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 At all times material hereto, Petitioner, R & R Guest Home, Inc., was licensed to operate an adult congregate living facility at 720 Southwest 6th Street, Dania, Florida. On February 5, 1987, the Respondent caused to be conducted an investigation at Petitioner's facility to determine whether a resident, J. T., was appropriately placed. That investigation resulted in the Respondent concluding that the resident needed care beyond that which Petitioner was licensed to provide. Pursuant to the mandate of Section 400.426(7), Florida Statutes, Respondent delivered to Petitioner that day a health assessment form for the resident, with directions that it be completed by the resident's examining physician and returned to Respondent within 30 days. The health assessment form was apparently completed by the resident's examining physician on February 10, 1987, but Petitioner did not submit it to the Respondent until March 30, 1987.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a Final Order be entered which sets and levies a $250.00 fine against R & R Guest Home, Inc., for its failure to comply with Section 400.426(7), Florida Statutes. DONE and ENTERED this 6th day of January, 1988, in Tallahassee, Florida. WILLIAM J. KENDRICK Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 904/488-9675 FILED with the Clerk of the Division of Administrative Hearings this 6th day of January, 1988. COPIES FURNISHED: Rholanda Higgs-Rule R & R Guest Home, Inc. 720 Southwest 6th Street Dania, Florida 33004 Leonard T. Helfand, Esquire Department of Health and Rehabilitative Services 5190 Northwest 167th Street Miami, Florida 33014 Gregory L. Coler, Secretary Department of and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700 Sam Power, Clerk Department of Health and Rehabilitative Services 1323 Winewood Boulevard Tallahassee, Florida 32399-0700
The Issue At issue is whether Respondent committed the offenses set forth in the Second Amended Administrative Complaint and, if so, what penalty should be imposed.
Findings Of Fact Stipulated Facts The Petitioner is the State Agency charged with the regulation of the practice of nursing pursuant to Chapters 20,456 (formerly Chapter 455, Part II; see Chapter 2000-160, Laws of Florida) and 464, Florida Statutes. Pursuant to the authority of Section 20.43(3)(g), Florida Statutes, the Petitioner has contracted with the Agency for Health Care Administration to provide consumer complaint, investigative and prosecutorial services required by the Division of Medical Quality Assurance, councils or boards, as appropriate, including the issuance of emergency orders of suspension or restriction. Respondent is Cynthia Chance. Respondent is a Licensed Practical Nurse in the State of Florida, having been issued license No. PN 0855441. On or between March 1997-May 1997, Respondent was employed by Health Force, a nurse-staffing agency. In or about March 1997, Respondent was assigned to work various shifts at Baptist Medical Center-Beaches. In or about March 1997, Respondent submitted time slips to Health Force alleging that she had worked an eight-hour shift on March 18, 1997. In or about March 1997, Respondent submitted time-slips to Health Force alleging that she had worked an eight-hour shift on March 21, 1997. Findings of fact based on the evidence of record Missing Drugs On May 13, 1997, Health Force received a "late call" from Cathedral Gerontology Center (Cathedral) needing a "stat" nurse because one of their nurses had not come to work. Tresa Streeter (now Calfee), administrator for Health Force, called Respondent who reported to Cathedral at 6:50 p.m. Kim Harrell, R.N., a supervisor at Cathedral, was the nurse who stayed until Respondent arrived. Also at 6:50 p.m. on May 13, 1997, Barbara Kelley, R.N., received and signed for a delivery of medications for residents from American Pharmaceutical Services. Included in that delivery was an order of Alprazolam (Xanax) and an order of Diazepam (Valium) for two residents on the floor where Respondent was working that evening. The delivery came with a separate medication or narcotics card for each medication. There were two floors of residents at Cathedral. Each floor had its own medication cart and its own nurse assigned to the floor. Controlled medications have a separate box in the medication cart with a separate key. The nurse on each floor had a key to her own medication cart but did not have a key to the medication cart of the other floor. The Director of Nursing (DON) also had a key to both medication carts in the event of an emergency such as a lost key. After receiving and signing for these drugs, Nurse Kelley locked the medications that belonged to her medication cart in it and inserted the narcotic cards for those medications into the notebook that corresponded to her cart. She then gave the medications and control sheets that belonged to Respondent's medication cart to Respondent, placing them in Respondent's hand. Nurse Kelley told Respondent that these were controlled drugs and instructed Respondent to lock up the medications in Respondent's medicine cart. There is conflicting testimony as to what happened next. Respondent admits to receiving the medications and the control cards. However, Respondent maintains that she placed the medications in the locked drawer of the medication cart and inserted the cards into the notebook in front of Nurse Kelley, whereas Nurse Kelley maintains that she walked away immediately after giving the drugs and cards to Respondent and did not see her place the drugs in the controlled drug lock box or the cards in the notebook. It was a policy at Cathedral for the out-going nurse to count controlled drugs with the on-coming nurse. When Respondent arrived on the night in question, she counted the controlled medications with Nurse Harrell. The narcotics count for both narcotics cards and actual doses was 16. At the end of her shift, Respondent counted the controlled medications with the on- coming nurse, Pamela Schiesser. The number of narcotics cards and tablets or doses was 16, the same as when Respondent came on duty. Nurse Schiesser was scheduled to work a double shift, 11 to 7 and 7 to 3. During the 11 to 7 shift, Nurse Schiesser was the only nurse for both floors of residents and she, therefore, had the key to both medication carts. Sometime during the 7 to 3 shift on May 14, 1997, Nurse Schiesser called the pharmacy to find out about a medication order she had placed for two residents so they would not run out. She was informed by the pharmacy that the drugs had been delivered the evening before and that they had been signed for by Nurse Kelley. She checked the delivery sheets and confirmed that Nurse Kelley had signed for the medications. After determining that there were no cards for the missing drugs and the drugs were not in the cart, she then reported to her supervisor, Kim Harrell, that the medication had been delivered but could not be located. Nurse Schiesser and Nurse Harrell checked the entire medication cart, the medication cart for the other floor and the medication room but did not find the missing medications. Nurse Harrell then notified the Assistant Director of Nursing (ADON), Lu Apostol, and the Director of Nursing (DON), Fely Cunanan, regarding the missing medications. The ADON began an investigation and secured written statements from all of the nurses on her staff who had access to the drugs: Nurses Kelley, Harrell, and Schiesser. She called Nurse Kelley to confirm that she had received the medications from the pharmacy and confirmed that the two missing medications, Alprazolam (Xanax) and Diazepam (Valium), were given by Nurse Kelley to Respondent. The ADON also called Tresa Streeter (now Calfee), the administrator of Health Force for whom Respondent worked to notify her of the missing medications. On May 14, 1997, Ms. Streeter (Calfee) called Respondent and informed her about the missing drugs. On May 15,2000, Ms. Streeter and Respondent went to Cathedral for a meeting. They were informed that the two missing drugs had not been located and they were shown the written statements of the other nurses. Respondent admitted that the drugs had been given to her the night before by Nurse Kelley, but stated that she had locked the drugs in her cart. She denied any further knowledge about the drugs. At Ms. Streeter's suggestion, Respondent took a blood test on May 15, 2000.1 The drug test result was negative thus indicating that the drugs were not in her blood at the time of the test, which was two days after the drugs were missing. No competent evidence was presented as to how long it takes for these drugs to leave the bloodstream. Cathedral had a policy that required that all controlled substances be properly accounted for and secured by each nurse responsible for the drugs. This policy was verbally communicated from the off-going nurse to the oncoming nurse. When Nurse Kelley gave the drugs and drug cards in question to Respondent, she specifically instructed Respondent to lock up the drugs in the narcotics drawer. Respondent maintains that other people had keys to her medication cart and could have taken the drugs after she put them in the locked narcotics box. This testimony is not persuasive. Every witness from Cathedral testified unequivocally that there was only one key in the facility for each medication cart and that key was in the possession of the nurse assigned to that cart. The only other key, which was in the possession of the Director of Nursing, was not requested or given to anyone at anytime material to these events. The persuasive testimony is that Respondent was the only person during her shift with a key to her medication cart. That key was passed to Nurse Schiesser who discovered that the drugs and narcotics cards were not in the medication cart or notebook. The count of the drugs and the cards on hand did not show that anything was missing at the change of shift from Respondent to Nurse Schiesser as the count was 16, the same as when Respondent came on the shift. If Respondent had put the drugs and corresponding cards in the medication cart, the count should have been 18. The only logical inference is that Respondent did not put the drugs or cards in the cart. In the opinion of the two witnesses accepted as experts in nursing and nursing standards, Respondent's failure to properly secure the narcotics and to document the receipt of these controlled drugs constitutes practice below the minimal acceptable standards of nursing practice. Time-Slips While employed by Health Force as an agency nurse, Respondent was assigned at various times to work at Baptist Medical Center-Beaches (Beaches). Respondent submitted time cards or slips for each shift she worked to Health Force so that she would be paid for the work. Respondent submitted time-slips for working at Beaches on March 18 and 21, 1997. When Health Force billed Beaches for these two dates, Anne Hollander, the Executive Director of Patient Services, the person responsible for all operations at Beaches since 1989, determined that Respondent had not worked on either March 18 or 21, 1997. Ms. Hollander faxed the time-slips back to Health Force for verification. She advised Health Force that Respondent was not on the schedule as having worked on either of those dates. She also advised Health Force that the supervisor's signatures on the two time-slips did not match anyone who worked at Beaches. Ms. Hollander is intimately familiar with the signatures of all the supervisors who are authorized to sign time-slips at Beaches and none of them have a signature like the signatures on the two time-slips. Health Force did an investigation and ended up paying Respondent for the two days, but did not further invoice Beaches. Health Force was never able to determine whose signatures were on the time-slips. Health Force did have Respondent scheduled to work at Beaches on March 21, 1997, but not on March 18, 1997. Beaches keeps a staffing sheet for every day and every shift. The supervisors are responsible for completion of the staffing schedules to ensure that the necessary staff is scheduled to work on each shift. These staffing sheets are used for both scheduling and doing the payroll. According to Ms. Hollander, it is not possible that Respondent's name was just left off the staffing sheets. The staffing sheets are the working sheets. If a person works who is not originally on the staffing sheet, the supervisor writes that person's name into the correct column at the time they come to work. Ms. Hollander has been familiar with these staffing sheets for 12 years and does not recall any time when someone's name has been left off the staffing sheet when he or she had worked. The two supervisors who testified, Erlinda Serna and Carol Lee, are equally clear that in their many years of experience as supervisors at Beaches, no one has worked and not been on the staff schedules. Anybody who worked would show up on the schedule. Every shift and every day should be on the staffing schedules. Ms. Serna is unaware of any time in her 10 years at Beaches that someone's name was left completely off the schedules, but that person actually worked. Respondent's name was on the staffing schedule for March 21, 1997, but it was crossed out and marked as cancelled. When agency nurses are scheduled at Beaches, but are not needed, they are cancelled with the agency. If the agency fails to timely notify the nurse and the nurse shows up for work, the agency must pay her for two hours. If the hospital fails to notify the agency timely and the nurse shows up for work, then the hospital must pay the nurse for two hours. In no event is a nurse who is cancelled paid for more than two hours. There are times when a nurse is cancelled and shows up for work, but the hospital has a need for the nurse either as a nurse or in another capacity such as a Certified Nursing Assistant (CNA). If that happens, the nurse's name is again written into the nursing unit staffing schedule. For March 18, 1997, Respondent's name is not on the schedule for Beaches. She did not work in any capacity on March 18, 1997. For March 21, 1997, Respondent's name was on the schedule, but she was cancelled. Even if she had not been timely notified that she was cancelled and she showed up for work, the most she could have billed for was two hours. If she had stayed and worked in a different capacity, her name would have been rewritten into the staffing schedule. Beaches is very strict and follows a specific protocol. No one except the supervisors is allowed to sign time cards. The signatures on these two time cards do not belong to any supervisor at Beaches. Therefore, it can only be concluded that Respondent did not work on March 18 or 21, 1997, at Beaches and that she submitted false time-slips for work she did not do on March 18 and 21, 1997. In June 1997, Respondent was also working as an agency nurse for Maxim Healthcare Services (Maxim). On June 8, 1997, Respondent submitted a time ticket to Maxim and to Beaches indicating that she had worked eight-hour shifts at Beaches on June 2, 3, 4, and 5, 1997. All four days were on the same time ticket and purported to bear the initials and signature of Carol Lee. This time ticket was brought to Ms. Hollander's attention because Beaches had a strict policy that only one shift could appear on each time slip. Even if a nurse worked a double shift, she would have to complete two separate time tickets, one for each shift. Under Beaches policy, no time ticket would ever have more than one shift on it. The time tickets are submitted to Ms. Hollander's office daily with the staffing schedules that correspond. Therefore, a time ticket for a person who is not on the staffing schedule would immediately stand out. When Ms. Hollander was given the time ticket for June 2-5, 1997, she investigated and reviewed the staffing sheets for those days. Respondent was not listed on any of the staffing schedules. Ms. Hollander then showed the time ticket to Erlinda Serna, who was the nursing supervisor on the 3 to 11 shift. Nurse Serna verified that Respondent had not worked on the shift any of those days. Ms. Hollander then showed the time-slip to Carol Lee, the 11 to 7 nursing supervisor. Carol Lee verified that she had not initialed or signed the time ticket and that the initials and signature were a forgery. Nurse Lee would not have signed a time ticket with more than one shift per time ticket because she was well aware of the policy prohibiting more than one shift per time ticket. Nurse Lee verified that Respondent had not been scheduled to work any of those days and that Respondent had not worked on June 3, 4, or 5, 1997. These inquiries to Nurse Serna and Nurse Lee took place within a few days after the dates for which Respondent had submitted this time ticket. Therefore, the matter was fresh in the minds of both nursing supervisors. Both are certain that Respondent was neither scheduled nor worked on June 2-5, 1997. Only nursing supervisors at Beaches are authorized to sign time tickets. Maxim Healthcare has a policy of never working a nurse in excess of 40 hours in one week. The same policy was in effect in 1997. Susan Ranson, the records custodian who also staffs for Maxim on the weekends and assists in their billing, indicated that Respondent was paid by Maxim for working at another facility the same week as June 2-5, 1997. June 2-5, 1997, are a Monday through Thursday. Specifically, Respondent submitted a time ticket to Maxim for another facility showing that she worked 12 hours on Saturday, June 7, 1997, and 13 hours on Sunday, June 8, 1997. Maxim pays from Monday through Sunday. If Respondent had worked 32 hours at Beaches on Monday through Thursday and then 25 hours at another facility on Saturday and Sunday, she would have worked more than 40 hours in one week, which would have violated their policy and would have required Maxim to pay overtime. When Maxim gets a request for a nurse and has no one to send who would not exceed 40 hours in one week, rather than exceed 40 hours, the agency does not staff the job. In the disciplinary document from Health Force dated June 18, 1997, Health Force advised Respondent that it would not be scheduling her based on the complaints they received regarding false billing, the missing drugs at Cathedral, and another incident at Beaches that occurred during this same time. Taken in its totality, the testimony of Respondent is not credible. Respondent's explanation of the discrepancy in the count of drugs and corresponding cards is that during her shift "there was [sic] one or two cards that only had one or two pills on them, so you just throw them away. And that's what made it back to 16." This explanation is unpersuasive. If there had been any pills left in the drawer from cards that Respondent threw away, the count would have been off at the change of shift. Moreover, several witnesses testified as to the care that is taken to carefully account for all narcotics. Respondent's assertion that narcotic pills were simply thrown away is not credible. Nurse Schiesser clearly remembered that there were no cards for the medications in question and there were no medications from this delivery in the medication cart. Respondent has been previously disciplined by the Board of Nursing in the Board's case No. 98-20122.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law set forth herein, it is RECOMMENDED: That the Respondent be found guilty of one count of violating Section 464.018(1)(h), Florida Statutes, by failing to secure and document receipt of the drugs at Cathedral Gerontology Center; That the Respondent be found guilty of one count of violating Section 464.018(1)(h), Florida Statutes, and of violating Rule 64B9-8.005(1), Florida Administrative Code, by falsifying employment and time records on multiple occasions; and That a penalty be imposed consisting of a fine of $1000 and payment of costs associated with probation, together with a reprimand and a three-year suspension of license to be followed by a two-year probation with conditions as deemed appropriate by the Board of Nursing. Reinstatement of Respondent's license after the term of the suspension shall require compliance with all terms and conditions of the previous Board Order and her appearance before the Board to demonstrate her present ability to engage in the safe practice of nursing, which shall include a demonstration of at least three years of documented compliance with the Intervention Project for Nurses. DONE AND ENTERED this 29th day of December, 2000, in Tallahassee, Leon County, Florida. BARBARA J. STAROS 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 29th day of December, 2000.
The Issue exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.
Findings Of Fact 1 At all times relevant to the inquiry Respondent has held license no. PN 12946-1 issued by the Board of Nursing in Florida. Petitioner is empowered to discipline that license if Respondent is shown to have violated her responsibilities as a nurse practitioner. Disciplinary action is taken in accordance with Chapter 464, Florida Statutes. Respondent had been referred to Memorial Medical Center a Jacksonville, Florida, hospital to work as a nurse on the 3:00 p.m. to 11:00 p.m. shift of April 9, 1988. This referral was from Consolidated Staffing and Home Health Services, a division of St. Vincent's Health Care System. Jacqueline L. Cumbie who is a registered nurse in Florida and a certified nursing administrator and the administrator and director of the nurses for the referring group was responsible for coordinating the assignment of this nurse. The referral here was consistent with that process. When Respondent reported for work at the hospital she was given a brief orientation by Debra Ellen Bearup, the staff R.N. on the floor where Respondent was assigned. That floor was Two Central, a surgical floor. The orientation included the location on the floor where materials could be found that the Respondent would need to carry out her duties to include an explanation about the medication room, supply room, an explanation of patient charts and the nursing flow sheets where the Respondent would have to do her charting and an indication of where the medications were being held that would have to be administered by the Respondent. In fulfilling this role Ms. Bearup was acting as the charge nurse. The assignment that Respondent had was to care for five patients in rooms 205, 209, 210, 214 and 215. The duties Respondent had with those patients was to assess the patients and to provide them with a level of care that they were supposed to be afforded to include monitoring vital signs, doing cepho-caudal assessment, administering medications, recording anything unusual that transpired and in general caring for the patients. Ms. Bearup's shift began at 7:00 a.m. on that date and ended at 7:00 p.m. Ms. Bearup was not at the hospital when the Respondent left the hospital. Ms. Bearup was not aware of any problems that the Respondent was experiencing in carrying out her duties while Ms. Bearup was in attendance with Respondent at the hospital. At times Ms. Bearup would approach the Respondent and state "are you doing o.k., are there any questions, are you running into anything that you do not understand." Respondent would reply that she was "doing fine." The contact between Ms. Bearup and the Respondent did not include any attempt on the part of Ms. Bearup to verify the treatment provided by Respondent for the benefit of the patients assigned to the Respondent such as looking at the patient charts. Ms. Bearup took the Respondent's word for the fact that things were proceeding as they should. Subsequently, Ms. Bearup did examine the charts of the patients that Respondent was responsible for and discovered that the patient in Room 205 had not had vital signs taken as called for and that Respondent had failed to administer antibiotics at 5:00 p.m. Ms. Bearup also discovered that the patient in Room 209 had not had vital signs taken at 4:00 p.m. and 8:00 p.m. and that medication was not given at 5:00 p.m. for that patient. Related to the patient in Room 209, Ms. Bearup found that the Respondent had not completed charting for the patient. Concerning the patient in Room 210, Ms. Bearup found that the Respondent had failed to take the patient's vital signs at 4:00 p.m. and 8:00 p.m. and had failed to complete the charting on the patient. Concerning the patient in Room 214, Ms. Bearup found that the Respondent had failed to take the patient's vital signs at 4:00 p.m. and 8:00 p.m. and had failed to complete the patient's charting. Concerning the patient in Room 215, Ms. Bearup discovered that the Respondent had failed to complete the charting on this patient. In all instances referred to Respondent was aware of her obligations. Ellen Lederman was a staff nurse who came on duty at 7:00 p.m. April 9, 1988 and whose shift was to end at 7:00 a.m. on April 10, 1988. After Ms. Lederman came on duty she had contact with the Respondent and the Respondent became tearful with complaints of pain in her knees and that she was very tired. Ms. Lederman and Katherine Mitchell, another nurse working on the floor at that time, Ms. Mitchell being since deceased, asked the Respondent if she wanted to go home. The Respondent told them that she would like to go home and the nursing supervisor was called and permission was granted to the Respondent to leave her duties at the hospital. Respondent left shortly after 9:00 p.m. Nurse Cumbie who was accepted as an expert in nursing practice gave the opinion that the performance by Respondent did not meet minimal standards for nursing practice related to the oversights in the patient care that have been previously described.
Recommendation Based upon the findings of fact made and the conclusions of law reached, it RECOMMENDED: That a Final Order be entered which dismisses the Administrative Complaint. DONE and ENTERED this 24th day of February, 1992, in Tallahassee, Florida. CHARLES C. ADAMS, 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 24th day of February, 1992. APPENDIX TO RECOMMENDED ORDER The following discussion is given concerning the proposed facts of Petitioner: The first 10 paragraphs in the proposed fact finding and paragraphs 12 through 14 are subordinate to facts found. Paragraph 11 is not necessary to the resolution of the dispute. COPIES FURNISHED: Roberta Fenner, Esquire Department of Professional Regulation 1940 North Monroe Street, Suite 60 Tallahassee, FL 32399-0792 Olean S. McCall Johnson 12929 Mandarin Point Jacksonville, FL 32223 Jack McRay, Esquire Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Judie Ritter, Executive Director DPR Board of Nursing 504 Daniel Building 111 East Coast Line Drive Jacksonville, FL 32202
Findings Of Fact Joanne N. Dickey is licensed by Petitioner as a licensed practical nurse and holds license number 37835-1. During the period November 24 through November 28 Respondent was so licensed and was employed by Memorial Hospital, Hollywood, Florida on the 11:00 p.m. to 7:00 a.m. shift. Standard procedures established by Memorial Hospital regarding the accounting for controlled substances are for the nurse withdrawing medication for administering to a patient to record the withdrawal on the Narcotic Inventory Sheet on which a running inventory for a 24-hour period is kept, and, upon administering the medication to the patient, chart the medication on the medication administration record and in the nurses notes for the patient. Standard procedures established for accounting for excess drugs withdrawn (e.g., where doctor's orders call for 50 mg. and only 100 mg. ampules are available) prescribe that the excess drug withdrawn be disposed of in the presence of another witness and so recorded on the waste record. These procedures are presented to all nurses at Memorial Hospital during their compulsory training periods before they administer to patients at Memorial Hospital. On November 26, 1978, Respondent, at 1:15 a.m., signed out on the narcotic control record for 100 mg. meperidine for patient Cohen, but this medication was not entered on either the medication administration record or on the nurses notes for this patient. At 4:30 a.m., Respondent signed out for 75 mg. meperidine for patient Cohen and the administration of this medication was not entered on the patient's medication administration record or in the nurses notes. Doctor's orders for Cohen at this time authorized the administration of 50-75 mg. meperidine presumably not given to Cohen. No entry was made on the waste record. On November 27, 1978 at 12:30 a.m., Respondent signed out for 75 mg. meperidine and at 4:00 a.m. for 100 mg. meperidine for patient Cohen on the narcotic inventory sheet, but the entry of the administering of these medications to patient Cohen was not entered on the medication administration record or in the nurses notes. Again, no waste record was made for the excess over the 50-75 mg. authorized. Further, doctor's orders in effect on November 27, 1980 for patient Cohen did not authorize administration of meperidine. At 2:15 a.m. on November 27, 1978 Respondent signed out for 75 mg. meperidine and at 5:30 a.m. 50 mg. meperidine for patient Barkoski. No record of administering these medications was entered on the patient's medical administration record or in the nurses notes. Doctor's orders authorized administration of 50 mg. meperidine as necessary. No entry of disposal of the excess 25 mg. was entered in the waste record. At 4:20 a.m. November 24, 1978 Respondent signed out for 75 mg. Demerol for patient Giles. No entry was entered on the medical administration record or in nurses notes that this medication was administered to patient Giles. At 3:30 a.m. on November 24, 1978 Respondent signed out for 25 mg. Demerol for patient Evins but no entry was made on the patient's medical administration record or in the nurses notes that this medication was administered to the patient. At 12:50 a.m. on November 24, 1978 Respondent signed out for 100 mg. Demerol and at 4:30 a.m. signed out for 50 mg. Demerol for patient Demma. No entry was made in the medication administration record or nurses notes for Demma that this drug was administered. Doctor's orders in effect authorized administration of 50-75 mg. Demerol as needed. No entry was made on waste record for the overage withdrawn. On the 11-7 shift on November 27, 1978, Respondent's supervisor noticed Respondent acting strangely with dilated pupils and glassy eyes. She suggested Respondent go home repeatedly and sent her to the lounge but Respondent soon returned to the floor. Respondent was finally told if she didn't go home the supervisor would call Security. The supervisor had checked the narcotic inventory log at 4:50 and saw no entries thereon. By the time Respondent was finally sent home at 6:00 a.m., the entries on the Narcotic Control Record at 12:30, 1:15, 2:15, 4:30 and 5:30 were entered. Failure to chart the administration of narcotics to patients does not comply with acceptable and prevailing nursing practices. No evidence regarding the administering of hydromorphone was submitted.
The Issue The issue in the case is whether the allegations of the Administrative Complaint filed by Petitioner are correct and, if so, what penalty should be imposed against Respondent.
Findings Of Fact Petitioner is the state agency charged with regulation of the practice of nursing in State of Florida. At all times material to this case, Respondent has been licensed as a registered nurse in the State of Florida, holding license no. 2003552, with a last known address of 1407 Wekewa Nene, Tallahassee, Florida 32301. Respondent was employed at all times material to this case by Tallahassee Memorial Hospital (TMH) until December 1, 2000, when her employment was terminated. On November 23, 1999, Respondent was working a day shift at TMH as a nurse at 1300 Miccosukee Road, Tallahassee, Florida. On November 23, 1999, Sharissa Holloway was a student nurse from the Florida State University (FSU) School of Nursing and happened to be doing a clinical rotation on the TMH orthopedic/neurological floor. Respondent was the primary nurse for the patients on that floor who were under the care of the student nurse. The student nurse received the patient assessment sheets from Respondent prior to 8:00 a.m. with entries already charted by Respondent for estimating Patient N.C.'s pain, and a sedation scale already charted by Respondent covering the period of time that stretched all the way to 12 o'clock noon. When handing the patient assessment sheets to the student nurse at approximately 7:30 a.m., Respondent stated "I have already started the notes." The note entries had Respondent's initials next to them in the appropriate column. Narrative notes on Patient N.C. had already been written indicating that a dressing change of a surgical wound had been done at 8:00 a.m. These notes bore Respondent's signature. The student nurse also got these notes from Respondent before 8:00 a.m. Concerned with the advanced notations that she discovered, the student nurse took the patient assessment sheets which bore Respondent's entries for future times up to 12 o'clock noon to her FSU clinical nursing instructor who was on the premises at the time. Proceeding to Patient N.C., the instructor verified that the patient's wound dressing had not been changed. The student nurse did the dressing change at approximately 8:30 a.m. The nursing instructor took the documents to the head nurse for the orthopedic/neurological floor, Kay Keeton. Keeton requested that both the student nurse and the nursing instructor submit independent written statements. They complied with Keeton's request. Contemporaneously with the drafting of statements by the clinical nurse instructor and the student nurse, photocopies of the patient assessment sheets were made at least two hours prior to 12 o'clock noon. Keeton made notes on the sheets to show entries charted by Respondent as opposed to entries charted by the student nurse. Keeton is familiar with Respondent's signature. After determining that Respondent had charted something that had not been done yet, Keeton made her report to the TMH administration. When questioned about the entries on December 1, 1999, Respondent denied making the entries. She was given a disciplinary form entitled "Notice of Corrective Action." Upon her refusal to sign the form, Respondent was terminated from her employment. Respondent has experienced employment problems at TMH for which Notices of Corrective Action were issued which date back to 1996. This history, in conjunction with Respondent's demeanor while testifying and her lack of candor, dictate that her denial of improper action in this case, cannot be credited. Minimal acceptable standards of prevailing nursing practice require that documentation of care provided to patients be recorded contemporaneously with the provision of the care. Respondent's "before the fact" documentation of care provided to the patients identified herein fails to meet minimally acceptable standards of prevailing nursing practice. The placing of a care provider's initials on a medication administration record indicates that medication has been administered to patients. "Pre-initialing" or signatures on medication administration records poses a risk of confusion to other care providers working in the facility and is not an acceptable practice.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Petitioner enter a final order against Respondent, imposing a fine of $250, requiring completion of appropriate continuing education in nursing records documentation in addition to any existing continuing education requirement, and placing the Respondent on probation for a period of one year under such conditions as the Board of Nursing determines are warranted. DONE AND ENTERED this 24th day of October, 2000, in Tallahassee, Leon County, Florida. DON W. DAVIS 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 24th day of October, 2000. COPIES FURNISHED: Michael E. Duclos, Esquire Agency for Health Care Administration 2727 Mahan Drive Building 3, Room 3240 Tallahassee, Florida 32308 Donna H. Stinson, Esquire Broad & Cassel 215 South Monroe Street, Suite 400 Post Office Box 11300 Tallahassee, Florida 32302 Ruth R. Stiehl, Ph.D., R.N. Executive Director Board of Nursing Department of Health 4080 Woodcock Drive, Suite 202 Jacksonville, Florida 32207-2714 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A00 Tallahassee, Florida 32399-1701
