the patient suffered another acute cardiac episode. The family understood that since Ms. Holloway, who arrived at 7:30 AM, had worked all the previous night at the hospital, she would be there for only three or four hours until relieved by someone that Respondent had found to do so. Her shift was to end at 11:00 AM, but she was not relieved until Respondent appeared at 3:00 PM on March 14, 1992. Respondent's arrival did not appear to be for the purpose of providing nursing care. She was, upon arrival, dressed in high heels, makeup, jewelry and a flowered dress. A man was waiting for her in the car outside the house, and it was obvious to everyone that Respondent was neither dressed for nor prepared to perform a shift providing care for this patient. It was clear she had no intention of staying for that purpose. Before the Respondent left, however, she began arguing with Ms. Holloway, which culminated in Ms. Holloway leaving. Respondent then began arguing with both of the patient's daughters, and attempted by telephone to find someone else to cover the shift. Respondent appeared to be very disturbed. She was screaming at people on the telephone and reacting to her conversations by slamming the receiver down. Before the Respondent had arrived that day, because they were having problems getting the patient's medications and a morphine IV set up, the family called the patient's physician and requested that the Respondent be replaced by Hospice. Someone other than the Respondent, presumably the physician, was able to contact a pharmacy which sent IV equipment and morphine, saline, and demerol solutions to the patient's home. These medications had been ordered by the physician for the patient's pain after he was called by the patient's daughter. Respondent was present when the pharmacy order arrived and requested that the delivery person set up the IV. That individual refused, however, indicating she was not authorized to do so by the physician. Consistent with the family's request, somewhat later a representative of Hospice arrived, and upon the arrival of that individual, the patient's wife discharged the Respondent. With this, the Respondent became very angry and began screaming, banging on the table and slamming things around. All of this served to disturb and upset the patient. Because of this, it was necessary for family members to calm him down. After the argument with the family, Respondent took the bag containing the patient's medications, the medication record kept by the patient's wife over the prior year, and the patient's hospital prescriptions, and told one of the daughters that the medications were hers because she had paid for them. Respondent then departed the home with the gentleman in the car. The daughter called the police and reported the theft. Respondent did not return the morphine, the saline solution and a bottle of 100 Valium tablets. Ms. Sangster, A Registered Nurse Practitioner for 24 years, evaluated Respondent's performance in this matter for the Department. According to her, a home health nurse is supposed to go into the patient's home and assess his physical status to see what care is needed at home and to assess the ability of the nurse to provide those needs. This function also includes working with the patient's family and to help them in understanding the care required so that family members can administer medications when the nurse is not present. Ordinarily, patients retain a home health agency which has an arrangement with the hospital, on referral by a physician, or directly. Before the patient is discharged the agency should have contacted the patient, and upon discharge an agency representative should go to the patient's home as quickly as possible to meet with the patient and the family. The home health agency is responsible to the family, and the nurse on duty is also responsible to provide the needed care. If the nurse sees that the needs are greater than her skills, she must notify the agency to get some with the requisite credentials. The standard of care applicable to home health nurses requires the practitioner to: Report to provide care on time. Stay with the patient as long as required. Perform all tasks assigned. Perform all tasks needed. Do a complete physical assessment of the patient at the first visit. Administer proper medications on time. Perform all procedures required. Document all activities performed. Provide necessary information to the successor shift personnel either verbally or in writing. If the assigned nurse cannot report on time or stay as long as scheduled, then the home health agency is responsible to provide a substitute. The nurse must advise the home health agency in advance and leave a report for the replacement. The nurse on duty must not leave until the replacement arrives. The initial physical assessment establishes the starting point for future patient status. It is a part of the care plan. It must be done the first time the nurse goes into the home for the initial home visit. It is usually done by a registered nurse or, if a licensed practical nurse does it, a registered nurse must evaluate and approve it. Standard practice requires that all patient contact be documented to include what services are to be provided, and entries in the record should be made when a particular service is rendered or as soon thereafter as is possible. Ms. Sangster reviewed the investigative file in this case. All nurses providing treatment to this patient under the terms of the agreement were to be registered nurses who had cardiac training. This was not what Respondent provided. In addition, the physician's order sheet indicates oxygen was to be delivered to the patient's home and that Maximum Care was to provide the home health care. It is the home health agency's responsibility to insure that what is needed for the patient's care is available if not present on the arrival of the patient. Here, in Ms. Sangster's opinion, since Respondent was the first agent of the home health agency to arrive at the patient's home, it was her responsibility to call and arrange for the oxygen to be delivered. She failed to do this. Ms. Sangster examined all the patient's records with the home health agency. Ordinarily such documents will describe the patient's condition, appearance and level of activity. Much of this information is in the records prepared by Respondent. However, Ms. Sangster found many inconsistencies in the assessment. These related to how the patient was described by two different people who observed him. Respondent describes the patient as confused and disoriented, suffering from blackouts, swollen and pale, but with a good appetite and normal urine. She does not, however, indicate how that confusion should be handled. Another individual notes that the patient activity is normal and he is alert, with normal respiration, temperature and skin, a clear chest, and can speak and hear without difficulty. The family contends the patient was neither confused or disoriented. The Respondent's assessment notes reflect the decubitus on the patient but do not indicate how it will be treated or how any anticipated problem the patient might have should be handled. The form is a three page document. Only the first page reflects the patient's name. Ms. Sangster notes that many of the "yes" or "no" blocks checked on the second page do not have explanatory comments, and it is so found. Based on her evaluation of the entire care package provided to this patient by the Respondent, Ms. Sangster concluded that Respondent's actions in this case did not meet required standards because: There was a lack of documentation to support the actions taken, and that documen- tation present was both inconsistent and incorrect. She failed to provide that care contracted for 24 hours per day, that is, care by cardiac trained registered nurses. She left the patient alone with his family, which constituted - The abandonment of the patient and his family, She failed to insure the required equipment was on hand. She did an improper and inadequate patient assessment. She failed to place the assessment she did in the patient's file. She failed to conduct herself with professionalism in her relationship with the patient and his family. She failed to address safety issues, and As a result of all the above, she placed her patient in great harm. The allegation of abandonment is of great import. Abandonment, defined as either the nurse's failure to show up on time or to leave her patient before relief, is viewed as very serious in the nursing community. The home health nurse must, if she cannot provide coverage, make sure that her agency knows her limitations. Since in this case the Respondent was at least in part owner of the agency, she had a multiple responsibility. She should have arranged for someone to be present at the patient's home when he arrived; insured the necessary oxygen equipment was present; and done an immediate assessment of the patient, while he was on the floor, and communicated the patient's status to his physician. Ms. Melegrito claims she did all that was necessary for this patient considering he was a terminal patient with a "do not resuscitate" order on record. She insists he was never neglected. The wife was briefed on the patient's medications because, Respondent claims, she wanted to administer the medications herself. Respondent got the impression that the patient's wife was resistant to her caring for the patient. Respondent claims the action taken against her is racially motivated based on the fact she is the only brown skinned person being charged. Aside from the fact there is no evidence to support this assertion, she overlooks the fact she was the most qualified person involved and her credentials placed upon her a higher standard of performance than that placed on the other two nurses. Her contention is without merit.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that Respondent, Maria C. Melegrito's license as a registered nurse in Florida be suspended for three years, following the expiration of which it be placed on probation for an additional period of three years, under such terms and conditions as may be prescribed by the Board of Nursing, and that she pay an administrative fine of $1,000. RECOMMENDED this 28th day of November, 1995, in Tallahassee, Florida. ARNOLD H. POLLOCK, 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 28th day of November, 1995. COPIES FURNISHED: Miriam S. Wilkinson, Esquire Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, Florida 32399-0792 Maria C. Melegrito Federal I.D. number 08343-018 Federal Prison Camp Pembroke Station Danbury, Connecticut 06180 Jerome W. Hoffman General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32309 Judie Ritter Executive Director Board of Nursing Daniel Building, Room 50 111 East Coastline Drive Jacksonville, Florida 32202
The Issue The issue for determination is whether Ferman Barrett committed unprofessional conduct and departed from minimal standards of acceptable nursing practice, in violation of Section 464.018(1)(f), Florida Statutes by abandoning his shift.
Findings Of Fact At all times material Ferman Barrett was licensed as a practical nurse, with State of Florida license number PN0628671. He was originally licensed by examination on December 14, 1981, and has regularly renewed' his license since then. Mr. Barrett was employed as a practical nurse at Westlake Hospital, in Longwood, Florida, from July 1987 until January 1988. Westlake is a psychiatric hospital serving individuals of all ages with complex psychiatric problems. On January 2, 1988, Mr. Barrett was assigned to the children's unit, consisting of 12-13 children with conduct disorders. He was given charge of three patients whose medication he was to maintain and whose activities he was to supervise. The children could have been combative and [illegible]. Barrett was scheduled to work a double shift on January 2, 1988 from 7:00 A.M. until 3:00 P.M., and from 3:00 P.M. until 11:00 P.M. At approximately 8:05 A.M., Barrett told Denise McCall, the charge nurse for that shift, that he "couldn't take it anymore" and was leaving. She asked him to wait until she could contact a supervisor to properly relieve him, but he left without permission. He was subsequently discharged by the hospital for abandoning his job. Diana Eftoda was qualified as an expert in the practice of nursing. She has been licensed as a registered nurse in Florida since 1978. She has 20 years experience in nursing, including beginning her nursing career as a licensed practical nurse. She has administered nursing staff of an entire hospital and has served in a policy making position with the Board of Nursing. Mrs. Eftoda established that abandonment of a shift without notice or permission is a breach of professional responsibility and constitutes misconduct. Ferman Barrett's action jeopardized the safety and well being of his patients and his license should be disciplined.
The Issue Whether Respondent engaged in unprofessional conduct and, if so, what penalty should be imposed on his nursing license.
Findings Of Fact The Department of Health is the state agency charged with regulating the practice of nursing pursuant to Chapter 464, Florida Statutes. Respondent, Cecil Harold Floyd, was at all times material hereto a licensed practical nurse in the State of Florida, having been issued a license numbered PN 0960631. At all times material hereto, Respondent was employed as a licensed practical nurse by the North Shore Senior Adult Community in St. Petersburg, Florida. At all times material hereto, Respondent was assigned to care for Patient M.F., a patient in the skilled nursing section of the North Shore Senior Adult Community. On February 26-27, 1996, Respondent worked as the charge nurse on the 11:00 p.m. to 7:00 a.m. shift. On February 27, 1996, at approximately 6:00 a.m., Respondent wrote in the nurse's notes that Patient M.F. was lethargic and having difficulty swallowing; that the patient's bottom dentures were out; and that the patient's tongue was over to the right side. In this entry, Respondent also noted "will continue to monitor." After Respondent completed his shift on February 27, 1996, Conchita McClory, LPN, was the charge nurse in the skilled nursing facility at North Shore Senior Adult Community. At about 8:10 a.m., Nurse McClory was called by the CNA who was attempting to wake up Patient M.F. Upon Nurse McClory's entering Patient M.F.'s room, she observed that the patient was sleeping, incontinent, and restless and that the right side of the patient's face was dropping. Based on these observations, Nurse McClory believed that Patient M.F. may have suffered a stroke and she immediately called 911. Following the 911 call, Patent M.F. was taken to Saint Anthony's Hospital in Saint Petersburg, Florida. Prior to coming to this country, Conchita McClory had been trained and worked as a registered nurse in the Philippines. However, Ms. McClory is not licensed as a registered nurse in the State of Florida. Saint Anthony's Hospital's records regarding Patient M.F. indicate that the patient had a history of multiple strokes beginning in 1986. The Department’s Administrative Complaint against Respondent included the following factual allegations, all of which were alleged to have occurred on February 27, 1996: At approximately 6:00 a.m., Respondent recorded in the nurse’s notes that Patient M.F. was lethargic and having difficulty swallowing; the patient's bottom dentures were out; and the patient's tongue was over to the right side. Respondent also noted in the nurses' notes that Patient M.F. should continue to be monitored. Patient M.F.'s roommate told Respondent that she believed that M.F. had suffered a stroke because she could not swallow and her speech was slurred. At about 8:00 a.m., Patient M.F.'s roommate went to the nurses' station and requested that a certified nurse's assistant check on M.F. Patient M.F. was found paralyzed on her left side, soaked in urine and unable to speak. There was no evidence presented to support the factual allegations referenced in paragraph 9b and 9c above and included in the Administrative Complaint.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Health, Board of Nursing, enter a final order dismissing the Administrative Complaint against Respondent. DONE AND ENTERED this 6th day of October, 1999, in Tallahassee, Leon County, Florida. CAROLYN S. HOLIFIELD 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 October, 1999. COPIES FURNISHED: Howard M. Bernstein, Esquire Agency for Health Care Administration Allied Health - Medical Quality Assistance 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308-5403 Cecil Harold Floyd 1680 25th Avenue, North St. Petersburg, Florida 33713-4444 Ruth Stiehl, Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207 Angela T. Hall, Agency Clerk Department of Health 2020 Capital Circle, Southeast, Bin A02 Tallahassee, Florida 32399-1701 Pete Peterson, General Counsel Department of Health 2020 Capital Circle, Southeast, Bin A02 Tallahassee, Florida 32399-1701
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 At all times pertinent to the issues involved in this hearing, Respondent, Phyllis Carol Holmes, was a licensed practical nurse licensed by the State of Florida under license number 31075-1, employed as a licensed practical nurse at Crestview Nursing and Convalescent Home (CNCH), in Crestview, Florida, as a charge nurse on the 11:00 P.M. to 7:00 A.M. shift. When Respondent first began work at CNCH, she was required to go through a modest training and orientation program starting on June 21, 1983. As part of this program, she was briefed by various section heads on such matters as personnel policies and procedures, knowledge of working units and various aspects of nursing procedures. The checklist utilized in accomplishing this orientation was signed by four different nurses who accomplished the orientation briefings and it reflects that all aspects of the orientation were accomplished. In addition, Respondent was furnished with a complete written job description outlining the summary of work to be performed and the performance requirements for each which she acknowledged. She was also furnished with a policy letter on nursing personnels' responsibilities for charting and a policy letter on decubitus care procedure. Under the above-mentioned policies and procedures, as charge nurse Respondent had the responsibility for some 60 patients. Part of the requirements of her position included: Making rounds when coming on duty to see that there were no special problems; Administering medications; Preparing and controlling all documenta- tion for individual patients; Making rounds at least every two hours and checking on seriously ill patients more often than that; and Administering treatment immediately as needed in those areas where appropriate. Charge nurses also have the responsibility to insure that patients are moved every two hours to be sure that pressure sores (bed sores) do not develop. On or about July 19, 1983, Barbara Ann Griffin was working as a nurse's aide for Respondent who was charge nurse over her on the 11 - 7 P.M. shift. She observed the Respondent involved in a catheter insertion into an elderly female patient whose name she cannot remember. The records admitted at the hearing do not identify the patient by name but merely as a patient number. In any case, the evidence clearly reflects Respondent inserted a catheter into the female patient's rectum by mistake, then pulled it out, wiped it off and then inserted the same catheter into the patient's meatus. The term meatus means passage or opening. In this case, the witness was referring to the external opening of the urethra. This incident was also observed by Linda Gibbons, an aide who also cannot recall the name of the patient. She recalls, however, that Respondent has had difficulty in inserting catheters on other occasions and in each case, would insert it, perhaps in the wrong opening, withdraw it, and insert it again. At the hearing Respondent admits that she had a problem one time with Mrs. Henderson in inserting a catheter, but she denies reinserting it once she discovered it had been improperly inserted. She states that she got a new catheter from the supply room and inserted it rather than utilizing the one previously inserted and denies ever having any other problems with catheters on any other patients. However, the incident in question was brought to the attention of Mr. Hopkins, the nursing home administrator, at the time in question, and when he spoke with Respondent about it, she admitted that she made a mistake, but said the room was dim and she was in a hurry at the time. From the above, it is found, therefore, that Respondent on or about the date alleged, improperly inserted a catheter into a patient without insuring that it was sterile. Ms. Griffin, an aide, also indicates that on or about September 15, 1983, when she was conducting her midnight rounds, she observed the resident in Room 213A having some sort of problems. According to Ms. Griffin, from the symptoms the patient was displaying, it appeared that the patient had had a stroke. She immediately reported this to the Respondent at the nurse's station and then went back to the patient's room. Approximately 15 minutes later the Respondent came in, looked at the patient, and decided not to call the doctor because, according to Ms. Griffin, "it was too late." Ms. Griffin contends that Respondent did not check on the patient again that night, but at 6:00 A.M., told her to get the patient up for the day. Ms. Griffin went off duty at 7:00 A.M. and did not again see the patient who she later heard had been hospitalized with a stroke. Respondent, on the other hand, contends that instead of waiting 15 minutes when advised by Ms. Griffin, she went to the patient's room almost immediately. Admittedly, she did not make any notes in the patient's record about this situation but claims this was because she was giving her midnight medicines and thereafter forgot. However, she claims she checked the patient approximately every 30 minutes all through the night. Respondent contradicts Ms. Griffin's description of the patient indicating that when she first saw her, the patient was displaying no symptoms and when she saw the patient later that morning, she looked fine. Though she did not make notes at the time, the following day Ms. Holmes entered an after-the-fact note in the records which indicated that the patient was checked at 30 minutes past midnight due to an elevation in blood pressure. Her observation at the time was that the patient's color was good and her skin was warm and dry. The patient appeared cheerful and smiling but not talkative and appeared to be in no acute distress. The admission physical done at the time the patient was admitted to the hospital on September 15, 1985, reflects that there was no swelling of the extremities which had a full range of motion and there was no evidence of Babinski's symptoms which relate to a reflex when the tendons to the extremities are palpated. The history also shows that on the day of admission, the patient was found to have a right-sided weakness and slurred speech but there is no evidence to support the symptoms reported by Ms. Griffin. In substance, then, it appears that while the Respondent failed to report the patient's symptoms to the physician, there is some substantial question that the patient was in the acute distress indicated by the witness, Ms. Griffin. Further, Ms. Griffin admitted that she was in and out of other rooms in the home throughout the remainder of the shift and though she contends she is sure Respondent did not visit the patient during the remainder of the shift, there is no way she can be so certain. In paragraph 4 of the Administrative Complaint, Petitioner alleged that on or about April 11, 1984, Respondent administered Ascriptin to a patient in her care even though the physicians's order for the patient had discontinued administration of this substance on April 4, 1984. Review of the documentation submitted by the Petitioner in support of its claim here, specifically the medication administration record for patient number 17, reflects that on April 11, 1984, the Respondent did administer Ascriptin to the patient. The physician's orders clearly reflect that on April 4, 1984, Ascriptin, along with several other medications were discontinued by the physician. However, on April 16, 1984, according to the medication administration record, another nurse also administered Ascriptin. Petitioner admits that the medical administration record did not show the fact that the medication was discontinued. The entry indicating discontinuance was made well after the second administration by the other nurse. However, Ms. LeBrun, the then Director of Nursing for CNCH, contends that even though the medication administration record did not show the discontinuance, Respondent should have noted that the medicine had not been given for quite a while and gone to the doctor's orders to see why that was the case. Had she done so, she would have noticed the order indicating the medication was discontinued. Ascriptin, however, is a pain medication and the doctor's original order indicated it was to be given in the event of pain. If the patient was not suffering pain, the patient would not have called for it and it would not have been given even if authorized. Respondent indicated that the patient did not complain of pain often. When she administered the medication last, there was no indication on the medication administration record that it had been discontinued and even as of April 11, 1984, when the medication was administered by the Respondent, seven days after the doctor's order discontinuing it, the medication was still in the patient's drawer on the medication cart. Inez Cobb has worked at CNCH for approximately 15 years as a nurse's aide and worked for Respondent during the 1983-1984 period. As she recalls, on the morning of May 2, 1984, while getting the patients up for the day, between 6:00 and 6:45 A.M., she entered the room of patient Haas. When she came in she observed the patient slumped in his chair. She checked his blood pressure and found it to be very low and his pulse was weak and faint. She immediately reported this to the Respondent who did nothing and as of 7:00 A.M., when the witness left duty, Respondent had failed to check on the patient. As she recalls, however, the incoming charge nurse who was to replace Respondent on the next shift also failed to check on the patient. Respondent contends that when she was notified of Mr. Haas' condition, she had the medicine nurse for the day shift check him and this nurse, acting on Respondent's instructions, called the doctor almost immediately after the Respondent was notified. Respondent was giving report to the oncoming charge nurse when Ms. Cobb mentioned Mr. Haas to her, and when she finished this report, she went and checked on him. Admittedly, she did not notify the physician. The nurse's notes made by Respondent on the day in question fail to reflect any mention of this incident. Ms. LeBrun noting that Respondent's nurse's notes fail to reflect any acknowledgment of the problem, indicated that proper practice would have been for Respondent to have immediately gone to observe the patient, made her own assessment, immediately called the physician, and then made her nurses notes entry. This is so especially in light of the comment regarding the incident in the flow sheet made by Ms. Cobb regarding the patient's condition. Also, according to Ms. Cobb, on May 11, 1984, she noticed a red area on the coccyx of patient Martin. She reported this to the Respondent several times even after the skin broke, but to her knowledge, nothing was done about it for several days. It is her understanding that when an aide sees an area like this, she is not allowed to treat it herself but must report it to the nurse on duty which she did. Unfortunately, the red spot turned into an ulcer which remained on the patient until he died at some later date. The decubitus care procedure and policy letter reflected above outlines the method of care to be taken with regard to the prevention of ulceration. It calls for keeping the patient's skin dry, massage and frequent turning. Ms. Gregg noted this situation on the flow sheets for May 11, at 5:15 A.M. The nurse's notes prepared by the Respondent at 5:15 A.M. in the morning on May 11 reflect merely that a bed bath was given with a linen change and that a broken area was noted on the patient's right buttox. There is no indication that any treatment was given by the Respondent or that the physician was notified. Respondent admits that she knew Mr. Martin had a broken area and she treated it often. Admittedly, she did not chart her treatment properly because she had to give all medicines at the time and do all the charts for more than 60 patients and did not get around to it. She contends she may not have heard Ms. Cobb report this situation to her because she is somewhat hard of hearing from time to time and as a result, has asked all her aides not to just give her information on the run but to be sure to get her attention when they need to report something. On the issue of whether Respondent's performance measures up to the standard of care required of nurses in Florida, Ms. LeBrun contends that the standard of care for licensed practical nurses is not that much different or much less than that required for registered nurses because in this State, licensed practical nurses do many of the same procedures often reserved for registered nurses elsewhere. In the area of medications, for example, there is no room for error. As a result, standards are high and Ms. LeBrun feels there is a need for checking and double checking. In the situation regarding the Ascriptin here, she believes that even though it is strictly a pain medication, the Respondent should still have checked the doctor's orders to insure the requirement was still valid before administering a medication which the records show had not been administered for quite a while. With regard to the catheter insertion, Ms. LeBrun states the fact that the patient did not develop an infection is irrelevant. The issue concerns the following of a procedure using a contaminated catheter which could easily have developed an infection for the patient. Referring to the stroke patient, Ms. LeBrun agrees with the testimony of Ms. Barrow, another licensed practical nurse, who was the day shift charge nurse relieving Respondent at 7:00 A.M. in the morning. As she recalls the situation on September 15, she observed the patient in question being brought out of the dining room. At that time, the patient was semi-lethargic. Ms. Barrow is of the opinion that if the patient was wakened at 6:30 A.M.; she would not have been in the condition she was in at 11:30 A.M. for a long time. Therefore, the stroke must have taken place just before 11:30 A.M.; as the patient was not in such poor shape during the preceding 11:00 P.M. - 7:00 A.M. shift. Ms. LeBrun feels that if the patient was in condition as described by the night nurse, it is not likely they would have gotten her up at 6:30 A.M. to go to the dining room. Nonetheless, she feels that Respondent should have responded sooner as the symptoms described by the night nurse are consistent with strokes as well as other things. On that basis, the Respondent should have made an assessment on the vital signs and notified the doctor immediately. Turning to the issue of the decubitus situation on the patient with the ulcer, Ms. LeBrun feels that the Respondent should have documented what she did for the broken area. If the records do not say what was done, it is presumed not to be done. When notified that the broken area was getting larger, the Respondent should have documented what treatment she administered since the nursing home had a procedure to be followed for this type of condition and it appears respondent did not follow this procedure. Several of the nurses who worked for the Respondent indicated that they had had other professional problems with her. For example, Ms. Griffin indicated that in addition to the catheter incident, she had instances when she would report problems to the Respondent but Respondent would make no record of it. She would, for instance, report patients with rashes to the Respondent but nothing would be done about it. It got so bad that the witness finally started to request Respondent to initial reports she made. Ms. Gibbons also has noticed Respondent to have had difficulty on other occasions than that involved in this hearing with the insertion of catheters. Ms. LeBrun prepared at least one efficiency report on Respondent which had to be reaccomplished because the Respondent would not sign for it and acknowledge the rating. In addition, Ms. LeBrun counseled Respondent on at least one occasion for jumping channels. On the basis of Ms. LeBrun's testimony, it would appear that there was some friction between the two nurses but this does not necessarily, in light of all the other evidence, indicate that Ms. LeBrun's testimony is biased or tainted. On the basis of the above incidents, Ms. Holmes was terminated from employment with the nursing home on June 29, 1984, because of poor performance. On December 21, 1983, the Board of Nursing entered an Order pursuant to a stipulation executed by the Respondent in another case which resulted in her being fined $250.00, being placed on probation, and being required to take certain continuing education courses. The stipulation reflects that the Respondent denied the allegations of fact contained in the Administrative Complaint which supported it which related to various failures by Respondent to conform to the minimal standards of nursing practice. Respondent indicated that she entered into the stipulation simply because she had no money with which to retain an attorney and was forced, therefore, to utilize the services of Legal Aid. It was her Legal Aid attorney who talked her into stipulating on the basis that she had no witnesses to support her position. She continues to deny the allegations in the former Administrative Complaint, however.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that Respondent's license as a licensed practical nurse in the State of Florida be suspended for a period of one year or until such time as she has completed a course of remedial study prescribed by the Board of Nursing and to its satisfaction, and that upon her completion of such course of study, she be placed on probation for a period of one year under such terms and conditions as prescribed by the Board of Nursing. RECOMMENDED this 29th day of July, 1985, in Tallahassee, Florida. ARNOLD H. POLLOCK 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 29th day of July, 1985. COPIES FURNISHED: William B. Furlow, Esquire, and Celia Bradley, Esquire Department of Professional Regulation 130 N. Monroe Street Tallahassee, Florida 32301 Dale E. Rice, Esquire Post Office Box 687 Crestview, Florida 32536 Fred Roche Secretary Department of Professional Regulation 130 N. Monroe Street Tallahassee, Florida 32301 Salvatore A. Carpino General Counsel Department of Professional Regulation 130 N. Monroe Street Tallahassee, Florida 32301 Judie Ritter Executive Director Board of Nursing Room 504, 111 E. Coastline Dr. Tallahassee, Florida 32202 =================================================================
