The Issue Whether Petitioner should be issued a license as a Licensed Practical Nurse, pursuant to Chapter 464, Florida Statutes.
Findings Of Fact Petitioner Mary Ellen Stone Zirkle, Huntington, West Virginia, submitted an application for Licensed Practical Nurse by Endorsement to Respondent Florida State Board of Nursing, dated August 29, 1978. The application was denied by Respondent by letter of September 28, 1978, for the reason that Petitioner had not completed a program approved by the Board for the preparation of Licensed Practical Nurses and had not completed the 12th grade. Petitioner, through her counsel's letter of October 19, 1978, requested an administrative hearing. (Exhibit 1, Case File) Petitioner attended high school in West Virginia for three years from 1940 to 1943. In November, 1958, she received a certificate from the Huntington East High Trades School, Huntington, West Virginia, certifying that she had completed the requirement in practical nursing prescribed in the adult trade extension program sponsored by the Practical Nurses of West Virginia, Inc., District No. II, and the National Association for Practical Nurse Education. The course in practical nursing consisted of 285 hours of classroom work which involved class attendance for two nights a week for approximately one and one- half years. Although the school was not accredited by the West Virginia State Board of Examiners for Practical Nurses until 1961, West Virginia permitted individuals who had engaged in practical nursing for a period of three years to be issued a license as a practical nurse by waiver. It further authorized such individuals who had completed extension courses equal in theory to those for the graduate practical nurses to thereafter take the examination prescribed by the Board and obtain a license without the designation of "waiver" thereon. In this manner, Petitioner obtained her West Virginia license by waiver on November 6, 1958 and, in 1959, she passed the State Board examination. During the time Petitioner attended the extension course at Huntington East High Trades School, she was simultaneously employed at Cabell Huntington Hospital performing the duties of a practical nurse. During the period March - September, 1960, she attended a "post graduate educational program" at the hospital in operating room technique and was awarded a certificate of graduation. She thereafter was employed as a licensed practical nurse at Doctor's Memorial Hospital, Huntington, West Virginia, from 1962 until 1976. Her duties included working in all areas of surgery as well as general central service type functions in the general nursing units. In 1974, she satisfactorily completed a required course of studies in operating room technician refresher program which consisted of 80 hours of classroom work. She was also certified as an Operating Room Technician in 1974. (Exhibits 2-6, 7-8) Petitioner submitted letters from the various physicians familiar with her performance of duty at Doctor's Memorial Hospital who "found her to be reliable and efficient in the Operating Room and seemingly quite knowledgeable as a Staff Nurse in the general nursing departments." Her former supervisor at Doctor's Memorial Hospital also submitted a letter in which she commented favorably on Petitioner's efficiency and reliability. The letter stated in part as follows: When assigned to other areas, she worked with as much efficiency as she did in the Operating Room. It was very evident she had been trained well to function as a L.P.N. Her knowledge of nursing procedures and medications was quite adequate even with long periods of absence from general duty. (Exhibit 7) In determining qualifications for licensure by endorsement, Respondent considers that an applicant's graduation from an "approved school of practical nursing" in another state is acceptable as meeting Florida's requirements and does not inquire into the number of hours of instruction required for such graduation. Its inquiry into Petitioner's qualifications in this respect was caused by the fact that the West Virginia State Board of Examiners for Practical Nurses indicated on Respondent's application form that Petitioner's education had been an extension course. It is a policy of Respondent that the equivalent of a four year high school education is completion of the General Education Development Test (GED). Petitioner has not taken such a test. (Testimony of Johnson, Zirkle)
Recommendation That Petitioner's application for license to practice practical nursing without examination pursuant to Section 464.121 (2), F.S., be approved. DONE and ENTERED this 21st day of February, 1979, in Tallahassee, Florida. THOMAS C. OLDHAM Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1107 Blackstone Building 233 East Bay Street Jacksonville, Florida 32202 Peter S. Penrose, Esquire 3175 South Congress Avenue Suite 103 Lake Worth, Florida 33461 Geraldine Johnson, R.N. Licensing and Investigation Coordinator State Board of Nursing 6501 Arlington Expressway, Bldg B Jacksonville, Florida 32211
The Issue Whether or not the Respondent, Hermine Ledoux Lane, is guilty of a violation of 464.21(1)(a), (1)(b), based upon a revocation of her license to practice as an licensed practical nurse, in the State of Vermont, effective January 14, 1976, after a hearing on December 3, 1975, in which it was concluded that the Respondent had on several occassions signed her name on a patient's clinical record and used the letters "R.N." after said signature and had on three occassions signed her name on a billing form using the initials "R.N." following her signature, when in fact the Respondent was not a registered nurse in the State of Vermont. The Vermont State Board of Nursing concluded this showed the Respondent was guilty of unprofessional conduct in willfully and repeatedly violating Vermont's statutes governing the practice of nursing, in that she did practice professional nursing without being duly licensed.
Recommendation It is recommended that the charges placed against Hermine Ledoux Lane, L.P.N., under license no. 05372-1 be dismissed. DONE and ENTERED this 11th day of February, 1977, in Tallahassee, Florida. CHARLES C. ADAMS, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1130 American Heritage Life Building Jacksonville, Florida 32202 Hermine Ledoux Lane 51 North Union Street Burlington, Vermont 05401
Findings Of Fact Between November 30, 1977, and December 6, 1977, Prado completed the Board's application for certification as an advanced registered nurse practitioner, in the category of family nurse practitioner. Prado was under the impression that her application was mailed shortly after its completion, however, the person to whom Prado gave the application for mailing did not do so. The application was discovered in Prado's desk on or about April 16, 1978. The application was then mailed to the Board and it was received on May 2, 1978. Among the requirements for certification of advanced registered nurse practitioners contained in Rule 210-11.04, Florida Administrative Code, is satisfactory completion of a formal education program conforming to program guidelines contained in the appendix to the cited Rule. The appendix provides in part that the program of study shall be at least one academic year in length (9 months full-time). On January 1, 1974, Prado completed the University of Miami School of Nursing and Medicine's six month advanced nursing practice course. At one of its meetings the Board established a policy that nurses completing such a program with all requirements except the one academic year length stipulation would, if otherwise qualified, be accepted if their application was made by March 31, 1978. This policy was never adopted as a rule. In fact, all nurses who had taken the same course as that taken by Prado, and who submitted their applications by March 31, 1978, were accepted for certification as advanced registered nurse practitioners. Thee evidence shows that the only difference between the six month course attended by Prado and others and the one year course now required as a condition for acceptance is its calendar length. The substantive content of the two courses is identical. That is to say, the one year course simply takes three months longer to teach the same subject matter as the six month course. The evidence further indicates that, had Prado's application been timely filed, she most probably would have been certified by the Board.
The Issue The central issue in this case is whether the Respondent is guilty of the violations alleged in the administrative complaint; and, if so, what penalty should be imposed.
Findings Of Fact Based upon the testimony of the witnesses and the documentary evidence received at the hearing, I make the following findings of fact: The Department is the state agency charged with the responsibility of regulating the profession of nursing pursuant to Chapters 455 and 464, Florida Statutes. At all times material to this case, Respondent has been licensed by the Department, license nos. RN 1672492 and 167249A. Respondent holds dual licensure since he is listed as a registered nurse (RN) and an advanced practice RN with specialty (ARNP). In Respondent's case, the advanced specialty practice is in the area of anesthesia. To become licensed as an ARNP, Respondent submitted an application, a fee, and copies of a certification from the Council on Recertification of Nurse Anesthetists (CRNA) which included an identification card specifying Respondent's CRNA number to be 24936. Respondent represented, under oath, that the copies were true and correct duplicates of the originals. Based upon this documentation, the Department issued the ARNP license. On or about March 25, 1986, Respondent was employed by the Hialeah Anesthesia Group (HAG). Respondent's supervisor was Manuel B. Torres, M. D., president of HAG. On or about November 30, 1987, Dr. Torres notified Respondent that his employment and privileges at Hialeah Hospital were being suspended. According to Dr. Torres, this suspension was to continue until confirmation was given by the Impaired Nurse Program at South Miami Hospital that Respondent's problem had been corrected. At the same time, Dr. Torres notified the CRNA that Respondent had voluntarily entered an impaired nurse program. Subsequently, Dr. Torres received a letter from Susan Caulk, staff secretary for CRNA, which notified him that, according to CRNA files, Respondent had not passed the certification examination, was not a member of the American Association of Nurse Anesthetists, and that Respondent's CRNA recertification number was not valid. Dr. Torres then notified the Department regarding the certification issue. Later, after Respondent had completed a controlled substance addiction program at Mount Sinai Medical Center, Dr. Torres advised him that, if he could prove his CRNA certification, he could be rehired at Hialeah Hospital. Respondent never returned to demonstrate his certification. An individual who represents himself to be certified as an ARNP when he has not qualified to be so certified has exhibited conduct which falls below the standard of care of the nursing practice. Further, such an individual, by practicing as an advanced practitioner without the educational background, compromises the safety of patient care.
The Issue The issue is whether either respondent bore a relationship to Petitioner, as described in Section 760.10, Florida Statutes, that confers jurisdiction upon the Florida Commission on Human Relations to investigate Petitioner's claims of racial discrimination under the Florida Civil Rights Act of 1992, Sections 760.01-760.11 and 509.092, Florida Statutes.
Findings Of Fact Petitioner has been a registered nurse licensed in Florida for 14 years. Her specialty is intensive care. Seeking advancement within the profession of nursing, Petitioner decided to pursue certification as a Certified Registered Nurse Anesthetist (CRNA). A CRNA has advanced training and education in anesthesia and passes a national certification examination, which is administered by neither Respondent. Upon passing the examination and meeting other requirements, an applicant is entitled to certification from the Council on Certification of Nurse Anesthetists. After obtaining this certificate and completing other requirements, such as financial responsibility, the applicant is eligible for certification by the Florida Board of Nursing as an advanced registered nurse practitioner in anesthesiology, pursuant to Florida Administrative Code Rule 64B9-4.002. In Florida, a CRNA is authorized to administer anesthesia in in- and out-patient settings and bears significant responsibilities for the safety of anesthetized patients. Petitioner enrolled at Barry University to fulfill the educational requirements for certification. Barry University is a private institution headquartered in Miami Shores and is one of several institutions in Florida that offer a program to satisfy the educational requirements for CRNA certification. The 28-month program at Barry University leads to a master of science degree in anesthesiology. A major component of the educational program is clinical practice. The clinical practice requires a student to perform clinical responsibilities, under supervision, with an anesthesiology group. At the time in question, Barry University maintained relationships with different anesthesiology groups in most major urban areas in Florida. Petitioner began the Barry University program in January 2005 and withdrew from the program in May 2006. She chose to take her clinical training in Orlando, where Wolverine Anesthesia Consultants accepted Barry University students for clinical practice. Wolverine Anesthesia Consultants served various hospitals forming part of the Orlando Regional Healthcare System. Petitioner began the clinical portion of the program in May 2005. No cash is exchanged between Barry University and Wolverine Anesthesia Consultants as part of the arrangement described above. The obvious benefit for Barry University, whose program is not inexpensive, is that Wolverine's supervision of its students in the clinical practice allows Barry to offer a comprehensive anesthesiology program that qualifies its students to sit for the CRNA examination. The obvious benefits to Wolverine Anesthesia Consultants are access to newly certified CRNAs, who are in high demand, and the ability to recruit the students likeliest to excel within the profession. It is less clear, from the present record, if Wolverine is able to bill for the services of more advanced students. From time to time, Wolverine provides Barry with financial support, such as a stipend so that a financially needy student may attend an out-of-town conference, as the tuition charged by Barry does not cover the cost of the program or incidental student costs. The economic relationship between the respondents is only of relevance, however, in providing the background from which to assess the economic relationship between the respondents, on the one hand, and Petitioner--and, more specifically, the value that flows to Petitioner from one or both respondents. Clearly, the educational and clinical programs provide educational value, and potential economic value, if and when certification is obtained, but, as explained in the Conclusions of Law, the key question is what, if any, economic value flows to Petitioner from either respondent during her relationship with each respondent. Neither respondent paid Petitioner any income, compensation, or other benefit, directly or indirectly. Neither respondent ever provided Petitioner with an IRS W-2 statement or Form 1099, as evidence of payments to an employee or independent contractor. She never received compensation of any type from either respondent, nor did she receive an IRS Form 1099, reflective of the payment of compensation to an independent contract. Petitioner never received any other employment- related benefits from either respondent, such as health insurance or retirement benefits. Neither respondent provided Petitioner with housing or a housing allowance. Wolverine did not insure Petitioner on its medical malpractice insurance policy. Neither respondent covered Petitioner under workers' compensation. Wolverine Anesthesia Consultants required Petitioner to sign her name on any anesthesia record pertaining to a case in which she was involved. When Petitioner was required, due to the needs of a particular patient, to work in excess of her scheduled time, she was entitled, from Barry University, to "comp time," which means only that she could receive credit for the additional time worked when setting a subsequent schedule. However, apart from a grant from Barry University as part of her financial-aid package, Petitioner never received any financial benefit from either respondent. In addition to the occasional stipend, which Petitioner does not appear to have received, Wolverine Anesthesia Consultants provided minor items, such as lunches for meetings of the interns, which Petitioner may not have attended, and $50 Christmas gift certificates to all interns, including Petitioner. In no way does the record support an interpretation of these minor acknowledgements or courtesies as compensation because Wolverine is under no obligation to provide them, no relationship exists between the recipient of the item and the amount of time worked, and no relationship exists between the value of the item or stipend and the amount of time worked by the student receiving the item or stipend. Although Barry University administers a comprehensive test to all candidates for a master's degree in anesthesiology, passage of which is required for a degree, Petitioner withdrew from the program prior to the administration of this test. She withdrew essentially due to reports from Wolverine to Barry University that she had failed to make adequate progress in the clinical program.
Recommendation It is RECOMMENDED that the Florida Commission on Human Relations enter a final order dismissing the petitions of Petitioner in these two cases. DONE AND ENTERED this 1st day of June, 2007, in Tallahassee, Leon County, Florida. S ROBERT E. MEALE 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 1st day of June, 2007. COPIES FURNISHED: Denise Crawford, Agency Clerk Florida Commission on Human Relations 2009 Apalachee Parkway, Suite 100 Tallahassee, Florida 32301 Andrea Bateman, Esquire 1999 West Colonial Drive Orlando, Florida 32804 Cecil Howard, Agency Clerk Florida Commission on Human Relations 2009 Apalachee Parkway, Suite 100 Tallahassee, Florida 32301 Susan T. Spradley, Esq. Deborah L. La Fleur, Esq. GrayRobinson, P.A. 301 East Pine Street, Suite 1400 Orlando, Florida 32801 John A. Walker, General Counsel Barry University Division of Legal Affairs and Human Resources LaVoie Hall, Office 209 11300 Northeast Second Avenue Miami Shores, Florida 33161
Findings Of Fact Respondent, Jean L. Hammer, was at all times material hereto a licensed practical nurse in the State of Florida, having been issued license number 0588011. In October 1986, respondent was employed by Pinewood Lodge, a treatment center for alcohol and drug rehabilitation, as a staff nurse on the midnight to 8:00 a.m. shift. Respondent was the only employee on duty during her shift, and was responsible for monitoring the patients for signs of distress, noting their progress on the medical records, and administering prescribed medications. For such services, respondent was paid $27,000 per annum; a salary consistent with that paid a registered nurse (R.N.) at the facility. In January 1987, respondent was offered and accepted the position of Supervisor of Nurses at Pinewood Lodge. The staffing of this position required the services of and provided an annual salary of $25,000 and other benefits. Respondent occupied this position until July 1987 when it was discovered that she was not a registered nurse and was discharged. The respondent's personnel file at Pinewood Lodge demonstrates that in seeking and gaining employment at the facility respondent represented herself to be a licensed registered nurse, the recipient of a Bachelor of Science degree from the University of Pittsburgh, and the recipient of an Associate in Science Nursing degree from Broward Community College. Such representations were false, and the documents submitted to support such representations were forgeries. The proof further demonstrates that respondent assumed the title of R.N., routinely signed documents in a manner that identified her as an R.N., and otherwise led the public and associates to believe that she was licensed as a registered nurse; all for pecuniary gain. While there was no showing that anything untoward occurred during the course of her tenure at Pinewood Lodge, respondent knew her actions were improper.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that a final order be entered suspending respondent's license for one year, that following such suspension respondent be placed on probation for two years subject to such terms and conditions as the board may specify, and imposing an administrative fine against respondent in the sum of $1,000. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 15th day of August, 1988. WILLIAM J. KENDRICK Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1050 Filed with the Clerk of the Division of Administrative Hearings this 15th day of August, 1988. APPENDIX Petitioner's proposed findings of fact have been addressed as follows: Addressed in paragraph 1. Addressed in paragraph 4. 3-4. Addressed in paragraph 3. 5-6. Addressed in paragraph 4. 7-8. Addressed in paragraphs 3 and 5. 9. Addressed in paragraph 5. COPIES FURNISHED: E. Raymond Shope, Esquire John S. Cobb Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Richard Smith, Esquire 1258 South State Road 7 Fort Lauderdale, Florida 33317-5989 Judie Ritter, Executive Director Board of Professional Nursing 111 East Coastline Drive Room 504 Jacksonville, Florida 32201 William O'Neil, Esquire General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
Findings Of Fact The Respondent, Betty Jean Dempsey Hatton, L. P. N., holds License No. 29095-1. She was employed as a licensed practical nurse at Riverside Convalescent Center in Jacksonville, Florida, during the month of January, 1979. An Administrative Complaint was issued against Respondent Hatton on April 20, 1979, alleging that she was guilty of unprofessional conduct. The Respondent requested an administrative hearing. On or about January 27, 1979, Respondent Hatton had become unhappy with her work at the convalescent center and had decided to resign. She was requested to work 11:00 o'clock p.m. to 7:00 o'clock a.m. shift beginning the night of January 27, 1979. The Respondent agreed to work that shift, although she informed Eleanor L. Hennessey, the evening supervisor, that she intended to resign. The Respondent had not submitted a written resignation at that time. Ms. Hennessey finished her work at 11:00 o'clock p.m. and expected the Respondent to begin work at that time pursuant to her work schedule and pursuant to her agreement. The Respondent did in fact report to work at the convalescent center as agreed on the night of January 27, 1979. Fiona M. Morris, R. N., the Director of Nursing at Riverside Convalescent Center, was notified by Ms. Hennessey that Respondent Hatton had quit work, but Ms. Morris did not receive either an oral or a written resignation from the Respondent. Introduced into evidence was a copy of an official time and signature sheet for the month of January, 1979, for the employee, Respondent Hatton. The Respondent signed in for work on the night of January 27, 1979, at 10:45 o'clock p.m. and signed out at 4:00 o'clock a.m. January 28, 1979. The Respondent had previously agreed by conversation with Ms. Hennessey that evening to work the 11:00 p.m. to 7:00 a.m. shift for which she had been employed and from which she had not resigned. Respondent Hatton in fact did not work all of said shift, leaving some three (3) hours early. She left without informing her supervisor, Ms. Hennessey, and left her floor unattended. In mitigation of leaving her night shift early, Respondent Hatton contended that she told someone on the floor she was leaving, and that she had injured herself the day before and was suffering pain from her back. The Respondent also said she had informed several people that she was resigning as of January 27, 1979. Neither party submitted proposed findings of fact, memoranda of law or proposed recommended orders.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer recommends that the Petitioner Board reprimand the Respondent, Betty Jean Dempsey Hatton. DONE and ORDERED this 16th day of October, 1979, in Tallahassee, Leon County, Florida. DELPHENE C. STRICKLAND Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1107 Blackstone Building 233 East Bay Street Jacksonville, Florida 32202 Betty Jean Dempsey Hatton 8201 Styers Court Jacksonville, Florida 32221 Geraldine B. Johnson, R. N. Board of Nursing Ill Coastline Drive East, Suite 504 Jacksonville, Florida 32202
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
Findings Of Fact At all times relevant to the issues, Respondent was licensed as a registered nurse in the State of Florida under license number 1262382 and was employed as a registered nurse at University Hospital of Jacksonville, Jacksonville, Florida. On the late afternoon or early evening of March 14, 1984, a female patient was brought into the emergency room at University Hospital suffering from an overdose of asthma medicine for which the prescribed treatment was dialysis to cleanse the blood of the drug. When the hospital personnel had determined that adequate dialysis had been accomplished the patient was removed from the dialysis machine. A patient is affixed to a dialysis machine through the insertion of tubes into a vein and artery which facilitates the removal and replacement of the blood being cleansed. When the catheters are removed, it is necessary that pressure be applied to the place of insertion for a period of time to allow clotting sufficient to stop bleeding from the vein or artery. Generally, the pressure is administered by a nurse physically applying pressure to the immediate area. This patient did not respond properly, however. As a result, Dr. Mendez-Vigo was called to examine her. He determined that because of her blood loss, a transfusion was appropriate, which he ordered, and then left the treatment area. Approximately ten minutes later, he was called again and advised that the patient's blood pressure was dropping and that the dialysis nurse, the nurse that was attending the patient at the time, needed him. Dr. Mendez-Vigo advised the nurse to start a saline solution and indicated he would come to the dialysis unit, where the patient was being treated, as soon as possible. The dialysis of this patient was accomplished in the dialysis room which is located contiguous to and immediately off the cardiac intensive care unit (ICU) in the hospital. Ordinarily, the dialysis room, which opens onto the ICU is not manned. It is however, generally fully equipped with its own supplies and equipment and when this patient was placed on the dialysis machine, she was moved to this dialysis unit and tended by a nurse, Ms. Domingo, whose sole job was in the dialysis unit. Ms. Domingo was called to come in from off-duty to attend to the patient in question and arrived at the dialysis unit at approximately 5:15 p.m. When she arrived, she found the patient stable, and the only treatment required at the time was pressure to the groin area as described above to promote clotting until the bleeding stopped. After Dr. Mendez-Vigo started the transfusion and left, as described above, the patient became restless and started sweating, which prompted Ms. Domingo to stop the flow of blood. This took place at approximately 6:00 p.m. Once she stopped the inflow of blood, she wanted to remove the needle through which the blood was being inserted, but because she was unable to remove the pressure from the patient's groin area and because she was alone in the dialysis unit, she called for help from those nurses assigned to the ICU. At first, no one responded, but shortly thereafter, after a second call for assistance, Nurse O'Brien did come in. Ms. O'Brien was, at the time, one of several nurses assigned to duty on the ICU and had worked there just a few days. She and Respondent, the nurse in charge of the unit, were the only two registered nurses on duty, along with several licensed practical nurses (LPN's). However, at the time in question, Respondent was off the unit at dinner and Ms. O'Brien is not sure where the LPN's were. When she heard the dialysis nurse call for help, she went into that room and saw the situation. Ms. Domingo told her that the patient looked to be in shock - sweating, with a high pulse rate, very low blood pressure, and in a semi-conscious state. At this point, Ms. O'Brien immediately opened up the IV point to put in a saline solution, then went outside the dialysis room to get equipment to start another intravenous line (IV), and to page Dr. Mendez-Vigo. When she brought back the equipment she needed and tried to start the second IV, she experienced difficulty because of the patient's low blood pressure. At this point, she asked another nurse from the ICU to speed the doctor up. At this time, in her opinion, the patient was extremely unstable and near critical. It was then that Ms. O'Brien first saw the Respondent. She told him she was going into the dialysis unit to help out. Respondent did not follow, but instead went to the nurse's station on the ICU from which he could see the door to the dialysis room and called to Ms. O'Brien telling her she was not to go into the dialysis unit since it was a separately staffed unit. Ms. O'Brien responded to the effect that while this might be the case, the patient was sick and needed help and she was going to give it. In response, Respondent told her several times that she was not to be in the dialysis room. Ms. O'Brien finally told Respondent that she was going to do what she had to do regardless of what he- said. She further contends that when Dr. Mendez-Vigo finally returned her call, Respondent took the call and spoke with the doctor but refused to tell Ms. O'Brien what the doctor said until she came out of the dialysis room to talk to him. To do so, she had to leave the patient with whom she was working to go to the nurse's station and get the message from the doctor which had been given to Respondent. When Dr. Mendez-Vigo arrived at the dialysis unit, he saw the Respondent and two other nurses in the ICU area. He went into the dialysis unit and observed the dialysis nurse still applying pressure to the artery and one other nurse, subsequently identified as O'Brien. At this point, Respondent and the other nurses in the ICU were standing around in that unit not assisting in the dialysis area. When he arrived, Dr. Mendez-Vigo found the patient to be nearly unconscious with a high pulse rate and low blood pressure. He suspected a transfusion reaction and because of that, started action to counteract that situation. Because both nurses in the dialysis room were totally occupied by the patient, he needed help to get other things ready for treating the patient. For example, he needed to get additional equipment, additional IV lines had to be prepared; and solutions had to be mixed. Both Ms. Domingo and Ms. O'Brien seemed to him to be upset because it appeared Respondent had attempted to keep the other ICU nurses from helping in the dialysis room when they were needed because the patient was not an ICU patient. During the initial telephone conversation between Dr. Mendez-Vigo and Respondent, the doctor requested Respondent to secure certain supplies. When the doctor got to the dialysis unit and saw the condition of the patient, he took a blood sample, which he asked Respondent to take to the lab for identification for transfusions. Respondent failed to respond to any of the doctor's requests. Another resident, Dr. Curran, was called into the dialysis from by Dr. Mendez-Vigo when she came to the ICU that same evening. On at least one occasion, after she started to work on this particular patient, she walked out to the nursing station of the ICU and asked Respondent for help. At that point he refused, stating that he was busy and responsible for all the other patients and could not leave. As a result, Dr. Curran took the blood to the lab for what lab work was necessary. When she got back from the lab, she asked Respondent where she could get MAST trousers for the patient and if he would call the emergency room to inquire. Respondent refused to do this, requiring Dr. Curran to do it herself. When she was advised that the operating room might have them and started to place that call, at that point, Respondent did make the call to try to secure what she needed. During the course of his treatment of the patient, Dr. Mendez-Vigo had occasion to attempt to use the cardiac monitor that was a part of the equipment in the dialysis room. It is unclear whether the doctor did not know how to operate the equipment or whether it did not work. In any event, the doctor requested the Respondent to get a portable monitor that was a part of the ICU's equipment. Respondent refused this request initially on the basis that the patient was a dialysis patient rather than an ICU patient, and that his instructions were that ICU equipment could not be used for dialysis patients. Notwithstanding his initial refusal, Respondent ultimately did provide the requested monitor, however. Dr. Mendez-Vigo's recollection of the incident was that the Respondent's total response was that since the patient was not an ICU patient, he could not help out and do what was necessary since he was assigned to ICU, not dialysis. He reportedly stated that he could get into trouble if he did. According to the doctor, however, none of the other patients in the ICU needed immediate attention so that, in his opinion, Respondent or some other member of his staff could have assisted in the treatment of this critically ill patient. What was unknown to Respondent at the time was that the patient had been identified for admission to the ICU, and orders to that effect had been written by Dr. Mendez-Vigo though the formal process of admission had not taken place. As was stated, this information regarding proposed admission had not been communicated to Respondent or the other ICU nurses even though the information was contained on the patient's chart which was with her in the dialysis room during this period of time. If Respondent had gone in to help as requested and looked at the chart, he would have seen this. According to Ms. O'Brien, through all the period of requests for help prior to the arrival of the doctor, and even through the period of requests for assistance and equipment after the arrival of the doctors, Respondent did not come into the dialysis room to see the patient's condition for himself. It was only after Dr. Mendez-Vigo started the neck IV line that the Respondent came into the dialysis room, and when he saw the patient he said something to the effect of, "Oh, I didn't know she was so sick." This was 20 to 25 minutes after the original call for help. Sometime after the incident, Respondent went to Ms. O'Brien and apologized to her for not responding more quickly and for trying to get her out of the dialysis room when he returned from dinner. At that time, he said his resistance was based on the fact that he did not want her to get into trouble. He also told her that if she intended to report the incident, he would just go ahead and submit his resignation because he had been in trouble previously and this would hurt him. Respondent's demands to Ms. O'Brien to come out of the room when she was in assisting Ms. Domingo, prior to the arrival of the doctor, were heard clearly by Ms. Domingo. Ms. Domingo also overheard the doctor ask Respondent to help hook the patient up to the monitor and overheard Respondent's initial refusal. What was most puzzling to Ms. Domingo was that though she had never dealt with Respondent prior to this time, whenever she had asked for help from the ICU nurses previously, she had always gotten it. According to another nurse on the ICU that evening, Ms. Bowers, who was on her break at the time of O'Brien's first confrontation with Respondent, emergency situations requiring help from the ICU personnel were not frequent and this was the first emergency situation she knew of involving Respondent. In this case, she was not aware of any "code" being announced, nor overheard the argument between Respondent and Ms. O'Brien. She had been in the ICU for an hour prior to this time and during that entire period, had received no request from Ms. Domingo for help. She had not previously been asked for assistance and until she became aware of the problem by overhearing the dispute referenced above, she had no idea there was an emergency situation in the dialysis room. Frank B. Bellamy works as a nurse manager at University Hospital for the ICU. As a part of his job, he oversees and evaluates nursing services in the ICU and was doing so at the time of the incident in question. To his knowledge, at that time, there was no written policy on support of the dialysis unit by the ICU. However, the oral instructions given to ICU personnel were that ICU equipment and supplies were not be used in routine cases in the dialysis unit - only in emergency cases. In an emergency case, anything could be used. The job description drafted for registered nurses in University Hospital does not delineate any separation for jobs between ICU and the dialysis unit, but it was generally followed at the time in question that ICU nurses did not help out in the dialysis room in routine situations. However, in an emergency situation, ICU nurses could and should help--out. In Mr. Bellamy's opinion, in the instant case, as the fact situation existed, extra help was needed and the ICU nurses, including Respondent, could have and should have helped out if this assistance could be provided without jeopardizing the patients in the ICU. In such a case, the ICU nurse would have called the nursing supervisor, reported the situation, and requested help. In his opinion, Respondent's conduct in this case was unprofessional misconduct. It was not negligence but willful misconduct in that the Respondent refused to render assistance in an emergency situation and attempted to prevent Ms. O'Brien from doing so as well. Both of these are evidence of willful misconduct. In addition, in an emergency situation, the Respondent's failure to provide the portable monitor in a timely fashion was both unprofessional and unsafe in that the ability of the physician to determine cardiac rhythm is crucial. Nurses are obliged to acknowledge physician's orders and, if considered safe, to follow them. In emergency situations, according to Mr. Bellamy, it is negligence and unprofessional conduct not to provide assistance and equipment to a doctor upon request. Here, in the professional opinion of Mr. Bellamy, the Respondent's failure to provide the requested assistance to the doctor was critical and constituted negligence and unprofessional misconduct. The mere fact that the Respondent delayed responding is negligence because in an emergency situation, as here, time can be and was of the essence. Respondent made much of the need for the charge nurse to oversee the patients on the ICU. In fact, these checks by the charge nurse, the job which Respondent was filling at the time, were done only every 10 or 15 minutes, and assuming that this was necessary and critical on a routine schedule, there was still ample time between the checks for the Respondent to respond to the dialysis unit. Here it is clear that Respondent was asked for help and either refused to give it all, or failed to respond in a timely fashion. It is also clear that Respondent refused to provide equipment and other supplies, even though under the guidelines in place at the time, and which, though oral, had been briefed to the ICU nurses, this situation was one where he could have properly done so. With regard to Respondent's contention that he had been told that he was not to go into the dialysis unit to help, Ms. Kamienski, the Director of Nursing who helped to interview Respondent when he was hired, advised him that the dialysis section was responsible for routine care but that it was placed where it was, contiguous to the ICU, so that ICU nurses could help out in an emergency. She categorically denies ever telling Respondent that dialysis was to get no help, nor that he was never to go in there. As Director of Nursing, Ms. Kamienski received the complaint about the Respondent in the incident in question, and on the basis of the complaint did some investigation. She determined from her interview of the physicians and nurses involved, that the allegations were true and Respondent's conduct was inappropriate. In her opinion, any registered nurse who has the knowledge and skills (and, as here, the resources) to render aid and assistance in a need situation, who does do so and who, as here, attempts to hinder aid, is guilty of negligence and should not practice nursing in the State of Florida. Ms. Kamienski is satisfied that Respondent used poor judgment in this assistance. He should have either helped out himself or assigned someone on the unit to assist and he did neither. Also, he could have contacted the house supervisor to get help either for his unit or for the dialysis unit and failed to do that. In her opinion, his conduct was unprofessional and insubordinate. He had the responsibility to help out in a life threatening situation and failed to do so. Admittedly, the dialysis unit had been requested to use its own equipment and supplies, but in a life threatening situation, they were to get anything they needed. This is now, and was the policy at University Hospital, and to the knowledge of Ms. Kamienski, a similar policy is found in almost any hospital. It is a general standard of practice in nursing to use whatever is needed from wherever located in an emergency situation. Here, Respondent's delaying tactics in making the telephone calls at the request of physicians, was unprofessional conduct because of the life threatening situation. Death to the patient could be imminent in a situation such as this, and Respondent had a duty to respond in a timely fashion. Respondent also makes much of the fact that none of the other nurses in the ICU offered assistance and that nothing was done to them. The fact is that none of the other nurses were asked for help, nor were they asked for supplies and equipment by physicians, nor did they interfere to tell Ms. O'Brien to come out. As to the monitor, Ms. Kamienski feels that while admittedly it is not Respondent's responsibility to ensure that the dialysis monitor was working, under the circumstances of this incident, when he was asked for a portable monitor in an emergency situation, he should have provided it and not argued about whether the dialysis monitor was working or not. In the opinion of Ms. Cayer, a professor of nursing at Jacksonville University, a registered nurse should respond to an emergency and provide whatever assistance is necessary in the situation in the geographical area of the nurse, even if the patient is not the nurse's patient. Having had an opportunity to review the extensive documentation which outlines the situation here and what Respondent did and failed to do, and which fairly reflects the facts in evidence, she concluded that the patient here was unstable and rapidly declining; this was very near or actually was a severe emergency, and there was a need for help. Ms. Cayer was made aware of a hypothetical situation which very closely parallels the factual situation in this case. Based on this hypothetical situation, she concludes that the Respondent in that case was negligent because: (1) when the nurse in question arrived on the scene, he should have gone into the dialysis unit, assessed the situation, and made staffing changes to help out and meet the situation, all of which he failed to do (he needed to gain the knowledge of what the needs were and to take action to meet those needs); (2) he improperly attempted to get the nurse (Ms. O'Brien) to come out of the dialysis room without assessing the situation and its needs (by the time he knew that the blood pressure was low and communicated this information to Dr. Mendez-Vigo, he surely must have known there was a problem); (3) while it would not have been proper for him to leave the floor to go to the blood bank himself, it was unprofessional of him not to arrange for someone else to go in light of the fact that he could have done so; (4) as to the monitor situation, he should have followed up on the request for an additional monitor to see why the request was made (If he had done so, it would have shown that the monitor was not working and he would have provided a replacement sooner. His failure to follow up on the request and his rejection of it without further inquiry was unprofessional); (5) his failure to communicate effectively in all these respects hindered the staff in their treatment of the patient and was unprofessional conduct. Much the same approach is taken by Dr. Eileen K. Austin, also an expert in the field of nursing, who indicated that nursing education generally teaches that first and foremost the interest of the patient takes precedence over policies and regulations which may be ignored if necessary. Also, the nurse must assess the situation and either provide the needed service or get someone else who can provide it. Emergency procedures care is taught as a part of several courses in nursing education. Nurses are also taught generally that if the need is there, the nurse acts regardless of where the patient is assigned and once in the picture, retains treatment status until relieved. As to the response to physicians, nurses are taught they are to respond promptly unless they suspect it is an improper order which would endanger the patient. Nursing assessment includes observing the patient for signs and condition, to take vital signs, to ensure there is an airway for breathing, and once having made an assessment, either provide or secure help. These basic concepts are universal to nursing training. The course title may vary among nursing schools and among nursing programs, but the subject matter is basically the same and these subjects are, in substance, on the nursing licensing examination. The primary difference between the two-year associate of arts program in nursing and the four-year bachelor program is in the other primarily non-nursing, non-scientific curriculum. Basic nursing material is the same in both. The requirements for the registered nursing license requires certain basic information be taught, and it does not matter through which program these requirements are met. Respondent's reputation is good among the people with whom he currently works. For example, Respondent has worked for JoAnn Hahn at Methodist Hospital as a staff nurse for one year and she has observed his work in both routine and emergency situations in the accomplishment of his duties which are equivalent to being the charge nurse on a particular shift. She finds Respondent to have a very good knowledge of critical care situations and to her knowledge, he has never mis-diagnosed a case. He anticipates medications correctly and has them ready, and he also knows what lines are needed and has them ready. In critical care his performance is above the standards she has observed in other hospitals. In responding to requests from supervisors or doctors, if he agrees with the request, he speaks out, somewhat abruptly sometimes, but this is what she wants her nurses to do. Above all, however, Respondent never lets the patient down, and Ms. Hahn has no reservations whatsoever about his training, ability or performance. When he is on duty, she feels quite safe. Ms. Hahn is aware of the incident in question here, having reviewed the statements regarding it and her knowledge is consistent with the facts in evidence. She has also reviewed the hypothetical situation and based on this, she feels that Respondent's actions in question were not a violation of the Nursing Practices Act. In Ms. Hahn's opinion, Respondent was not incorrect in calling Ms. O'Brien out of the dialysis room because the ICU was, in her opinion, under-manned in light of the serious condition of the patients on the floor, and Respondent did not have a report on the condition of the patient in the dialysis room. As to the monitor situation, she feels the patient should not have been put on the dialysis machine in this case without being put on a monitor as well from the very beginning. Also, the needed IV lines should have already been started prior to the dialysis in case of need. As to Dr. Mendez-Vigo's telephone request to the Respondent to start an IV line, since Ms. O'Brien was already trying to get it started and Respondent could see this, it was not necessary for him to go in and attempt the same thing. The fact that Ms. O'Brien could not accomplish the start and it was necessary for the doctor to start a sub-clavian line is immaterial since a registered nurse would not do that procedure anyway. In short, in light of the condition of the patients on the ICU, Ms. Hahn feels Respondent could not have properly left the unit. He also could not have gotten the blood because he did not have the patient's proper plates or bands as required by the lab. As for the portable monitor, he could have asked why they did not use the monitor they had, but, Ms. Hahn feels the delay based on his understanding of the monitor being in there was "just common sense." Cathy Carvery has known Respondent from the time she hired him at University Hospital. She observed him in his work there in the handling of patients and feels that his competence, training, and other skills are very good. He handled crisis situations very well and knew what he was doing. She, too, has reviewed all the background information on the situation and is familiar with the dialysis room and equipment at University Hospital. In light of the staffing in the ICU at the time, in her opinion, it was not at all improper for the Respondent to have refused to send any more of his staff to the dialysis room. Also, in her opinion, though he could have tried to get the blood as requested, he would not have been able to do so without more information on the patient, which was not available to him. In addition, even if he had tried to insert the IV line as requested by the doctor, the likelihood is great he would not have been able to get it started. What is overlooked by both Ms. Hahn and Ms. Carvery in their exulpatory comments regarding Respondent's failure to assist, failure to go for blood, and failure to attempt to start the IV line as requested, is that though what they say may well be true and that Respondent could not have accomplished anything, the fact is he did not even try. With regard to assisting or providing more help, a telephone call to the supervisor of nursing would have resolved that situation without either he or any more of his people being required. Though he called Ms. Lee, he did so to report what he considered to be Ms. O'Brien's improprieties and at no time requested any help. Though he most likely could not have accomplished getting the blood as requested because of the lack of plates, the fact is that though asked to do so, he did not even try and the same is true with regard to the IV line. It does not matter that the sub-clavian insertion was done by the doctor. Respondent was not asked to insert a sub-clavian catheter. He was asked to attempt an intravenous line and did not even try. It is impossible to say what he would have done if he had attempted to assess the situation and find out what the condition of the patient was as he should have done. He did not, and it this particular especially, he was deficient. With regard to the incident in question, when Respondent came back from dinner he was told by one of the LPN's on staff that Ms. O'Brien was in the dialysis room because a patient was bleeding from an arterial line. In his experience, this was not too serious and in light of the fact that Ms. O'Brien was off the ward, one nurse was out to dinner, another was on duty, and he did not know here the fourth was, he was miffed. As a result of this, he called Ms. O'Brien out of the dialysis room to talk to her and she did not respond to his request. This made him angry. He did not have any responsibility for dialysis patients and his understanding of support to be furnished to the dialysis unit was that he was not to take any equipment in there. In light of his previous chastisement for doing so, he was upset. Though he denies refusing to convey Dr. Mendez-Vigo's message to Ms. O'Brien unless she came out of the dialysis room to get it, it is clear that in light of his admittedly poor frame of mind at the time, he did just that. He also admits to first suggesting, when requested to get another monitor, that they use the one in the dialysis room. Nonetheless, he says he went and got the portable within just a few minutes and hooked the patient up to it. Since Dr. Mendez-Vigo did not ask for any further assistance or give him any additional orders thereafter, he went back to work. When Dr. Curran asked him for the blood from the lab, he asked for a charge plate and was told it was in the dialysis room. He found, however, that the patient had not been admitted and did not have a charge plate, and he would therefore be unable to get the blood requested. He then started the admission process because he felt that when that was accomplished, within a 30-minute period or so, he could then get the blood as requested. As for the MAST trousers, when asked by Dr. Curran to get them, he, because of other duties, could not respond immediately, but did so several minutes later, at which time the request was refused. Dr. Curran, parenthetically, also was refused when she requested the trousers. When, as stated before, Respondent called Ms. Lee, the 3:00 p.m. to 11:00 p.m. supervisor, to report Ms. O'Brien, he was told to let her stay there. No request for assistance, equipment or supplies was made. On the basis of the investigation by Ms. Kamienski and after consultation with Mr. Bellamy, a recommendation of termination was prepared and delivered to the Respondent. In accordance with the procedures that were in effect at the time, he requested a hearing and one was afforded him. Respondent contends that the hearing was a farce and he was not given the opportunity to confront any of the witnesses or evidence against him. After the hearing was over, he was offered the opportunity to resign in lieu of termination and did so.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore, RECOMMENDED, that Respondent's license as a registered nurse in the State of Florida be suspended for one year and that upon completion of the period of suspension, he be reinstated and placed on probation for a period of three years under such terms and conditions as prescribed by the Board of Nursing. RECOMMENDED in Tallahassee, Florida this 27th day of September, 1985. ARNOLD H. POLLOCK Hearing Officer Division of Administrative Hearings 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 27th day of September, 1985. COPIES FURNISHED: Stephanie A. Daniel, Esq. Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 L. Haldane Taylor, Esq. 331 East Union Street Jacksonville, Florida 32202 Judie Ritter, Executive Director Board of Nursing Room 504 111 East Coastline Drive Jacksonville, Florida 32202 Fred Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Salvatore Carpino, Esq. General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
