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 Standard procedures established for accounting for excess drugs withdrawn (e.g., where doctor's orders call for 50 mg.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 ampules are available) prescribe that the excess drug withdrawn be disposed of in the presence of another witness and so recorded on the waste record.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
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 pertinent hereto, Respondent, Erin Gayle McCormick, was a registered nurse and licensed as such by the State of Florida under License No. 101652-2. On June 24, 1981, Respondent's nursing license was suspended because of charges relating to drug use and the forging of prescriptions and their subsequent issue while she was employed at Leesburg Nursing Center during August and September, 1980. Thereafter, on October 12, 1982, the suspension was lifted and Respondent's license was reinstated on one year's probation, subject to certain conditions, one of which was that she not violate any federal or state laws, or rules or orders of the Board of Nursing. Another condition of probation was that she not consume or otherwise self-medicate with any unprescribed controlled substances. Respondent has been a long-term patient of Dr. Paul F. Tumlin, her family physician for many years and who, during the period August through October, 1982, treated her several times for two separate types of headaches, cluster headaches and migraine headaches. Both generate great pain when an attack is ongoing. During the period in question, he treated Respondent with several types of pain killers, some of which are controlled and some of which are not. Among the drugs he used to treat Respondent are: Florinal, Zomax, Phenergan, Inderal, Ludiomil, Talwin and Nubain. Each of these drugs has some side effect. However, over prolonged use, a tolerance may develop in the patient so that the magnitude of the side effect is reduced. Several of them produce such side effects as drowsiness and blurred vision (Ludiomil and Talwin). Another (Inderal) produces depression and weakness. Phenergan is a drug which used in conjunction with others tends to accentuate or extend the effect of that drug. The side effects are of varying duration, and a nurse should not practice her profession when those side effects, such as drowsiness, unclear vision, unsteadiness and weakness, interfere with the full effective control of her facilities and the safe performance of her duties. However, reasonable use of any drug, consistent with a medically indicated purpose, does not constitute drug abuse. Dr. Tumlin cannot recall from memory or from his records any instance where Respondent abused medications prescribed for her by him. All of the drugs Dr. Tumlin prescribed for Respondent during this period are listed in her medical records. These records reflect that on October 14, 1982, Dr. Tumlin prescribed for the Respondent 36 tablets of Florinal #3, a pain killer which contains codeine, which he directed be taken either one or two at a time every four hours for pain. This prescription was authorized one refill. Pursuant to the terms of the October 12, 1982, Order, on October 18, 1982, less than one week after the reinstatement of Respondent's license, Nita Edington, an investigator for the Department of Professional Regulation (DPR), contacted Respondent and requested she provide a urine sample for testing. This was not done because of any report of drug abuse by Respondent and was less than a week after the Board of Nursing, in its October 12, 1982, Order, indicated receipt of good reports on her rehabilitation. This urine sample provided by Respondent was subsequently tested by DPR's contract laboratory and determined to be positive for codeine. However, this codeine residue was from the ingestion of Florinal #3, which had been previously prescribed for Respondent by her physician. Respondent was employed in a full-time position as a nurse at the Leesburg Nursing Center, Leesburg, Florida, during August and September, 1980. When she had indication her license was to be reinstated, on August 12, 1982, she applied for a position at the Lakeview Terrace Retirement Center (LVT). The application form filled out, signed and submitted by Respondent calls for "Former Employers and Experience (References)" and reflects that the position desired by the applicant was "sitter." Respondent, in listing former employers, listed the following: Shoe-Biz III 10/81-2/82 Belks 1/81-6/81 Tampa Critical Care 9/79-6/80 Nursing Pool Leesburg General-Hospital 6/78-11/78 11/78-7/78 This total period covered includes the months of August and September, 1980, but the application form fails to reflect the August and September, 1980, employment at Leesburg Nursing Center. On November 11, 1952, Respondent applied for a position as a registered nurse at Lake Community Hospital, Leesburg, Florida, and filled out and submitted an application form which called for the applicant to list the last four employers, starting with the last one first. On this form, Respondent listed: Lakeview Terrace Retirement Center 5/82-10/82 Tampa Med. Pool 11/79-10/80 Waterman Memorial Hospital 11/78-7/79 Leesburg General Hospital 6/78-11/78 Again, she failed to list her employment at Leesburg Nursing Center during August and September, 1980, including that period in the employment period at Tampa Med. Pool, which was untrue, nor did she reveal this employment when she was interviewed for the position. Had she done either, the reference would have been checked, and the information provided by this reference would have had a definite bearing on the decision to hire Respondent or not. Respondent was hired by Lakeview Terrace Retirement Center as a sitter on August 24, 1982, and her position was converted to that of a registered nurse on August 30, 1982, when a vacancy came about. On several occasions from that date until she resigned from employment on October 29, 1982, Charles W. Dick, at that time a food supervisor at the facility, now head baker and a former Baptist minister who, he says, has counseled 100 drug addicts over a 35-year ministry, observed Respondent when she came to the kitchen to pick up food for a resident/patient. On three particular occasions, he saw that her eyes were glassy; her speech was unclear, though understandable; and she appeared unsteady on her feet. Mr. Dick did not, however, report these incidents or discuss them with anyone other than his wife, also an employee of the facility. These symptoms, which are often indicative of drug ingestion, are, according to Dr. Tumlin, also consistent with the effects of severe migraine headaches. Laura Burley, a licensed practical nurse (LPN), worked with Respondent at Lakeview Terrace Retirement Center during August through October, 1982. Ms. Burley has had 10 years' experience with drug abuse patients and is familiar with the symptoms of drug abuse. In her opinion, she saw similar conduct on the part of Respondent during this period. She saw, for example, the Respondent frequently ingest white tablets while on duty, though she does not know what they were. She has heard Respondent complain of the cold and put on a lab coat when the witness, herself, was not cold. She has observed Respondent clutching her stomach and holding her head and has heard Respondent say she did not know if she would make it through the day. She observed Respondent to have radical mood shifts and to eat a lot of sugar or foods with heavy sugar content. She has seen Respondent frequently try to get into the drug carts or get the keys to the drug cart. Ms. Burley also keeps a notebook in which she records what she perceives as unusual conduct on the part of her coworkers. She does this because of her interpretation of a request by the facility administrator for her to report to him any significant occurrences. Doris Draper was also an LPN at LVT while Respondent worked there. A part of Ms. Draper's duties was to dispense drugs. On one occasion, while she was doing so, Respondent came to her and asked for the keys to the medication cart, as she needed to get some Tylenol for another nurse, Mrs. Dick. On a later discussion, Mrs. Dick denied having asked Respondent to get her Tylenol, but said she had wanted some other medicine for a patient. On the basis of this, the two nurses concluded that Respondent intended to substitute regular Tylenol for a patient's Tylenol #3 so as to convert the latter codeine-included medication to her own use. However, though Ms. Draper heard other nurses say they suspected Respondent was taking drugs, she never saw her do so. Nurse Donna Devoe also worked with Respondent at LVT during the period in question. At one point during Respondent's employment, at the request of Ms. Burley and Ms. Draper, she reviewed the charts on a patient, Mrs. Testerman, who, by her recollection, rarely received pain medication. Her review of these patient records revealed that the patient was recently being given pain medicine more frequently than usual by Respondent, whom she counseled about the situation. Ms. Devoe also discussed the situation with the Center administrator, but, because there was no evidence of drug diversion, nothing further was done about it. Her review of the records also revealed that all medications given to patients by the Respondent were given in accordance with a physician's orders, and there was no evidence that Respondent violated these orders. Based on all the above, if Respondent was under the influence of any medication, it was the medication prescribed for her by Dr. Tumlin and not non- prescribed substances. The symptoms described by Mr. Dick, certainly not a trained drug therapist, are equally pertinent to migraine headaches. The innuendos of Ms. Burley, Ms. Draper and Mrs. Dick are just that--innuendos--and not probative of any improper drug usage. Not one witness could conclusively state there was any instance where Respondent failed to properly treat patients or was incapable of doing so because of drugs, alcohol, or illness. Mr. Speener, to whom Ms. Devoe and Ms. Burley both admittedly reported, stated that he had no reports of poor or improper treatment. By his own admission, due to her prior involvement, for which she had been disciplined, Respondent was the subject of "preconceived concerns and misinformation, rumors, and etc.," and she found it difficult to function. In his letter to Ms. Keefe, Mr. Speener said that if there was any conclusive, provable evidence of incompetence, or if there was any substantiation of drug involvement, Respondent would be immediately terminated. Mr. Speener could find no evidence of such and neither can I. In fact, he found her to be a highly professional nurse. During the period of her employment, Respondent had responsibility for the care of, inter alia, Clifford Bryant and Arthur Everett. Arthur Everett was an elderly, paralyzed individual who, on the occasion in question, was administered treatment by Respondent for an impacted bowel. This procedure was inordinately messy and resulted in fecal material getting on both Mr. Everett's clothing and the bed clothes. Both had to be changed. When Respondent came to the patient's room to perform this procedure, she failed to bring a clean gown with her. As a result, by her own admission, Mr. Everett was left totally undressed and uncovered without the screen drawn for the period of time it took her to go get him a clean gown. While this was going on, Mr. Everett was one of two patients in a semiprivate room. The other was a blind, stroke patient. No one else was in the room at the time, but Ms. Burley came in for one brief period while Mr. Everett was unclothed. With regard to Mr. Bryant, at the time in question, he had just arrived at the facility by ambulance and was in wrist restraints because he had previously tried to pull out his catheter. Respondent was in the midst of completing an admission examination of the patient when Ms. Burley entered the patient's private room to find out what was taking so long. She observed the patient to be fully unclothed with the bed clothes pulled down to the foot of the bed. This was also observed by Mrs. Dick, who, when she entered the room, saw the patient nude and the Respondent there with a stethoscope in her hand. While Ms. Burley does not consider this to be patient abuse, she does consider it to be an abuse of his privacy, poor practice and a violation of the standards of LVT. This opinion is shared by several others employed there, such as Nurse Warren and Mary Willis, a registered nurse of long standing and vast experience who is currently Supervisor of Investigative Services for DPR. Respondent denies that Mr. Bryant was totally unclothed at any time she was with him. When he arrived at the facility, he was in pajamas, and she helped him from the wheelchair to the bed before she began the examination. In order to complete the examination, it was necessary for her to unbutton his pajama top to listen to his chest sounds and to observe his chest movement. She also had to lower his bottoms to examine that part of his body as well, but in each case, she asserts she replaced the clothing when she was finished. In light of the nature of Ms. Burley's and Mrs. Dick's testimony on other aspects of this case, nebulous and devoid of specifics as it was, the fact that both were in the room only briefly and the apparent animosity felt by these witnesses toward the Respondent, the evidence shows that Mr. Bryant was not left totally unclothed at any time. On October 29, 1982, Mrs. Catherine Devore was visiting her husband, Henry, in his private room at LVT when Respondent entered the room to give him his medication. Mr. Devore is blind and has had a stroke and generally is uncommunicative. Because of his resistance to taking his medicine, it is concealed in ice cream which is fed to him. Mrs. Devore indicates that at the time in question, her husband's head was forward with his chin on his chest, and Respondent lifted it up for the medicine by entwining her fingers in the hair at the top of his head and pulling it up. Respondent did not yank his head up, but lifted and held the head up by the hair while she administered the medication. When Respondent released the head, the hair where Respondent had been holding remained standing up. Mrs. Devore did not consider this to be abuse, nor did she feel her husband was hurt by this action. She did, however, consider it unusual and unnecessary and felt that if the Respondent would treat her husband that way with her there, she was uncertain of the treatment he would get if she were not there. As a result, when she got home, she called one of the owners of LVT, to whom she reported the incident and who suggested she report it to the administrator, Mr. Speener, which she did. Respondent indicates a somewhat different story. When she went in to give Mr. Devore his medicine, Mrs. Devore stated, "He's not going to like that," at which point Mr. Devore put his head on his chest. Respondent then put one hand on his head and began to rub it while at the same time placing her other hand on his chin. With this, Mr. Devore voluntarily raised his head. When Respondent moved the hand on top of the head, the hair where she had been rubbing remained standing. In light of the basic improbability that a nurse would, without provocation, grab a patient by the hair and pull his head up with the patient's wife standing by and the fact that the actions described by Respondent could readily be mistaken for pulling, it is clear that Respondent did not pull Mr. Devore's hair on October 29, 1982, and, therefore, her actions did not constitute abuse. No report of abuse was ever filed with the Department of Health and Rehabilitative Services regarding this incident. Because of Mrs. Devore's report, however, Respondent was shortly called to the office of Mr. Eugene K. Speener, administrator of the 20-bed skilled nursing facility at LVT. After some discussion of the incident and of some other discussions they had had relating to Respondent's alleged rigidity of personality, he suggested, and she agreed, that her immediate resignation would be appropriate and accepted. Respondent was not discharged from employment, and her departure had nothing to do with drugs. Unfortunately, however, because of the knowledge of her former difficulty and the continued gossip and insinuations by coworkers, there was always present the spectre of her earlier problem, and Mr. Speener admits telling Respondent he felt it was difficult for her to function as a nurse at that facility because of it. He also included these sentiments in a letter he sent to Ms. Keefe of the Board of Nursing, sometime between October 15 and October 29, 1982. When it was determined that Respondent would resign effective immediately, Mr., Speener called Ms. Burley, who was off duty at the time, and requested that she come in and replace Respondent at 5:00 p.m. Ms. Burley agreed. In the interim, Respondent remained in another office until her departure from LVT sometime between 5:00 p.m. and 7:00 p.m. on October 29, 1982. When Ms. Burley got to the ward that day, she discovered that Respondent had already made entries in various patients' records showing procedures taken, medications given, vital signs taken and patient condition noted, all as of 8:00 p.m., October 29, 1982. Respondent admitted to Ms. Burley before she left that day that she had advance-charted the 8:00 p.m. medications that had not been given, and at the hearing admitted the other advanced chartings. She contends, however, that she did so partially upon the previous written advice of Ms. Burley, who, early in Respondent's tenure at LVT, suggested to her that she lump together three hours' medication at one time. It is also common practice to chart activities at a time other than when the actual function is accomplished. To do otherwise would make it impossible for a person to do what was required and at the same time accomplish the attendant paperwork. It is, however, unacceptable practice within the nursing profession, according to Ms. Willis, to chart substantially in advance. This is because things may change which alter the patient's condition, so that a particular precharted drug, for example, is not actually given, or some procedure is not followed. Generally, a leeway of one half hour on each side of the procedure or drug is acceptable. Somewhat after the submission of her application to Lake Community Hospital, she was employed by that facility as a nurse and is still employed there. According to two former coworkers, Respondent has performed in an excellent manner and has been recommended for promotion. Respondent's drug therapist for the last few years is of the opinion that Respondent is not now, nor was she during the August through October, 1982, period, abusing medications. Respondent is involved in nursing and has continued to improve. In fact, her supervision was terminated as unneeded in March, 1982. It was only because supervision was made a part of the Order of Probation that she is back with Petitioner.
Recommendation Based on the above, it is, therefore, RECOMMENDED: That Respondent be reprimanded and that probation be continued one additional year until October 11, 1984. RECOMMENDED this 21st day of September, 1983, in Tallahassee, Florida. ARNOLD H. POLLOCK Hearing Officer Division of Administrative Hearings Department of Administration 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 21st day of September, 1983. COPIES FURNISHED: Stephanie A. Daniel, Esq. Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 George L. Waas, Esquire Slepin, Slepin, Lambert & Waas 1114 East Park Avenue Tallahassee, Florida 32301 Mr. Fred Roche Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Ms. Helen P. Keefe Executive Director Board of Nursing Department of Professional Regulation Room 504 111 Coastline Drive, East Jacksonville, Florida 32202
Findings Of Fact At all times material hereto, Respondent has been a licensed practical nurse in the State of Florida, having been issued license number PN 0867041. At all times material hereto, Respondent was employed by American Nursing Service, Fort Lauderdale, Florida, and was assigned to work at Broward General Medical Center, Fort Lauderdale, Florida. On July 30-31, 1989, Respondent worked both the 3:00 p.m. to 11:00 p.m. and the 11:00 p.m. to 7:00 a.m. shifts at Broward General Medical Center. She was responsible for 20 patients on that double shift. An hour or two before her double shift ended, she checked the I.V. of a patient near the end of the hall. The I.V. was not running, and Respondent attempted to get it running again by re-positioning the I.V. several times. She then went to the medication room and obtained a syringe to use to flush the I.V. to get it operating again. When she returned to the patient's room, the I.V. was running and Respondent tucked the syringe inside her bra. The syringe was still packaged and unopened. She then continued with her nursing duties. At 7:00 a.m. on July 31, while Respondent was "giving report" to the oncoming nursing shift and making her entries on the charts of the patients for whom she had cared during the double shift she was just concluding, one of the other nurses noticed the syringe underneath Respondent's clothing. That other nurse immediately reported the syringe to her own head nurse who immediately reported the syringe to the staffing coordinator. The head nurse and the staffing coordinator went to where Respondent was still completing the nurse's notes on the charts of the patients and took her into an office where they confronted her regarding the syringe. They implied that she had a drug problem and offered their assistance. Respondent denied having a drug problem and offered to be tested. They refused her offer to test her for the presence of drugs. Instead, they sent her off the hospital premises although she had not yet completed making her entries on the patient's charts. Hospital personnel then went through Respondent's patients' charts and found some "errors." A month later an investigator for the Department of Professional Regulation requested that Respondent submit to a drug test on one day's notice. She complied with that request. She asked the investigator to go with her to Broward General Medical Center so that she could complete the charts on the patients that she had not been permitted to complete before being sent away from the hospital. Her request was denied. At some subsequent time, the Department of Professional Regulation requested that Respondent submit to a psychological evaluation. She did so at her own expense and provided the Department with the results of that evaluation. Respondent has had no prior or subsequent administrative complaints filed against her.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is recommended that a Final Order be entered finding Respondent not guilty and dismissing the Second Amended Administrative Complaint with prejudice. RECOMMENDED this 18th day of November, 1991, at Tallahassee, Florida. LINDA M. RIGOT 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 18th day of November, 1991. APPENDIX TO RECOMMENDED ORDER, CASE NO. 91-1775 Respondent's proposed findings of fact numbered 1-3, 6, and 8 have been adopted either verbatim or in substance in this Recommended Order. Respondent's proposed findings of fact numbered 4 and 7 have been rejected as not constituting findings of fact but rather as constituting conclusions of law or argument of counsel. Respondent's proposed finding of fact numbered 5 has been rejected as being subordinate. COPIES FURNISHED: Jack McRay, General Counsel Department of CProfessional Regulation 1940 North Monroe Street Tallahassee, Florida 32399-0792 Judie Ritter, Executive Director Department of Professional Regulation/Board of Nursing Daniel Building, Room 50 111 East Coastline Drive Jacksonville, Florida 32202 Roberta Fenner, Staff Attorney Department of Professional Regulation 1940 North Monroe Street Tallahassee, Florida 32399-0792 Christopher Knox, Esquire 4801 S. University Drive, #302 W. Box 291207 Davie, Florida 33329-1207
The Issue Whether the Respondent is guilty of unprofessional conduct. Whether her license as a registered nurse, certificate no. 8829 should be suspended or revoked or whether Respondent should be put on probation.
Findings Of Fact The Respondent, Christine Richter, who holds license no. 88294-2 was employed as a registered nurse at Tallahassee Memorial Hospital, Tallahassee, Florida, during the month of February, 1977. She worked as a certified nurse and anesthetist under Ann Marie Connors, the chief nurse anesthetist. The chief nurse anesthetist reported to the Associate Executive Director April 11, 1977, that there were gross discrepancies in the narcotics record kept by the Respondent and at that time she presented him with some of the records. On April 12, 1977, Respondent was requested by the Associate Executive Director to report to his office for a conference. Nurse Connors, the chief nurse anesthetist, was also called to be present at that conference. At the conference the Associate Executive Director asked Respondent for an explanation as to the discrepancies between the narcotic and barbiturate administration record and the patient records. In reply the Respondent stated that she needed a hysterectomy and could not afford it. Upon the insistance of the Associate Executive Director that she give an explanation for the discrepancy in the hospital records, she indicated that she needed to improve her charting. She gave no explanation for discrepancies in the narcotics chart which she signed, and indicated that she would resign. The Director stated that he would accept her resignation and she left the conference. The Respondent mailed her written resignation to the Tallahassee Memorial Hospital the following day. The Accreditation Manual for Hospitals, 1976 edition, published by the Joint Commission on Accreditation of Hospitals "Anesthesia Services" pages 59 through 64 is used as the standard for anesthetic procedure. A department standard book approved by the American Hospital Association and the joint commission on the accreditation of hospitals is required to be read by each employee of the Tallahassee Memorial Hospital as it pertains to the department in which the work is to be performed. The instructions in the department standards book are the same as in the Accreditation Manual for Hospitals as far as anesthesia services is concerned. Medical records of eight patients were introduced into evidence together with Narcotic and Barbiturate Record no. 081291. This shows the date, time, patient's name, room number, doseage, attending physician and administering nurse. The doseage of drugs secured by and signed for by the Respondent, Christine Richter, was more than the records show was administered to the various patients. No accounting was made for the difference between the amounts of drugs secured and the amounts, if any, administered to the patients, although it is the duty of the nurse checking out drugs to account for its use in writing on a form provided for that purpose. The Respondent offered no verbal explanation for the missing drugs when given the opportunity to explain her actions by the Associate Executive Director at Tallahassee Memorial Hospital and her immediate supervisor, Ann Marie Connors, chief nurse anesthetist.
Recommendation Revoke the license of Christine Richter. DONE AND ENTERED this 12th day of December, 1977, in Tallahassee, Florida. DELPENE C. STRICKLAND Hearing Officer Division of Administrative Hearings 530 Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1005 Blackstone Building 233 East Bay Street Jacksonville, Florida 32202 Rivers Buford, Jr., Esquire Post Office Box 647 Tallahassee, Florida 32302
The Issue The issue is whether Respondent's license to practice nursing should be revoked, suspended, or otherwise disciplined under the facts and circumstances of this case.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made: At all times material to this proceeding, Respondent Rita Flint (Flint) was a licensed practical nurse in the State of Florida, holding license number PN0655201. Flint's last known address is 6494 South West 8th Place, North Lauderdale, Florida 33068. At all times material to this proceeding Flint was employed by North Broward Medical Center (NBMC) located in Pompano Beach, Florida, as a practical nurse. On August 3, 1990, Flint was assigned to care for patients J. C. and J. K. including administering their medications and charting same on their Medication Administration Record (MAR). On August 3, 1990, J. C.'s physician prescribed one (1) nitroglycerine patch each day. Flint failed to administer the patch on this date. On August 3, 1990, J. C.'s physician prescribed 100 mg. of Norpace every six (6) hours. Flint failed to administer the 2:00 p.m. dosage of Norpace to J. C. On August 3, 1990, J. C.'s physician prescribed 120 mg. of Inderal each day. Flint failed to administer the 9:00 a.m. dosage of Inderal until 1:30 p.m. without noting any explanation on J. C.'s MAR. On August 3, 1990, Flint failed to document the administration of J. K's own medications on the MAR. On August 3, 1990, Flint failed to sign the MARs for J. C. and J. K. as required by hospital policy. On August 15, 1990, Flint left an intravenous bag with an exposed needle hanging at the bedside of a patient. On August 29, 1990, Flint was assigned to care for patient R. R. including administering his medications. Flint failed to administer the following medications leaving all of them at R. R.'s bedside: (a) Timolo (9:00 a.m. and 2:00 p.m. doses); (b) Mixide (9:00 a.m. dose); (c) Zantac (9:00 a.m. and 4:00 p.m. doses); (d) Lasix (9:00 a.m. dose); and, (e) Entozyme (8:00 a.m. and 12:00 noon doses). On August 30, 1990, NBMC terminated Flint's employment as a result of the aforementioned conduct. There is no evidence that any patient suffered any actual harm as a result of Flint's errors. In September of 1990, NBMC referred Flint to the Intervention Project for Nurses. At all times relevant to this proceeding, Flint's job performance was adversely affected by long work schedules necessitated by severe financial problems. During the week of August 3, 1990, Flint worked a ninety-two-hour week. The acute financial stress was due to domestic problems including the breakup of her twenty-two-year-old marriage. Flint had no problems involving substance abuse. Flint attended individual therapy sessions with a clinical psychologist, Priscilla Marotta, Ph.D., and participated in group therapy designed primarily for persons with substance abuse problems. Flint attended weekly therapy sessions for approximately one month after which she could no longer afford treatment. Even though Flint was financially unable to continue treatment with Dr. Marotta or any other counseling program recommended by the Intervention Program for Nurses, she diligently undertook a self-help program to educate herself on stress management techniques, to develop self-reliance, and to improve self-esteem. Flint's effort to participate in therapy, to the extent financially possible, and to rehabilitate herself shows a strong commitment to her profession. Flint has been licensed to practice nursing since May 31, 1982. There is no evidence of any disciplinary action against her license prior to or after the incidents herein described. Flint is currently employed as a nurse in a hospice. Her recent performance appraisal reports indicate that, on an average, she fully meets all job requirements.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore recommended that the Board of Nursing enter a Final Order finding Respondent guilty of violating Section 464.018(h), Florida Statutes (1989), as defined in Rule 210-10.005(1)(e)1 and Rule 210-10.005(1)(e)2, Florida Administrative Code, and not guilty of violating Section 464.018(1)(j), Florida Statutes. It is further recommended that the Board's final order: (1) place the Respondent on probation for one year subject to such requirements as the Board may require; and (2) require the Respondent to pay an administrative fine in the amount of two hundred fifty dollars ($250). DONE AND ENTERED in Tallahassee, Leon County, Florida, this 21st day of November 1994. SUZANNE F. HOOD, Hearing Officer Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 21st day of November 1994. APPENDIX TO RECOMMENDED ORDER IN CASE NO. 93-2715 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case. FOR THE PETITIONER: Incorporated into Findings of Fact 1. Incorporated into Findings of Fact 2 and 11. Incorporated into Findings of Fact 4. Incorporated into Findings of Fact 5. Incorporated into Findings of Fact 6. Incorporated into Findings of Fact 7. Incorporated into Findings of Fact 8. Incorporated into Findings of Fact 9. Incorporated into Findings of Fact 10. The first sentence is incorporated into Findings of Fact 13. The remaining portion of this proposed fact is not supported by competent substantial evidence. Furthermore, Respondent's Exhibit 3, as it relates to a diagnosis of a mental condition, is hearsay which does not supplement or explain any other psychological or medical evidence. Thus, any reference in Exhibit R3 to a generalized anxiety disorder is insufficient to support Petitioner's proposed finding. Unsupported by competent substantial evidence. Unsupported by competent substantial evidence. See number 10 above. FOR THE RESPONDENT: 1. Respondent did file proposed findings of fact or conclusions of law. COPIES FURNISHED: Laura Gaffney, Esquire Natalie Duguid, Esquire Agency for Health Care Administration 1940 North Monroe Street Tallahassee, Florida 32399-0792 Rita Flint 3313 South East Second Street Pompano, Florida 33063 Judie Ritter Executive Director Board of Nursing AHCA 504 Daniel Building 111 East Coastline Drive Jacksonville, Florida 32202 Harold D. Lewis General Counsel The Atrium, Suite 301 325 John Knox Road Tallahassee, Florida 32303
