The Issue Whether the Respondent failed to appropriately chart the administration of medications and make the appropriate entries in the drug inventory procedures, and whether this constituted a departure from the accepted and prevailing nursing standards.
Findings Of Fact Jane Adelaide Drake is a registered nurse licensed by the Florida State Board of Nursing. She was employed at Holy Cross Hospital, Fort Lauderdale, Florida from approximately 1973 until March, 1978. She was the assistant head nurse on Ward 4 South on March 23, 24 and 25, 1978. Her duties included responsibility for the narcotics and other controlled substances maintained on 4 South, and the administration of controlled substances to patients. The scheme or procedure for control of narcotics and other; controlled substances called for their issuance in individual dosages daily by the hospital pharmacy to each ward, including 4 South. A Controlled Substances Disposition Record (CSDR) was used to issue controlled substances to the wards. Each ward was issued sufficient new stock daily to maintain its stockage level at the level indicated by the numbered entries on the CSDR for each drug. Additional stockage was indicated by the addition of letters following the numerical entries for a particular drug on the CSDR. Each individual drug dose was issued in an envelope which was clear on one side and had a preprinted form on the other. As drugs were administered, an entry was made by the person responsible for narcotics control on the CSDR opposite the type and strength of drug to be administered. An inventory was conducted daily from this sheet to check drugs on hand against those which had been administered. Doctor's orders for medication were transferred to an electronic data system, and daily printouts were received by each ward for each patient indicating the drugs to be administered and the times or conditions for administration. This preprinted form was referred to as the medication administration record (MAR) or patient profile. Administration of the medication was indicated by striking through the time for administration and initialing, or writing in the time of administration and initialing when it was a drug not given at a specified time. One apparent exception to the use of preprinted MARs existed when a new patient was received on a ward. In this event, hand written orders were taken prior to the preparation of the preprinted MAR. Nursing notes were maintained by each shift on each patient. Nursing notes were kept on a form which provides spaces for the patient's name and identifying data to be stamped at the top of the form, and headings for the date, time, treatment or medication administered, remarks, and signature and title of the individual making the entry. The work force on 4 South was organized into LPNs and RNs who worked directly with patients and are referred to in the record as bedside nurses. The ward supervisors, to include the Respondent, maintained the ward records, drug inventory records, doctor's orders, and administration of controlled medication. Nursing notes for the various shifts and by various RNs and LPNs reflect that only rarely did entries in nursing notes indicate that a specific drug had been administered by the bedside nurse. When recorded at all in nursing notes, generally the only remark is that the patient complained of pain and was medicated. Although acceptable nursing practice would dictate that the nurse who administers medication would sign out for a drug, administer the drug, make an entry on the MAR, and chart the drug on nurse's notes, this was not uniformly followed by the nurses on 4 South at Holy Cross Hospital. This was the result of a hospital policy that personnel not trained in the drug records system would not make entries in the drug record, complicated by a shortage of nursing staff that necessitated utilization of "pool" nurses or nurses obtained from local registries. The majority of these nurses were not trained in the hospital's drug records system. These nurses, who were used as bedside nurses, could not make entries on the drug administration records, therefore, they could not administer the drugs. This necessitated that the administration and maintenance of the drug control records be done by the regular staff. Because bedside nurses were responsible for patient charting generally, it became the prevailing practice for bedside nurses to chart the administration of medications which were administered by other staff. The specific allegations of the complaint relate to Rose Ferrara, Minnie C. Ward, and Josephine Locatelli. Regarding Locatelli, the allegation of the complaint is that the Respondent signed out for and administered Demerol (Meperidine) to the patient on March 23, 1978 but failed to properly sign out for the drug on the C8DR. Exhibit 12 is a handwritten 4AR for both March 23 and 24, 1978, on which Demerol is listed under the date March 23. Entries on this record would appear to reflect that the patient was administered Demerol by the Respondent at 1100 and 1430 on March 23, and by Ann Fosdick at 1900 on that date. The CSDR indicates that Meperidine was signed out for Locatelli at 1035 and 1435 by the Respondent and at 1900 by Ann Fosdick on March 24. The hospital records indicate that the patient was not admitted to the hospital until March Obviously, neither the Respondent nor Fosdick could have administered the drug on March 23. What the records do reflect is that on March 24, the Respondent and Fosdick signed out for Demerol which was administered to the patient on March 24, but recorded on the handwritten MAR under the date of March 23, the date the doctor's order was entered. The administration of pain medication by Fosdick is reflected in the nursing notes of J. Hughes, GN, for 2000 hours March 24, 1978. No nursing notes exist in the record for the Respondent's shift. See Exhibits 2, 12 and 13. The CSDR reflects the Respondent signed out on March 25 for Meperidine at 0700. 1000, and 1430 hours for Locatelli. The nurses notes reflect no entry relating to the administration of these medications for March 25, 1978. The MAR for March 25, 1978, was not introduced. The nursing notes for March 23, 24 and 25, 1978, were maintained by persons other than the Respondent or Fosdick. Regarding Ferrara, the testimony indicates that the Respondent signed out for medications on the CSDR and made appropriate entries on the MAR except in one instance. Again, the administration was not charted in nurses notes. However, the MAR submitted as an exhibit is for March 24, 1978, while the nurses notes cover primarily March 23, 1978. The primary failure reflected in the testimony relates to Respondent's failure to chart nurses notes. However, review of the nurses notes on this patient from February until March reveals that the only pain medication received by the patient, and that only on one occasion, was Percodan which was given several weeks after the patient's leg was amputated. Although there may be individual variations to pain, it is hardly conceivable that Ferrara could have undergone the amputation of her leg without any pain medication except Percodan which was administered one time several seeks after the operation. Presumably, the patient did receive pain medication and this was not charted in nurses notes by any of the nursing staff. Regarding Minnie Ward, the CSDR shows that the Respondent signed out for Meperidine at 12 noon on March 23, 1978. The nurses notes show no complaint of pain or administration of pain medication at 12 noon on that date. However, the CSDR reflects that "PM" signed out for 50 mg of Meperidine at 0200 hours for the same patient. The MAR for March 23 does not reflect administration of the drug by "PM'. or charting of administration in the nurses notes on March 22, 23, or 24, 1978, by "RM." See Exhibits 1, 9 and 10. Further, regarding Ward, a review of her records for other dates reflects that on March 17, the Respondent signed out for Meperidine at.1105 and 1530. The nurses notes, which on that date were kept by the Respondent, reflect administration of the drug at 1100. No entry was made regarding the 1530 administration. An entry is contained at 1900 hours on that date indicating that Ward complained of pain and was medicated; however, no corresponding entry is contained in the CSDR indicating that a controlled substance was signed out for administration to this patient. The shift on 4 South would have changed between 1500 and 1530 hours. The pain medication administered necessarily had to come from some source, presumably the 1530 sign-out by the Respondent. However, it is unclear whether it was administered at 1530 and not charted until 1900, or not administered until 1900 when it was charted. On March 18, 1978, the CSDR reflected that Ward was given 50 mgs of Meperidine at 1300 hours by the Respondent. Nurses notes for that date reflect administration of pain medication at that time. The CSDR also reflects that Ann Fosdick signed out for 50 mgs of Meperidine at 1900 hours on March 18. However, the nurses notes for Fosdick's shift do not reflect that the patient complained of pain or received pain medication. On March 19, Ann Fosdick signed out for 50 mgs of Meperidine at 1800 hours as reflected on the CSDR for that date. The nurses notes kept by M. Green, title illegible, for that date reflect that Ward was medicated for pain by the team leader at approximately 1800. On March 20, 1978, the Respondent signed out for 50 mgs of Meperidine at 0900 hours and at 1330 hours, and "REK" signed out for Mereridine at 2100 hours. The nurses notes by R. Ezly, R.N., for March 20, reflect the administration of medication at approximately 1330 and the nurses notes by an LPN whose name is illegible reflect the administration of pain medication at 2000 hours. Again, the nurses notes were kept by an individual other than the person administering the medication. The MARs on March 17, 18, 19 and 20, 1978, were properly executed by the Respondent and the other nurses referred to above. The nurses notes for Minnie Ward do not reflect any remarks between 1400 hours on March 23, 1978 and 1530 hours on March 24, 1978, and two separate sets of entries for March 25, 1978. A supervisor was called to testify to what constituted acceptable and prevailing nursing practices at Holy Cross Hospital. She had been a nursing supervisor since 1976, and was supervisor on the 3 to 11 shift in March, 1978. In addition, she stated that she had only administered medication four times in the approximately four years she had been at Holy Cross Hospital as a supervisor. Her testimony was based solely upon her observations on her own shift and the review of the records of her shift which she stated that she spot- checked. The supervisor's testimony revealed that she was aware of the fact that shifts on the wards were divided into those nurses giving bedside care and those nurses administering medication. Her testimony and the testimony of the director of nursing shows that the records of the shift on which the Respondent served were spot-checked. Spot-checking was reportedly the means by which the alleged discrepancies in the Respondent's charting were noted. From even cursory inspection of the records, it is evident that medication nurses were not charting the nurses notes and bedside nurses were charting the administration of medication in nurses notes. Such spot-checking also reveals the discrepancies in charting noted above. All of those discrepancies constitute a departure from minimal standards of acceptable and prevailing nursing practice. The Respondent offered the only explanation of why these practices had occurred. During the winter months of 1977-78, there had been an increase in patient census, and shortage of staff nurses which caused working conditions to deteriorate. Some regular staff members quit their jobs worsening the already bad situation. The number of Nurses on 4 South varied between three and six to treat forty-eight patients. Even with six nurses on duty, this was 1.3 nurse hours below the hospital's goal of 4.3 nurse hours per patient per twenty-four hours. An attempt was made to make up the personnel shortages by using "pool" or registry nurses; however, hospital policy prevented these nurses from making entries on the CSDRs and MARs which kept all but a very few from administering medication. Theme nurses were used to provide bedside care and were permitted to chart nurses notes. Because of the acute shortages, the medication nurses, to include the Respondent, executed the CSDRs and MARs, prepared medications, and administered them, but permitted the bedside nurses to chart the administration in nurses notes. The Respondent complained concerning the staffing levels to her supervisor and to the director of nursing. The director of nursing requested a written memorandum from the Respondent, which she received; however, the situation was not improved. Thereafter, the Respondent was terminated for errors in charting, although there had been no prior complaints or counseling with regard to her charting errors, and in spite of the fact that her charting was consistent with the patterns seen with other nurses on other shifts. The general practice concerning charting errors was that nurses were counseled, required to correct errors, and required to prepare incident reports where necessary.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer recommends that the Florida State Board of Nursing issue a letter of reprimand to the Respondent. DONE and ORDERED this 12th day of December, 1978, in Tallahassee, Florida. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Eugene A. Peer, Esquire 2170 NE Dixie Highway Jenson Beach, Florida 33457 Julius Finegold, Esquire 1107 Blackstone Building Jacksonville, Florida 32202 Geraldine Johnson, R.N. Licensing and Investigation State Board of Nursing 6501 Arlington Expressway, Bldg B Jacksonville, Florida 32211 ================================================================= AGENCY FINAL ORDER ================================================================= BEFORE THE FLORIDA STATE BOARD OF NURSING IN THE MATTER OF: Jane Adelaide Drake North Western University Institute CASE NO. 78-1450 of Psychiatry 3203 E. Huron Chicago, Illinois 60611 As a Registered Nurse License Number 76252-2 /
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following facts are found: By an administrative complaint dated December 15, 1978, respondent was charged with unprofessional conduct in violation of Florida Statutes, Section 464.21(1)(b). The respondent timely requested an administrative hearing which was granted. The envelope which contained the request for hearing was mailed from Buffalo, New York, but the return address was 717 Breakers Avenue #3, Ft. Lauderdale, Florida, with the notation "Note: Address Change." All future correspondence was sent to this address, including the notice of hearing dated May 16, 1979. The hearing was scheduled to commence at 9:30 a.m. At approximately 9:50 a.m., the hearing proceeded without the appearance of the respondent. On July 20 and 21, 1978, the respondent Miller was employed as a registered nurse on the 11:00 p.m. to 7:00 a.m. shift at Cypress Community Hospital in Pompano Beach, Florida. At 3:55 a.m. on July 21, 1978, respondent signed out for 75 milligrams of injectable Meperidine (Demerol), a Class II controlled substance, for patient Frank Mantovi, and then walked into the patient's room with the substance. Another registered nurse on duty, Oletta Jones, observed that the patient was sleeping at the time. Nurse Jones called her supervisor, Anita Johnston, and they awakened the patient and inquired whether he had requested or received any medication for pain. He replied in the negative. The patient appeared oriented and alert, and his vital signs were stable and not indicative of receiving 75 milligrams of Demerol. The administration of Demerol was not charted on the patient's medication record, as it should have been had it been administered. Nurses Jones and Johnston then confronted respondent Miller in the nurses' lounge. At first respondent told them that she had administered the Demerol intermuscularly, but then said she had given it by I.V. push. The doctor's order sheet for patient Mantovi contained a notation for 75 milligrams of Demerol administered intermuscularly as needed for pain every three hours. There is nothing to authorize an I.V. introduction of this medication. It is not acceptable or prevailing nursing practice for a nurse to alter the mode of administration prescribed by the physician. After talking with respondent, patient Mantovi's vital signs were again checked. There was no indication that he had received Demerol. Respondent was then asked to leave the hospital. The pupils of her eyes were observed by Nurse Johnston to be of pinpoint size.
Recommendation Based upon the findings of fact and conclusions of law recited above, it is RECOMMENDED that the Board of Nursing find respondent guilty of unprofessional conduct within the meaning of Florida Statutes, 464.21(1)(b), and suspend her registered nursing license for a period of three (3) months. Respectfully submitted and entered this 14th day of August, 1979, in Tallahassee, Florida. DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Jane M. Miller 717 Breakers Avenue #3 Ft. Lauderdale, Florida 33304 Julius Finegold Esquire 1107 Blackstone Building Jacksonville, Florida 32202 Geraldine Johnson, R.N. Coordinator of Investigation and Licensing 111 East Coastline Drive Suite 504 Jacksonville, Florida 32304 ================================================================= AGENCY FINAL ORDER ================================================================= BEFORE THE FLORIDA BOARD OF NURSING IN THE MATTER OF: Jane Marie Miller 717 Breakers Avenue No. 3 Ft. Lauderdale, Florida 33304 CASE NO. 79-212 As Registered Nurse License Number 66021-2 /
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant facts are found: The respondent Eunice Lyles Nicholson is 53 years of age and has been a registered nurse since 1947. She moved to Florida in 1970 and went to work for Jess Parrish Memorial Hospital, where she remained until February of 1977. Since that time, she has been employed in private nursing jobs and at the Titusville Nursing and Convalescent Center. At all times relevant to the incidents which are the subject of the Administrative Complaint, respondent was the charge nurse for the second floor of Jess Parrish Memorial Hospital. Her employee evaluations at the Hospital between 1970 and 1976 were "very good" overall. On or about December 2, 1979, respondent destroyed an ampule containing 100 mg of Demerol, a controlled substance, in the presence of another nurse. She did not sign for the destruction at this time. Later, when the nurse who witnessed the event was out, respondent requested another nurse to sign the document stating that she had witnessed the destruction. It is not acceptable or prevailing nursing practice to request one who did not actually witness the event to sign a document stating that she had witnessed the destruction of a controlled substance. Between February 4, 1977, and February 17, 1977, a period of time in which the Hospital was busier than normal, various discrepancies, inconsistencies and insufficiencies were -noted in the charts and records of approximately six patients under respondent's care. These included incomplete and insufficient nurses notes on the patients' charts; failure to chart the administration of controlled susbstances on the patients' medical record; discrepancies between the nurse's notes, the patient's medication record and the narcotic control record; and the administration of medication at more frequent intervals then called for by the physician's orders. It was respondent's testimony that the charting errors were not intentionally made. She could not explain the errors and could only recall that the Hospital was very busy during that period of time. There was no evidence that any patient was harmed by the charting errors or that there was any similarity in the errors found. There was no evidence that respondent converted any controlled substance to her own use. On or about February 17, 1977, respondent was the head nurse on the 7:00 A.M. to 3:00 P.M. shift. After respondent left this shift, it was noticed that there were two extra ampules of Demerol 75 in the narcotic cart. Respondent was called at home and notified of the discrepancy. She returned to the Hospital. Rather than making an attempt to determine the reason for the narcotic count being incorrect, respondent simply destroyed the two extra ampules. Witnesses observed this event. It is the responsibility of the nurse in charge of each shift to account for, reconcile and verify the inventory of controlled substances with the narcotic records before she leaves her shift. The reason for the discrepancy was never determined.
Recommendation Based upon the findings of fact and conclusions of law recited above, it is recommended that the Board: find the respondent guilty of unprofessional conduct in violation of Florida Statutes, 464.21(1)(b); and impose a six-month suspension of respondent's registered nursing license; and suspend the enforcement of the suspended license and place the respondent on probation for a period of one (1) year. Respectfully submitted and entered this 5th day of September, 1979, in Tallahassee, Florida. DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Julius Finegold 1107 Blackstone Building 233 East Bay Street Jacksonville, Florida 32202 Carl Wasileski Post Office Box 1286 150 Taylor Street Titusville, Florida 32780 Geraldine Johnson Board of Nursing 111 Coastline Drive East, Suite 504 Jacksonville, Florida 32202 ================================================================= AGENCY FINAL ORDER ================================================================= BEFORE THE FLORIDA BOARD OF NURSING IN THE MATTER OF: Eunice Rae Lyles Nicholson 1813 Lilac Circle Titusville, Florida 32780 CASE NO. 79-623 As a Registered Nurse License Number 53804-2 /
The Issue At issue in this proceeding is whether respondent committed the offenses set forth in the administrative complaint and, if so, what disciplinary action should be taken.
Findings Of Fact At all times material hereto, Respondent, Carmalita Thomas, was licensed as a registered nurse in the State of Florida, license number RN 1329552. From November 11, 1987, to September 1988, respondent was employed as an independent contractor by Hi-Tech Medical Services, Inc., (the Agency), a comprehensive health maintenance organization. Pursuant to the terms of her employment, respondent was responsible for the Agency's pediatric program, and was to provide skilled nursing visits in homes where ill or disabled persons were receiving care from the Agency. Regarding compensation, their agreement provided: The Contractor will be paid for Agency authorized visits. The Agency will not pay nor be responsible for visits rendered or expense incurred due to the Contractor's execution of unauthorized visits. The Agency will pay the Contractor 30 days after receipt of a statement reflecting number of authorized visits rendered during the previous period at the prevailing rate of 22/27 per visit. The Contractor will prepare and submit a written clinical report for each visit in keeping with Agency policy and requirements. The Agency's written policy regarding the preparation and submittal of written clinical reports required, for verification of visits and billing purposes, that respondent, for each visit, prepare and sign a written nurses progress report. Respondent was aware of this policy, but did not consistently present such reports with her billing form by which she received her compensation. Notwithstanding such failures the Agency routinely paid respondent upon presentation of her billing form. During the period of May 23, 1988, through June 17, 1988, respondent prepared and signed four progress notes reflecting nursing care rendered to pediatric patient Jessica Metzel, and submitted a billing form to the Agency for payment at $27.00 per visit. Respondent was compensated by the Agency, who in turn billed the patient's insurance carrier for the services. While requesting and receiving payment for four visits, the proof demonstrates that respondent was only at the Metzel residence on two occasions. The first occasion was to have Jessica's father sign some paper work, and the occasion was to insure that the family was satisfied with the respiratory therapist that was treating Jessica. At no time did respondent examine or otherwise treat Jessica, and the progress notes prepared by respondent were a fabrication. Respondent also submitted billing forms to the Agency on at least two occasions, which resulted in her being compensated twice for the same working hours. More particularly, respondent billed the agency in December 1987, and was paid, for having worked from 10 a.m. to 1 p.m. (3 hours) on December 21, 1987, and from 10 a.m. to 3 p.m. (4 1/2 hours) on December 24, 1987. Thereafter, by separate billing, she also billed the Agency, and was paid, for services purportedly rendered from 9:30 a.m. to 1:00 p.m. (3 1/2 hours) on December 21, 1987, and from 10:30 a.m. to 2:00 p.m. (3 1/2 hours) on December 24, 1987.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that respondent be found guilty of having violated the provisions of Section 464.018(1)(d) and (f), Florida Statutes, as heretofore found in the conclusions of law, and that respondent's license be suspended for 90 days, followed by a two (2) year term of probation upon such terms and conditions as the Board of Nursing deems appropriate. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 25th day of February 1991. WILLIAM J. KENDRICK 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 25th day of February 1991.
The Issue The matters presented for consideration in this instance concern an Administrative Complaint brought by the Petitioner against the Respondent seeking to suspend, revoke or take other disciplinary action against the Respondent's license, in particular, against her license as a Registered Nurse. The substance of the Administrative Complaint is contained in five (5) counts. Count I to the Administrative Complaint alleges that on or about March 10, 1981, Respondent signed out a controlled substance, to wit: two (2) ampules of Demerol, between the approximate hours of 7:00 P.M. to 7:15 P.M. for a patient, DeFrisco [sic]. DeFrisco [sic], reputedly states that she did not receive the Demerol. Based upon the foregoing alleged facts, Respondent has purportedly violated Subsection 464.018 (1)(d), Florida Statutes (1979), by making a false report of record which she knew was false and in addition has violated Subsection 464.018(1)(f), Florida Statutes (1979), by failing to conform with the minimal standards of acceptable and prevailing nursing practice. 1/ Count II to the Administrative Complaint alleges that on or about March 5, 1981, the Respondent administered a controlled substance, to wit: Demerol, in excess of that ordered by the attending physician and for that reason violated Subsection 464.018(1)(f), Florida Statutes (1979), in that she failed to conform with the minimal standards of acceptable and prevailing nursing practice. 2/ Count III alleges that the Respondent wasted, without a witness, certain controlled substances, in violation of hospital policy, as follows: On 2/28/81 Dilaudid, 1 mg On 2/23/81 Demerol, 100 mg. On 2/22/81 Demerol, 50 mg. On 2/16/81 Demerol, 100 mg. On 2/22/81 Morphene Sulphate 3 mg. On 1/28/81 Demerol, 25 mg. On 1/22/81 Demerol, 100 mg. Based upon these alleged facts, the Respondent purportedly violated Subsection 464.018(1)(f), Florida Statutes (1979), by failing to conform with minimal standards of acceptable and prevailing nursing practice. Count IV to the Administrative Complaint alleges that on or about March 5, 1981, Respondent signed out a controlled substance, to wit: Demerol, at approximately 9: 02 A.M., and at 12:15 P.M., for the use of patient Theodora Durham. It is further alleged that patient Durham states that she did not receive the above mentioned Demerol. Based upon those alleged facts Respondent purportedly violated Subsection 464.018(1)(d), Florida Statutes (1979), in that she made a false report of record which she knew was false. Further, Respondent, based upon those facts, has allegedly violated Subsection 464018(1)(f), Florida Statutes (1919), by failing to conform with minimal standards of acceptable and prevailing nursing practice Count V alleges that on or about April 12, 1981, the Respondent reported to her place of employment, Beaches Hospital, under the influence of alcohol to the extent that it affected her body coordination Further, it is contended that Respondent's supervisor; Joyce Strarnes, did not allow her to complete her work shift because she, Respondent was unable to function safely and to conform with minimal standards of acceptable nursing practice Based upon these allegations, the Respondent has purportedly violated Subsection 464018(1)(f), Florida Statutes (1979), for failure to conform to the minimal standards of acceptable and prevailing nursing practice, in which case actual injury need not be established. 3/
Findings Of Fact This case is presented for consideration based upon the aforementioned Administrative Complaint filed by the Petitioner, State of Florida, Department of Professional Regulation, Board of Nursing, against the Respondent, Rebecca Lael Calhoun. The Petitioner, agency, is a regulatory body which has been granted the authority by the State of Florida to license, regulate and discipline those persons who practice nursing in the State of Florida. The Respondent Rebecca Lael Calhoun has been issued a license to practice as a Registered Nurse in the State of' Florida and at all times pertinent to this Administrative Complaint, has held that license issued by the Petitioner. Calhoun was employed at St. Luke's Hospital, in Jacksonville, Florida, between the months of December, 1980, and March 10, 1981. Her position with that institution was that of Registered Nurse. On March 10, 1981, the Respondent worked at the St. Luke's Hospital on Ward 1-C. In that capacity, she had responsibility for the medication cart where controlled substances and other medications were kept for patient use. One of the patients who was on Ward 1-C on March 10,1981, and for whom controlled substances and other medications were made available by physician's orders was one Barbara L. DiFrancesco. On that date, DiFrancesco had an operative procedure known as dilatation and curettage performed and after the procedure, was brought to room 161, which was a room on the ward where the Respondent was on duty. It was 4:30 P.M. when the patient was placed in that room. After DiFrancesco returned to her room, between the hours of 4:30 P.M. and 8:00 P.M. on March 10, 1981, she did not receive any form of controlled substance, in particular, Demerol. The Demerol was in fact removed from the hospital inventory in DiFrancesco's name and Respondent knew that the patient did not receive the Demerol. Nonetheless, the Respondent documented that the patient DiFrancesco had the substance withdrawn for the patient's benefit and had received such a controlled substance. The false documentation was discovered by Kathleen Lawson, Assistant Director of Nursing at St. Luke's Hospital who was investigating possible "discrepancies" on the part of the Respondent in the recordation of entries on the controlled substance forms kept by the hospital. On the evening of March 10, 1981, Lawson checked the controlled substance form at approximately 7:00 P.M., which pertained to Ward 1-C where the Respondent was working. This controlled substance form may be found as a part of the Petitioner's Composite Exhibit No. 1, admitted into evidence. (The entries on that form pertain to the time of the sign-out, name of patient, room number, nurse's signature, dosage amount, amount of wastage, if any, and signature of a witness to wastage, and the description of the medication or controlled substance signed out by the practitioner) Lawson's review of the controlled substance form on March 10, 1981, at around `1:00 P.M. did not indicate that Demerol had been signed out for the benefit of DiFrancesco; however, when Lawson returned to Ward 1-C at approximately 7:15 P.M. on that same evening, she observed an entry on the controlled substance form which had been made by the Respondent. This entry indicated that Demerol in the amount of 50 mg. had been signed out for the benefit of DiFrancesco at approximately 5:30 P.M. When confronted with the discrepancy of having failed to make a timely entry of the sign-out of the controlled substance, Demerol, for the benefit of the patient DiFrancesco, that is to say the fact that the 7:00 P.M. check revealed no sign-out and a 7:15 P.M. check revealed a sign-out post-timed to 5:30 P.M.; the Respondent was than asked to perfect all necessary documentation to conform all records on the question of the administration of a controlled substance for the benefit of the patient DiFrancesco. In response to this request, the Respondent made an entry on the nurse's notes portion of the patient DiFrancesco's medical chart, to the effect that at 5:00 P.M. Demerol in the amount of 50 mg., IM, intramuscular, was administered to the patient DiFrancesco for "cramping." A copy of those nurse's notes may be found in Petitioner's Composite Exhibit No. 3, admitted into evidence. Some of the aforementioned "discrepancies' that officials at St. Luke's Hospital had been concerned about in terms of the Respondent's reporting procedures pertained to the controlled substance form, related to wastage of Schedule II controlled substances. St. Luke's Hospital had a written policy dealing with this subject as may be found in Petitioner's Exhibit No. 6, which is a copy of that policy related to unit doe drug distribution. That written policy was to the effect that when Schedule II controlled substances are wasted, or partially administered to the patient, the wastage or partial administration is recorded on the controlled substance form through the name of the patient; room number; the nurse who wasted material; the material; the amount injected and/or the amount wasted. The substance is shown to a witness in the process of recording the incident description as set forth herein. Pursuant to the written policy, there is also a line on the controlled substance form for the placement of . Off initials of that person who witnessed the accountability of the wasted Schedule II controlled substance, when the substance is only partially administered. In addition, the Respondent and other nurse practitioners in the hospital underwent an orientation which apprised the Respondent and others of the matters pertaining to wastage of Schedule II controlled substances as set forth in the written procedures and the utilization of the controlled substance form. Also, a customary practice within the hospital was established in which totally wasted narcotics were witnessed by initials placed by the witness on the controlled substance form, in the same fashion as partially wasted substances. Having been made aware of the requirements of that drug distribution handout, the utilization of the controlled substance form and custom, the Respondent did, in fact, on occasion have wastage which was recorded on the controlled substance form and initialed by another nurse practitioner as may be seen in a review of Petitioner's Composite Exhibit No. 1, which is a series of controlled substance forms for various dates. Notwithstanding her knowledge of procedures and customs within the hospital, there were a number of dates in which the Respondent failed to have a witness initial the wastage of Schedule II controlled substances Those occasions were as follows: Date: January 28, 1981 Patient: Pinkney Dose: 50 mg. Demerol Waste: 25 mg. Demerol Witness: No entry Date: February 16, 1981 Patient: Gression Dose: 100 mg Demerol Waste: 100 mg. Demerol Witness: No entry Date: February 22, 1981 Patient: Perry Dose: 50 mg. Demerol Waste: 50 mg. Demerol Witness: No entry Date: February 23, 1981 Patient: Fraser Dose: 100 mg. Demerol Waste: 100 mg. Demerol Witness: An entry made to the effect that a witness was unavailable Date: February 28, 1981 Patient: Bergdorf Dose: 1 mg. Dilaudid Waste: 1 mg. Dilaudid Witness: No entry There were no facts presented other than those related to the patient Fraser on the presence of a witness to the events of wastage and destruction of the Schedule II controlled substances. In addition to the incident with DiFrancesco, there were two other occasions in which the Respondent had signed out a controlled substance and indicated giving that controlled substance to a patient, when in fact the patient did not receive the controlled substance. This pertained to incidents on March 5, 1981, involving a patient on Ward 1-C, where the Respondent was employed as a Registered Nurse at St. Luke's Hospital. On the aforementioned date, i.e., March 5, 1981, the patient Theodora Durham was in the hospital for procedures related to curettage and packing of the uterus. She was assigned to Room 158 on Ward 1-C as her patient's room. The controlled substance sign-out form for March 5, 1981, which is found as part of Petitioner's Composite Exhibit No. 1, indicates that at 9:02 A.M. and 12:15 P.M., Demerol in the amount of 50 mg. on each occasion was signed out for the benefit of the patient Durham. The sign-out and other entries were made by the Respondent. The Demerol was in fact removed from the hospital inventory. The patient's chart, a copy of which may be found as Petitioner's Composite Exhibit No. 2, admitted into evidence, also indicates nurses notes authored by the Respondent stating that the 50 mg. amounts of Demerol were administered intramuscular to the patient Durham at 9:00 A.M. and 12:00 Noon. In fact, the patient Durham never received the Demerol on either of the occasions referred to herein. The Respondent knew the patient had not received the Demerol. Following her employment at St. Luke's Hospital, the Respondent received employment at Beaches Hospital in Jacksonville Beach, Florida. On April 12, 1981, she reported work as a Registered Nurse at Beaches Hospital for the 11:00 P.M. to 7:00 A.M. shift. During the transition from the prior shift into the shift of the Respondent, two (2) fellow employees noticed the aroma of what they felt to be alcohol on the breath of the Respondent. The employees having reported their observation to the nurse supervisor, the Respondent was summoned into the office of the nurse supervisor and under questioning admitted that she had been "drinking." This response was related to the issue of whether the Respondent had been consuming an alcoholic beverage. The nurse supervisor detected an unkempt appearance about the person of the Respondent and the fact that the Respondent's eyes were bloodshot Following this discussion, the Respondent was asked to leave the hospital because she could not afford patient care to those patients on her ward, due to the fact that she had been consuming an alcoholic beverage before coming on duty which was contrary to the policy of the hospital.
The Issue The issues for determination are whether allegations of the two four-count Administrative Complaints filed by Petitioner against Respondent are correct, and, if so, what penalty is appropriate.
Findings Of Fact Based upon observation of the witnesses and their demeanor while testifying; documentary materials received in evidence; stipulations by the parties; evidentiary rulings made pursuant to Section 120.57, Florida Statutes (2002); and the record compiled herein, the following relevant and material facts are found herein below: AHCA, at all times material hereto, is the agency for the State of Florida charged with licensing nursing homes in Florida pursuant to Section 400.021(2), Florida Statutes (2002), and the assignment of a licensure status pursuant to Section 400.23(7), Florida Statutes. AHCA is charged with evaluating nursing home facilities to determine their degree of compliance with established rules as a basis for making the required licensure assignment. AHCA is also responsible for conducting federally mandated surveys of those long-term care facilities receiving Medicare and Medicaid funds for compliance with federal statutory and rule requirements. These federal requirements are made applicable to Florida nursing home facilities pursuant to Florida Administrative Code Rule 59A-4.1288 that, in part, states, "[n]ursing homes that participate in Title XVIII or XIX must follow certification rules and regulations found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference." Pursuant to Section 400.23(8), Florida Statutes, AHCA must classify deficiencies according to the nature and scope of the deficiency when the criteria established under Section 400.23(2), Florida Statutes, are not met. The classification of any deficiencies discovered is determinative of whether the licensure status of a nursing home is "standard" or "conditional." AHCA surveyors use the "State Operations' Manual" (SOM) as guidance in determining whether a facility has violated the Federal regulation, 42 C.F.R. Chapter 483. The evaluation or survey of a facility includes a resident review and, depending upon the circumstances, may consist of record reviews, resident observations, and interviews with family and facility staff. Surveyors note their findings on a standard prescribed Center for Medicare and Medicaid Services Form 2567, titled "Statement Deficiencies and Plan of Correction" and is commonly referred to as a "2567" form. During the survey of a facility, if violations of regulations are found, the violations are noted and referred to as "Tags." A "Tag" identifies the applicable regulatory standard that the surveyors believe have been violated, provides a summary of the violation, sets forth specific factual allegations that they believe support the violation, and indicates the federal scope and severity of the noncompliance violation. Abbey is a nursing home located in St. Petersburg, Florida, licensed pursuant to Chapter 400, Florida Statutes. On October 8, 2002, AHCA conducted a complaint investigation3 survey of Abbey. As to the federal compliance requirement, AHCA alleged in the four-count Administrative Complaints that Abbey did not comply with certain requirements, which are significant for this proceeding. In Count I, AHCA alleged failure to implement written policies and procedures regarding advanced directives in violation of 42 C.F.R. Section 483.10(b)(8), Tag F-156. In Count II, AHCA alleged failure to implement written policies and procedures to prohibit neglect of residents in violation of 42 C.F.R. Section 483.13(c), Tag F-224. In Count III, AHCA alleged failure to provide or arrange services that meet professional standards of quality of care in violation of 42 C.F.R. Section 483.20(k), Tag F-281. In Count IV, AHCA alleged failure to ensure that residents are free of any significant medication errors in violation of 42 C.F.R. Section 483.25(m), Tag F-333. As to state licensure requirements of Section 400.23(7) and (8), Florida Statutes, and by operation of Florida Administrative Code Rule 59A-4.1288, AHCA determined that Abbey had failed to comply with state established rules. Under the Florida classification system, AHCA classified the noncompliance in Tag F-156, Tag F-224, and Tag F-281 as Class I deficiencies and classified the noncompliance in Tag F-333 as a Class II deficiency. When AHCA finds violations in a facility, it assigns a classification based on the severity of the specific violation. The classifications are Class I, Class II, Class III, or Class IV, with Class IV being the least severe. Class I means a deficiency in which immediate corrective action is necessary because noncompliance has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Class II means a deficiency which has compromised the resident's physical, mental, or psychological well being, but which does not require immediate corrective action. AHCA also assigns a "scope" rating to an alleged deficiency. Scope is either "isolated," "patterned," or "widespread." An isolated deficiency is a deficiency that affects one or a very limited number of staff or is a situation that occurs only occasionally or in a very limited number of locations. A widespread deficiency is a deficiency in which the problems are pervasive in the facility or which represents systemic failure that has affected or has the potential to affect a large portion of the facility's residents. Based upon the three Class I deficiencies and the one Class II deficiency discovered during the complaint investigation survey, AHCA assigned a "Conditional" licensure status to Abbey commencing October 8, 2002, through October 28, 2002. As of September 15, 2002, Resident 1 was housed in the Windmoor Healthcare drug rehabilitation treatment center located in Clearwater, Florida. While there, her rehabilitation program included taking the following prescribed medications: Effexor, Trazodone, Depakote and Zyprexza, for mood swings and depression. On September 19, 2002, Abbey admitted Resident 1 for the limited purpose of undergoing a pain management program. Resident 1's pain management treatment consisted, in part, of the prescribed medication Vicodin (brand name for the generic drug hyrdocodone/acetaminophen) in preparation for her future endometriosis surgery. At the time of her admission, Resident 1, a 23-year- old female, weighed approximately 190 pounds; had multiple diagnoses, including bipolar disorder, depression, polycystic kidney disease, cystitis, herpes, endometriosis, and infections; and had a history of drug abuse. She was ambulatory, competent, alert, oriented, and independent, requiring no special assistance or treatment, and was assigned a semi-private room. Resident 1 was not restricted to the facility. She was free to leave the facility only during the day and was required to return each evening. During one or more days, she left the facility and returned each night material to this proceeding. Resident 1 designated herself a "full-measure" resident. A "full-measure" resident is one whose admission medical record contains the resident's election that requires immediate initiation of "compressions and breathing" assistance including Cardio Pulmonary Resuscitation (CPR) and other life- saving efforts, if at any time the resident is found to be non- responsive and/or not breathing. Abbey's policies and procedures required staff to first assess a non-responsive resident; have someone ascertain if the resident is Do Not Resuscitate (DNR) or No Do Not Resuscitate (NO DNR), and if NO DNR initiate "compressions and breathing" assistance including CPR and other life-saving efforts immediately.4 As used by the witnesses in this case, the term "full measure" is synonymous with NO DNR; therefore, Abbey's staff is required to initiate “compression and breathing" assistance immediately on "full- measure" residents. Resident 1 did not self-medicate. Harold Hawkins, M.D. (Dr. Hawkins), Resident 1's treating physician, previously prescribed two Vicodin tablets every eight hours as needed for pain before Resident 1's admission to Abbey. The most frequent adverse reactions of the prescribed medication Vicodin are vomiting, lightheadedness, dizziness, drowsiness, constipation, sedation, nausea, sleepiness and spasm of the urethra, which can lead to difficulty in urination. Abbey's Prescriber Medication Orders policy and procedures required its nursing staff to inquire, to know, to assess and to administer the correct prescribed medication to its residents.5 On September 23, 2002, five days after her admission into the facility, Dr. Hawkins visited Resident 1. During his midday visit, Resident 1 was somewhat lethargic but responsive. At the conclusion of his visit, Dr. Hawkins entered a written medication change order in Resident 1's medical chart regarding her pain management treatment program. He reduced Resident 1's dosage from two Vicodin tablets every eight hours as needed for pain to one Vicodin tablet every eight hours as needed for pain. To evaluate the effect of the reduction in her medication dosage, Dr. Hawkins entered a physician's order requiring staff to take urine samples from Resident 1 throughout the night. This physician's order was not followed by staff nor did staff contact the physician and inform him of their failure. On September 23, 2002, at approximately 7:30 p.m., some six hours after Dr. Hawkins ordered reduction of medication to one Vicodin tablet as needed for pain, the 3:00 p.m.-to- 11:00 p.m. shift nurse, unaware of Dr. Hawkins' ordered reduction in the prescribed medication dosage of Vicodin, gave Resident 1 a dosage of "two" Vicodin tablets. After ingesting two Vicodin tablets, Resident 1 went onto the facility's smoking porch. There she fell asleep in a chair and from approximately 7:40 p.m. until approximately 11:30 p.m., she snored loudly while asleep. Janice Dellaert (Dellaert), registered nurse (RN), was the 11:00 p.m.-to- 7:00 a.m. duty nurse on September 23 and the morning of September 24, 2002. On September 23, 2002, the 3:00 p.m.-to- 11:00 p.m. shift nurse informed Dellaert when she came on duty that Dr. Hawkins had visited with Resident 1 earlier that day. The 3:00 p.m.-to-11:00 p.m. shift nurse shared with Dellaert her opinion that during her shift, Resident 1 "was somewhat 'sleepier' than usual and to keep an eye on her to make sure she was alright during the night." The evidence demonstrated that Dellaert did not heed the cautionary advice given her. At 11:30 p.m., the nursing staff aroused Resident 1 from her four- hour nap. Once awakend, Resident 1's condition was described as somewhat dizzy, slightly disoriented, and able to ambulate to her semi-private room without assistance. Once in bed, Resident 1 went to sleep and resumed her loud snoring throughout the night of September 23, 2003. The credible evidence demonstrated that on September 23, 2002, at approximately 11:30 p.m., Resident 1 was in the condition of being responsive to stimulated arousal efforts and was capable of being aroused from sleep after ingesting two Vicodin tablets some three hours and 50 minutes earlier. Based upon credible and material evidence adduced, a reasonable inference is that Resident 1's 11:30 p.m. capacity to be aroused apparently began to diminish throughout the night and continued diminishing into the early morning hours. Resident 1's gradual diminishing of responsiveness was either undetected or ignored by the night duty nurse. At approximately 3:00 a.m., on the morning of September 24, 2002, Robert Miller (Miller), an experienced certified nursing assistant (CNA), came on duty. Following his normal service routine to those residents assigned to him, he would enter each resident's room, fill the ice-water jug and pass out new drinking cups. He briefly observed each resident when he entered each room. Miller observed Resident 1 when he entered her room, but noticed only that she was snoring loudly. Thus, at 3:00 a.m., four hours after having been aroused and put to bed, Resident 1 was alive. Dellaert recalled from memory that between 11:30 p.m. on the 23rd to 6:30 a.m. on 24th of September 2002, she entered Resident 1's room on three different occasions, awakened her, and attempted to give her medication and take her urine samples. According to Dellaert, Resident 1 was uncooperative, refused to take the medication, and refused to give urine samples on each occasion. During her three visits with Resident 1, Dellaert recalled that she observed no change in Resident 1's condition from her earlier condition (aroused-then sleeping and snoring loudly) at 11:30 p.m. on September 23, 2002. Dellaert, however, chose not to assess Resident 1 by taking her vital signs and chose not to call Dr. Hawkins regarding Resident 1's alleged lack of cooperation in giving urine samples. She chose not to inform him of the medication error of administering two Vicodin tablets to Resident 1. Dellaert's decisions violated Abbey's Prescriber Medication Orders policy. Comparing Dellaert's recollection testimony of her actions and those of Resident 1 the morning of September 24, 2002, to her nurses' note entries covering five hours from 12:00 a.m. to 5:00 a.m. revealed contradictions. Dellaert's initial nurses' note entry covered an hour and 15 minutes from 5:00 a.m. to 6:15 a.m., on September 24, 2002. In that single entry Dellaert entered: "[I] attempted X3 to arouse resident [1] and unable to arouse-snoring very loudly on bed during this time." (emphasis added) This entry contradicts her recollection testimony in paragraph 29 hereinabove. Confronted with a loudly snoring resident, who was non-responsive to stimulated arousal throughout an approximate six-hour period as reflected in her nurses' note entry hereinabove, Dellaert chose not to inform Dr. Hawkins of her inability to get the ordered urine sample from this resident. She chose not to inform the doctor that she had not taken the vital signs of the resident. Dellaert chose not to inform the doctor that Resident 1 had been given two Vicodin tablets instead of one Vicodin tablet as ordered. It was the responsibility of Abbey's nursing staff to inform the physician that Resident 1 would not take the prescribed medication nor give the ordered urine sample. The above choices made by Dellaert exemplified her failure, as an experienced, professional nurse, to provide nursing care in conformity with required professional nursing care standards. Credible evidence established that staff made no attempt to arouse and awaken Resident 1 during the six-hour period between approximately 12:00 a.m. to the early morning hours of approximately 5:30 a.m. on September 24, 2002. The evidence supports a reasonable inference that if staff had attempted to arouse Resident 1 three times and could not do so, the failure to investigate and to determine the cause of Resident 1's non-responsiveness was not an oversight, but was intentional. If, however, one accepted Dellaert's recollection that Resident 1 was aroused on three separate occasions and intentionally refused to take medication or give urine samples, one is led to conclude that Dellaert's failure to report Resident 1's refusals to her treating physician was also intentional. Based on the foregoing, viewed either independently or collectively, and upon reasonable inferences, the evidence convincingly demonstrated that Resident 1 had undergone a change from her responsive condition at 11:30 p.m. to a non-responsive condition at 6:15 a.m. As a direct result of staff's failure and/or refusal to recognize and to note this change in Resident 1's condition, there was created and continued to exist the distinct possibility of "impending harm" to Resident 1. Taking no action under these particular circumstances exemplified nursing care conduct beneath the standard of care required of an experienced, knowledgeable, and professional nursing staff. Between 6:45 a.m. to 7:00 a.m. on September 24, 2002, Edwina Burke (Burke), RN, came on duty to relieve Dellaert. Dellaert recalled informing Burke that she had awakened Resident 1 several times throughout the night and that the resident repeatedly refused to take medication and give a urine sample. Upon entering the resident's room at approximately 6:34 to 6:40 a.m., Burke found Resident 1 on the floor of her bedroom, between the bed and the nightstand, lying on her stomach with vomitus "coming" out of her mouth. At the time she was found, staff described Resident 1's condition as "lips appeared bluish in color, her fists were clenched, and her feet were warm." Burke did not take Resident 1's pulse nor did she check her vital signs when she found her on the floor. Burke did not initiate CPR when she found Resident 1 on the floor. Her initial response was to give instructions to Dellaert to "call 911 and to get paper work prepared to send Resident 1 to the hospital" and to find Miller because "she needed him on the floor to help her with something." From her initial actions and instructions, viewed either independently or collectively, and upon reasonable inference, Burke then considered Resident 1 to have been (alive and) in need of immediate hospitalization. Likewise, from the acquiescence by Dellaert, a reasonable inference is that Dellaert agreed with Burke; Resident 1 was (alive and) in need of hospitalization. This inference is buttressed by the fact that Burke and Dellaert chose not to do an assessment, initiate CPR or any other compression breathing assistance on Resident 1 at any time during their presence in Resident 1's room, in violation of Abbey's CPR policy and procedures. At all times material, Burke did not know whether Resident 1 was DNR (no CPR) or NO DNR (CPR) (i.e. “full measure”). Burke's lack of knowledge was the result of her failure to dispatch someone to review Resident 1's resident care plan file as required by Abbey's CPR policy and procedures. It is significant to note here that Resident 1's resident care plan and medical records identified her as a "full-measure" resident (i.e. when found non-responsive-Abbey's policy and procedures require staff to immediately initiate "compression and breathing" assistance, including initiating CPR and other life- saving efforts). Abbey's CPR policy and procedures do not include the specific term "full-measure" resident. This lack of specificity coupled with only requiring ascertaining whether a non-responsive resident is DNR (no CPR) or NO DNR (CPR), could create confusion among staff. When Miller arrived, Burke instructed him to "get a sheet, come, and help me get her off the floor and back in bed." Miller, trained in administering CPR, did not initiate CPR on Resident 1. When the crash cart arrived, neither Burke nor Dellaert, utilizing the equipment thereon, attempted breathing assistance or attempted revival of this resident. The evidence established that Abbey's three CPR qualified staff members (Burke, Dellaert, and Miller) were simultaneously present in Resident 1's room on the morning of September 24, 2002, and not one initiated "compression and breathing" assistance, CPR nor any other life-saving efforts on Resident 1 (a full-measure/NO DNR resident). When she returned to the resident's room, Dellaert observed her colleagues place Resident 1 in bed and, at that time, concluded Resident 1 was dead. According to Dellaert, Burke informed her that she had tried but did not get a pulse (presumably during her absence from the room) from Resident 1. Between 7:00 a.m. and 7:05 a.m., Dellaert made a nurses' note entry that stated: "CPR was initiated before the paramedics arrived." When questioned, Dellaert acknowledged that "someone" (unnamed in the record) told her to make that entry but she had no personal knowledge of anyone "initiating CPR before the paramedics arrived." Dellaert, continuing: "When I returned from calling 911-I told them not to move Resident 1 because that's what the paramedics instructed me-but Edwina Burke and Miller had already turned her over on her back." Dellaert had no personal knowledge of what occurred, if anything, when she was not present in the room. Following removal of the resident's body, Abbey conducted its internal investigation of the circumstances surrounding the death of Resident 1. After completing its investigation, Abbey's director of nursing, Lyn Homicillada, reviewed the investigative findings. She concluded Dellaert and Burke to have been negligent-"in their failure to follow written policies and procedures regarding advanced directives"- while on duty the night and morning of Resident 1's death. Because of their negligence while on duty (by their joint failure to follow policies and procedures regarding advance directives), Abbey terminated Burke on October 2, 2002, and Dellaert on October 9, 2002. Dellaert understood her termination was--"because of the particular resident (Resident 1) passing away." The expert opinion testimony of Lyn Homicillada that nursing decisions made by Dellaert and Burke were appropriate under Abbey's advance directives and, therefore, permissible decisions is contrary to the facts and to the written policies and procedures regarding advance directives and is therefore rejected. Through interviews conducted with three randomly selected staff members, AHCA clearly demonstrated those staff members: (1) were unable to determine whether a resident was "full-measure" (use every attempt to resuscitate) because the color code system6 did not have a color code to identify a "full- measure" resident; (2) understood the yellow dot meant do not resuscitate (DNR) when found non-responsive; (3) were unable to identify a color code symbol regarding full-measure advanced directives; and (4) were unable to identify the specific locations of the crash carts within the facility. Through a random check of several residents' medical records, AHCA proved that three of those residents on the DNR list did not have DNR identifying yellow dots (policy/procedure required each DNR resident to have a yellow dot sticker in their medical records, on their bed-side medical charts and on their arm/wrist bands). To assist the staff's identification of each color of the color-coding system, staff I.D. tags worn during duty had colored coded dots on the back of each I.D. tag. Even though Abbey had in place a system of identification regarding the DNRs, there existed a lack of consistency in its application and a lack of understanding, among at least three staff members, of the DNR/advanced directives system regarding what to do when confronted with a non-responsive resident who had elected "full- measure" treatment. Neither the advance directives nor the color code system included "full-measure" residents. Through the admissions of three staff members, it was established that Abbey's policies and procedures did not include provisions nor had Abbey provided training for its staff on the critical issue of "when to" initiate CPR on "full-measure" (NO DNR) residents who were found non-responsive. AHCA proved that Abbey failed to include in its policies and procedures an essential written proviso regarding: first, the term "full measure," also used to identify a NO DNR resident; and second, the critical issue of "when to" initiate CPR on "full-measure" residents as a life-saving effort based on advanced directives as alleged in Tag F-156. Abbey's policy and procedures did not include the term "full-measure" residents. AHCA alleged in Tag F-281 a "failure to meet a quality of care requirement by failing to meet professional standards of practice." Specifically, AHCA alleged that Abbey (1) failed to continually assess Resident 1 throughout the evening and early morning hours preceding her death; (2) failed and/or refused to notify Resident 1's physician, Dr. Hawkins, of the resident's "failure to respond" after three attempts to arouse her were made; (3) failed to correctly administer pain medication; and (4) failed to initiate CPR on a "full-measure" resident. In violation of Abbey's written policy and procedures regarding Prescriber Medication Orders and CPR General Guidelines for Assessment. Between 7:00 a.m. and 7:05 a.m., Dellaert made a nurses' note entry that stated: "CPR was initiated before the paramedics arrived." By admission, Dellaert acknowledged that "someone" (unnamed in the record) told her to make that entry but she had no personal knowledge of anyone "initiating CPR before the paramedics arrived." In explaining this nurses' note entry, Dellaert admitted she was "wrongly assuming the other nurse [Burke] started CPR-but she didn't." AHCA proved that Abbey's nursing staff: (1) failed to continually assess Resident 1 throughout the evening and early morning hours preceding her death on September 24, 2002; (2) failed to initiate CPR; (3) failed to correctly administer pain medication; and (4) failed and/or refused to notify Resident 1's physician, Dr. Hawkins, of Resident 1's "refusing medication and lack of response." These failures constitute violations of Abbey's policies and procedures regarding CPR, Prescriber Medication Orders, and Physician Notification requirements. Dellaert acknowledged a familiarity with Abbey's written policies and procedures regarding residents who did not sign advanced directives and those residents who have a DNR and those residents who elected "full measure." She had prior training on Abbey's policy and procedures regarding "how to" administer CPR. When a non-responsive resident is discovered, the facility's written policy and directives require staff to: assess (checking vital signs) and determine the resident's non-responsiveness (breathing or not breathing) by tapping or gently shaking the resident and shouting, "Are you okay”; call out for help; and (3) delegate a specific individual to check the resident care plan for DNR (do not administer CPR) or NO DNR (administer CPR) order and call paramedics, attending physician, and administrative personnel. The above "procedures" to assess and determine Resident 1's non-responsiveness, to notify the attending physician, and to determine a reason for her breathlessness when she was discovered on her bedroom floor were not followed by either Burke or Dellaert. It is significant and noted that the above-referenced procedure makes no mention of a NO DNR resident who is identified by the term "full-measure" as opposed to residents who are identified by acronyms DNR or NO DNR. Dellaert, again from memory, disavowed any knowledge of Abbey's policies and procedures booklets containing instructions to the nursing staff on "when to" administer CPR to a non-responsive resident (to include a "full-measure" resident). She had not attended nor did she know of any staff training on "when to" initiate CPR on a non-responsive, "full- measure" resident. A reasonable inference is that Dellaert did not fully understand the term "full measure" to have the same meaning, regarding CPR treatment, as the acronym NO DNR. AHCA proved that Abbey failed to implement written policies, procedures, and training regarding advanced directives, by omission of clearly written policy and procedures regarding "when to" initiate CPR to residents who are identified by the term "full-measure" resident. Abbey's policies and procedures do not provide a system to inform and alert staff working the facility floor of the resident's election of "full- measure" (i.e. NO DNR) immediate CPR treatment. The "full- measure" information is contained in a resident's medical files and required checking the non-responsive resident's medical record file before administering CPR to the resident. The delay, to the determent of the non-responsive "full-measure" resident, is to determine if CPR is to be administered to the resident based upon the resident's election of DNR or NO DNR. Upon finding Resident 1 non-responsive, on the bedroom floor between the nightstand and bed, staff did not check for a pulse, did not take vital signs, and did not send anyone to check her medical records. Staff did not initiate CPR nor call Resident 1's physician. Staff did not use the crash cart equipment when it arrived. Confronted with these specific circumstances in the early morning hours of September 24, 2003, Abbey's nursing staff chose to return Resident 1 to her bed. After returning Resident 1 to her bed, Abbey's nursing staff called 911 for Emergency Medical Technicians (EMTs) who arrived some three to eight minutes after receiving the call. The EMT took Resident 1's vital signs, initiated CPR, got no response, and pronounced Resident 1 dead at approximately 7:10 a.m. on September 24, 2002. Abbey's nursing staff's failure to assess the non- responsive resident and the failure to initiate compression breathing and other life saving measures, including initiating CPR, to the "full-measure" (NO DNR) resident constituted a violation of Abbey's existing policy and procedures regarding discovery of a non-responsive resident. The policy and procedures required checking for vital signs, determining from the medical chart whether the resident is DNR or NO DNR, and following through with compression breathing and other life saving measures or not. It is reasonable to assume that finding a "full- measure" resident non-responsive and face down on the floor created the time and the occasion for a professional nursing staff to conclude that such time was the appropriate time and appropriate occasion "when to" initiate CPR on a non-responsive resident. The assumption is valid whether or not staff knew, at that moment, if the resident was identified "full-measure" or NO DNR. The finder of fact is not determining whether CPR would have revived or would have prevented Resident 1's death. The unrefuted evidence demonstrated that upon finding the resident on the floor of her bedroom, Resident 1 was not clinically dead. Confronted with those circumstances, staff made no attempt to ascertain whether the resident was "NO DNR," "DNR" or "full-measure"; failed to administer resuscitative efforts; and, thereby, failed to attempt and failed to provide care and services that met professional standards of quality of care of a professional nursing practice. Abbey's argument that Resident 1 was in rigor mortis at approximately 7:00 a.m. when discovered on her bedroom floor is a false cause argument without foundation in fact and summarily rejected by the fact finder. Assuming arguendo that the expert opinion of Abbey's director of nursing--"rigor mortis occurs after a person is dead and, for a person the size of Resident 1, it would take less than two hours [i.e. between 5:00 a.m. and 7:00 a.m.]" is accepted; Resident 1's death would then have occurred during the 5:00 a.m. to 6:15 a.m. time span. During this very time span, Dellaert testified and included in her nurses' notes that Resident 1 was (alive and) "snoring very loudly." Based upon credible evidence, AHCA proved that Abbey's staff failed to assess and to continually assess Resident 1 throughout the night of September 23, 2002, from 12:00 a.m. through the early morning hours of September 24, 2002, between 6:15 a.m. and 7:00 a.m. AHCA proved that Abbey's nursing staff failed and refused to notify Resident 1's physician, Dr. Hawkins, of Resident 1's "failure to respond" during the time span of 12:00 a.m. through 6:30 a.m. to 7:00 a.m. on September 24, 2002. 58.. AHCA proved that Abbey's nursing staff failed to correctly administer prescribed pain medication to Resident 1, by proving that staff gave her a dosage of two Vicodin tablets within six hours after Dr. Hawkins ordered her medication be reduced to one Vicodin tablet dosage as needed for pain. AHCA proved that Abbey's nursing staff failed and refused to follow Abbey's directives and policy upon discovering Resident 1 on the floor non-responsive. The policy and procedures required staff, when a resident is found non- responsive (without specific reference to NO DNR or DNR), to make an assessment (check vital signs) to determine responsiveness (have someone ascertain from medical records if resident is DNR or NO DNR), and if NO DNR, immediately initiate "compression and breathing" assistance, to include immediate initiation of CPR and other life-saving efforts. Staff chose to ignore all of the above policy and procedural requirements. Tag F-333 alleged that Abbey failed to ensure that Resident 1 was free of any significant medication error. Resident 1 was not given the correct medication as ordered by her treating physician, Dr. Hawkins, during his earlier visit on September 23, 2002. Within less than six to eights hours after Dr. Hawkins' medication change order of September 23, 2002, staff gave Resident 1 two tablets of the prescribed drug Vicodin. It is significant that no evidence of record suggests that Dellaert or Burke knew of the medication change order. Additionally, the fact that Resident 1's certificate of death report list the cause of death as "morphine toxicity" and the manner of death as an "accident" does not absolve nor mitigate Abbey's responsibility to administer the correct dosage of medication as ordered by the resident's physician and contained in her residential medical record. At all times material, Abbey had in place written policies and procedures regarding: CPR, Resuscitator (Manual, Portable),7 Prescriber Medication Orders, and Physician Notification. Other than the written requirement that a resident's election of "full-measure" treatment be included in that resident's care plan file, the omission of any references to "full-measure" (compared to NO DNR) resident elsewhere in Abbey's policies and procedures under consideration herein is systemic and the primary causation factor in this case. The only implied reference to a "full-measure" resident is found in the provision requiring staff to: "delegate a specific individual to check resident care plan for DNR or No DNR [and “full measure”] order." Abbey's CPR policy and procedures does not include the term "full-measure" (NO DNR) residents and does not include nor refer to a color code system as a means of identifying a "full- measure" resident, thereby enabling an immediate identification and determination when a "full-measure" resident is found breathless to initiate CPR. AHCA proved by evidence that is clear and convincing that Abbey's staff was negligent in their failure to immediately identify Resident 1 as a "full-measure" (NO DNR) resident and to immediately implement CPR procedures when Resident 1 was found non-responsive on the floor. The evidence is equally clear that the staff did not initiate CPR or any other compression breathing procedures on Resident 1 at any time during the morning of September 24, 2002. AHCA assigned a Class I deficiency to Tag F-156 (advance directives), Tag F-224 (neglect of residents), and Tag F-281 (beneath standard of quality of care). The staff demonstrated inconsistency in their knowledge of the facility's DNR/advance directive system. Tag F-224 generally alleged failure to provide or arrange services that meet professional standards of quality care through the implementation of the policy that prohibits neglect of residents. When Abbey's nursing staff found Resident 1 non-responsive on the floor, staff made two decisive choices. Staff chose not to take her vital signs to assess her condition and staff chose not to initiate "compression breathing" or CPR. As a result of Resident 1's death, Abbey investigated and dismissed both nurses for not following Abbey's policies and procedures regarding advanced directives that were directly related to the critical time period preceding the death of Resident 1. Immediate corrective action is necessary to prevent similar reoccurrences that would cause or is likely in the future to cause serious injury, harm, impairment, or death to other "full-measure" residents found non-responsive in the facility. The evidence clearly and convincingly demonstrated that at every critical juncture, staff chose to neglect the appropriate care of Resident 1. Staff did not recognize or chose to ignore clinical signs of distress (continuous loud snoring) and/or pending death (inability to be aroused over an extended time period). Staff chose not to assess Resident 1's condition by taking her vital signs when confronted with a non- responsive resident. Staff chose not to notify Resident 1's physician and inform him of her condition and inform him of the amount of medication administered to her. Staff chose not to seek advice, direction and medical instructions from the physician. In view of the cited conduct of Abbey's professional nursing staff, immediate corrective action is necessary because staff's non-compliance and lack of training caused or is likely in the future to cause serious injury, harm, impairment, or death to "full-measure" residents found non-responsive in this facility. Tag F-281 generally alleged failure to meet a quality of care requirement by the failure to meet professional standards of practice. Staff chose not to assess and continually assess Resident 1, the night of September 23, 2002, and early morning hours of September 24, 2002. Staff chose not to check or not to accept or lacked the ability to identify non- responsiveness of Resident 1 as a "change in condition." Staff did not possess knowledge and/or training of "when to" initiate "compression breathing," CPR, or other life saving efforts on a "full-measure" (NO DNR) resident found on the floor of the facility. Staff was negligent in administering the incorrect dosage of a controlled drug pain medication with the known side effect of "sleepiness." Staff chose not to inform the physician that his patient, who was snoring loudly, had been administered incorrect medication. Immediate corrective action is necessary. Non-compliance by staff resulting from either omissions in facility policies and procedures and/or staff's lack of knowledge and training regarding the above-cited areas of professional responsibility has caused or is likely in the future to cause serious injury, harm, impairment, or death to another "full-measure" (NO DNR) resident similarly situated. Tag F-333 generally alleged that Abbey had failed to ensure that Resident 1 was free of any significant medication errors. The physician's medication order decreased Resident 1's level of Vicodin from two tablets to one tablet approximately seven hours before staff gave two tablets to Resident 1. The two-tablet medication error contributed to an increase in one of its side effects- "sleepiness." Earlier, when Resident 1 was given one Vicodin tablet she was capable of being aroused and awakened four hours later. When she was given two Vicodin tablets at approximately 11:30 p.m., assuming staff did attempt unsuccessfully to arouse Resident 1 on three occasions thereafter throughout the night, staff chose not to inform the attending physician of the change, from 11:30 p.m. (arousal) to early morning (non-arousal), in condition Resident 1 had undergone. The admitted failure of staff to administer the correct medication dosage caused actual harm to Resident 1. Though the seven-hour delay from administering the incorrect dosage of medication to the jeopardy in which Resident 1 was put may not have been immediate; the medication error was none the less a contributing factor to her increased "sleepiness." Resident 1's inability to be aroused, after three attempts, if made, is a change from the 11:30 p.m. condition when she was aroused, awakened, and put to bed. Abbey's nursing staff chose not to report the difficult-to-be-aroused change in the resident's condition to her physician. This choice was a direct violation of Abbey's Physician Notification policy in effect at the time. AHCA also assigns a "scope" rating to an alleged deficiency. A scope can be "isolated," "patterned," or "widespread." Tag F-156 alleged and AHCA proved that Abbey's policy and procedures did not contain directives to staff regarding "when to" initiate CPR on a resident whose medical records reflect their election of "full-measure" when found by staff to be non-responsive. Through interviews with at least three other staff members and the testimony of two nurses, AHCA proved that five staff members did not know "when to" initiate CPR on non- responsive residents. Likewise, Abbey had not trained those five staff members on how to assess and identify situations such that they would know "when to" initiate CPR on non-responsive, "full-measure" residents. A lack of knowledge and a lack of staff training by the facility contributed to staff's failure to administer CPR to Resident 1 when she was discovered in a non- responsive condition. Abbey has the obligation and responsibility to educate and train its staff. Abbey's failure to educate and train its staff resulted in five staff members not knowing "when to" administer CPR to a non-responsive resident. Such lack of training is pervasive and widespread among staff. The scope of the negative effect of this lack of training includes every "full-measure" (NO DNR) resident found non-responsive. This lack of training poses a real and potential impact on every non-responsive, "full-measure" resident found in the facility. The omission of advance directives specifically including identification, assessment, and treatment of a "full-measure" resident in Abbey's policies and procedures is systemic.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order: Upholding the assignment of the Conditional licensure status for the period of October 8, 2002, through October 28, 2002, on Respondent's facility and imposing costs of $6,000 for costs associated with the six-month survey; Finding that Respondent failed to implement written policies and procedures regarding advanced directives addressing treatment of "full-measure" residents, in violation of 42 C.F.R. Section 483.10(b)(8), as alleged in Tag F-156 and imposing an administrative fine of $15,000 for non-compliance found in Count I of the Administrative Complaint; Finding that Respondent failed to implement written policies and procedures to prohibit neglect of residents in violation of 42 C.F.R. Section 483.13(c), as alleged in Tag F- 224, and imposing an administrative fine of $10,000 for non- compliance found in Count II of the Administrative Complaint; Finding that Respondent failed to provide or arrange services that meet professional standards of quality care in violation of 42 C.F.R. Section 483.20(k), as alleged in Tag F- 281 and imposing an administrative fine of $10,000 for non- compliance found in Count III of the Administrative Complaint; and Finding that Respondent failed to provide or arrange services that meet professional standards of quality care in violation of 42 C.F.R. Section 483.20(k), as alleged in Tag F- 281, and imposing an administrative fine of $2,500 for non- compliance found in Count VI of the Administrative Complaint, for a total of $43,500. DONE AND ENTERED this 25th day of February, 2004, in Tallahassee, Leon County, Florida. S FRED L. BUCKINE 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 25th day of February, 2004.
The Issue Whether the license of the Respondent, Cynthia A. Means, should be revoked or suspended, or whether Respondent should be otherwise disciplined for abuse of a patient.
Findings Of Fact The Respondent, Cynthia Ann Means Sapp, is a licensed practical nurse who holds License No. 0460011. She was employed at the Clearwater Convalescent Center during the month of August, 1978. An administrative complaint dated November 2, 1978, was filed by the Petitioner, Florida State Board of Nursing, alleging that the Respondent had physically abused an elderly patient in her care; that while administering medications in the course of her duties the Respondent left medications unattended and the door to the medication room unlocked; and that while dispensing medications the Respondent left the medication cart unattended. The Petitioner Board also alleged that the Respondent had injected a patient with 2,000 mg. of Tigan I.M., whereas the physician's order had called for only 200 mg. to be injected, and that when said patient was transported to the hospital she was diagnosed as having a marked atrial fibrilation secondary to the overdose of the Tigan. Respondent requested an administrative hearing. Respondent admitted at the hearing that on or about August 11, 1978, while on duty as a licensed practical nurse at the Clearwater Convalescent Center in Clearwater, Florida, she had administered 2,000 mg. of Tigan I.M. to an 80-year-old patient in her care, although the physician's order had called for only 200 mg. to be injected. After being transported to the hospital said patient was diagnosed as being "in a marked atrial fibrilation with a marked decreased ventrical response probably secondary to the overdose of Tigan." Respondent expressed regret over the incident. On or about August 14, 1978, Ms. Marie Parel, an elderly patient in the Clearwater Convalescent Center, was walking from the dining room with a walking cane. Said patient had a history of being more or less belligerent at times and would become upset when forced to do anything against her will. The Respondent attempted to get Ms. Parel into a Gerry chair and met with some opposition from her. A struggle ensued, and Respondent pushed, shoved and roughly forced Ms. Parel into the chair. During the struggle Ms. Parel was bruised on the face and arms. Ms. Parel became so upset that her daughter had to be called. The daughter talked to her mother, but Ms. Parel remained in an emotional state for several hours. The Respondent's actions were reported to the center's Director of Nurses by another nurse who was present at the time. Subsequent to this incident, the Respondent was discharged from her employment at the center. There were no written or oral instructions given to employees of the convalescent center relative to the locking of the door to the medication room, or to the attendance or placement of the medication cart. There is insufficient evidence to show that the Respondent did in fact leave the medication room unattended and the door unlocked, or that she left the medication cart unattended in the hallways and in the patients' rooms.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law the Hearing Officer recommends that the Respondent, Cynthia A. Means, be placed on probation for a period not exceeding one year. DONE and ORDERED this 6th day of July, 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 Martin J. Jones, Esquire 145 Fifth Avenue, Northeast St. Petersburg, Florida 33701 Geraldine B. Johnson, R. N. Florida State Board of Nursing 111 East Coastline Drive, Suite 504 Jacksonville, Florida 32202 ================================================================= AGENCY FINAL ORDER ================================================================= IN THE MATTER OF: Cynthia Ann Means Sapp BEFORE THE FLORIDA STATE BOARD OF NURSING As a Registered Nurse Case No. 78-2212 2220 U.S. Highway 19 North License Number 0460011 Bldg. 25, Apt. 242 Clearwater, Florida 33515 /
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant facts are found: At all times pertinent to this proceeding, respondent was a licensed practical nurse holding license number 11005-1. On April 8th and 9th 1975, respondent was employed at St. Vincent's Medical Center in Jacksonville, Florida. As required by federal law and the normal course of the business of pharmacy, the pharmacist of the Center maintains and retains narcotic control records which chart the withdrawal and disposition, of controlled substances. The narcotic control records introduced into evidence as Exhibit 2 record the disposition of various dosages of meperidine ampuls. Demerol is the trademark name of the generic drug meperidine, which is a controlled substance under Ch. 893 of the Florida Statutes. St. Vincent's Medical Center has specific procedures to be followed when withdrawing and administering narcotic drugs. When a nurse withdraws a narcotic drug for a patient, it is her duty to fill out the narcotic control record showing the date, the time, the dosage, the patient to whom the drug is to be administered, the treating physician and the signature of the person withdrawing and administering the substance. The substance should then be administered to the patient within minutes of the withdrawal time, and the time of administration and dosage should immediately be noted or charted on that portion of the patient's medical record entitled "Nurses Notes." From the testimony adduced at the hearing, and by comparing the narcotic control records with the "Nurses Notes" on several patients; it is clear that on April 8th and 9th, 1975, respondent did not chart or note as having administered a substantial quantity of the drugs withdrawn by her. Furthermore, many that she did chart were not specific as to the time administered or the time charted was a half hour or more from the time listed on the narcotic control record. There was no evidence that respondent was using these drugs for her own purposes or that the patients, in fact, did not receive their medication after it was withdrawn by respondent. It was respondent's testimony that the discrepancies existing between the narcotic control sheets and the "Nurse's Notes" resulted from either errors in charting on another patient's chart or mistakenly forgetting to chart the administration due to being so busy or short-staffed. Respondent denied taking any of the narcotic drugs herself.
Recommendation Based upon the findings of fact and conclusions of law recited above, it is recommended that the Board of Nursing find respondent guilty as charged in the administrative complaint and suspend respondent's license for a period of six (6) months. Respectfully submitted and entered this 9th day of August, 1976, in Tallahassee, Florida. DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Ms. Geraldine Johnson Florida State Board of Nursing 6501 Arlington Expressway Jacksonville, Florida 32211 Mr. Juluis Finegold 1130 American Heritage Life Building Jacksonville, Florida 32202 Ms. Dorothy M. Hall Cobb 1720 West 13th Street Jacksonville, Florida 32209
