The Issue The issue is whether the nursing license of Connie Sue Ward Reeves should be revoked or otherwise penalized based on the acts alleged in the Administrative Complaint.
Findings Of Fact At all times relevant to the charges, Connie Sue Ward Reeves has been licensed in Florida as a practical nurse, holding license number 0739211. In April 1990 Ms. Reeves was employed as a practical nurse at the Silvercrest Manor Nursing Home in Crestview, Florida. On April 18, 1990, Ms. Reeves worked the 7:00 a.m. to 7:00 p.m. shift. Her duties included administering and charting medication. Ms. Reeves punched out on the time clock at 7:30 p.m. The Director of Nurses, Helene Metts, came on the floor when Ms. Reeves left because there was a staffing shortage. In determining what needed to be done, Ms. Metts examined the charts for the patients for whom Ms. Reeves had been responsible. Ms. Metts found that some 8:00 p.m. medications and one 10:00 p.m. medication were already charted as having been administered by Ms. Reeves. It is not the accepted practice at Silvercrest for the nurse on the prior shift to give the next shift's medications. In fact, the policy and procedure manual of Silvercrest requires that medications be given at the right time and that the medication be charted immediately after it is given. It is permissible according to policy to give medications up to one hour on either side of the prescribed time unless the prescribed time falls in the next shift. These practices also are required by principles of good nursing practice. Ms. Reeves was given the policy and procedure manual as part of an orientation which she attended prior to beginning at Silvercrest. Because Ms. Reeves had already left the premises, Ms. Metts never was able to determine the night of April 18, 1990, whether the medications had actually been given or whether they had just been pre-charted. If Ms. Reeves did administer the medications which she had charted, then she gave them in contravention of the policies and procedures. The way these medications were charted was negligent in that the medications either were administered at the wrong time, by the wrong shift, or were pre-charted before the medications were actually administered. Further, by signing the medication charts of the patients involved, Ms. Reeves was making a record that she administered the medications at the time stated on the charts. This cannot be so since Ms. Reeves left work up to two and one-half hours before the medications were to be given. Additionally, if Ms. Reeves pre-charted the medications, but did not administer them, the act of charting something that was not actually done would constitute negligence and the creation of a false record. Ms. Reeves' negligence resulted in a situation where patients could either receive no medication or double medication. In either case, the patients were put at risk.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Department of Professional Regulation, Board of Nursing, enter a Final Order and therein: Find Connie Sue Ward Reeves guilty of violating Sections 464.018(1)(f) and (h), Florida Statutes. Place Ms. Reeves on probation for a period of one (1) year. Require Ms. Reeves to attend continuing education classes in an amount and subject area to be established by the Board. Impose a fine of $250.00. RECOMMENDED this 31st day of May, 1991, in Tallahassee, Florida. DIANE K. KIESLING Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 31st day of May, 1991. APPENDIX TO THE RECOMMENDED ORDER, CASE NO. 91-0266 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted by the parties in this case. Specific Rulings on Proposed Findings of Fact Submitted by Petitioner, Department of Professional Regulation 1. Each of the following proposed findings of fact is adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1-8(1-12). COPIES FURNISHED: Tracey S. Hartman, Senior Attorney Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Connie Sue Ward Reeves Rt. 1 , Box 390 Laurel Hill, FL 32567 Jack McRay, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Judie Ritter Executive Director 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202
Findings Of Fact The Respondent, Cindy Louise Jirak, was licensed as a Registered Nurse pursuant to Florida law on May 14, 1979. Her license was last actively renewed to May 30, 1983, and now is in a lapsed status. P. Ex. 1. The Respondent was employed as a licensed Registered Nurse at the Central Florida Regional Hospital in Sanford, Florida, during the six month period up to and including October, 1986. On July 8, 1986, the Respondent was on duty as a licensed Registered Nurse and improperly set up intravenous fluids for a patient. The Respondent set up a previously ordered fluid, stating that the currently ordered fluid was not available. The correct procedure when a currently ordered fluid is not available is to hang a normal saline solution. By hanging the previously ordered solution, the Respondent's procedure was below minimally acceptable nursing practice. On October 6, 1986, the Respondent failed to turn on an intravenous solution pump after hanging an intravenous solution. The patient, therefore, did not receive the fluid that had been hung. The Respondent's action in failing to turn on the pump on October 6, 1986, was below minimally acceptable nursing practice. On August 23, 1986, the Respondent signed out 10 milligrams of morphine (one ampule) to be administered to a patient. Only 6 milligrams had been ordered for that patient. The procedure is to waste the excess before the narcotic is administered, and to have that act of wasting witnessed. The "waste and/or destroyed narcotic disposition record" shows that 4 milligrams were properly wasted since only 6 milligrams had been ordered for this patient. The records show that the 6 milligrams were then refused by the patient, but there is no subsequent entry to show that the 6 milligrams of morphine were properly wasted by the Respondent. The Respondent's failure to record the wasting of the 6 milligrams of morphine on August 23, 1986, was below minimally acceptable nursing practice. On August 22, 1986, the Respondent left two doses of Bumax in her cart with no explanation as to why the medication was not given. She was responsible for administration of that medication to a patient under her care, and the medication had been ordered for the patient. The medication was not given to that patient as ordered on that evening, and the Respondent did not make an entry in the records that the medication had not been administered. The Respondent's failure to administer the prescribed medication, or to chart that failure to do so, is below minimally acceptable nursing practice.
Recommendation It is recommended that the Department of Professional Regulation, Board of Nursing, enter its final order suspending the registered nursing license of Cindy Louise Jirak for a period of two years. DONE and ENTERED this 31st day of August, 1987. WILLIAM C. SHERRILL, JR. Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 31st day of August, 1987. COPIES FURNISHED: Judie Ritter, Executive Director Board of Nursing Department of Professional Regulation Room 504, 111 East Coastline Drive Jacksonville, Florida 32201 Van Poole, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Joseph Sole, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 John Namey, Esquire 22 East Pine Street Orlando, Florida 32801 Cindy Jirak 2718 Dellwood Drive Eustis, Florida 32726 =================================================================
The Issue An administrative complaint dated August 16, 1989 alleges that Respondent, Atalia Dacosta G. Sagastume, L.P.N., violated certain provisions of Chapter 464, F.S., related to the practice of nursing, by failing to properly chart the administration of controlled substances to patients. The issue in this proceeding is whether the alleged violations occurred, and, if so, what discipline is appropriate. Procedural Matters Ms. Sagastume responded to the administrative complaint with a request for formal hearing. The case was referred to the Division of Administrative Hearings and was scheduled for hearing on May 9, 1990. On April 24, 1990, Ms. Sagastume called the hearing officer to request a continuance, as she was working with the U.S. Census Bureau and also had surgery scheduled. She asked that the case be reset for the end of June, or thereafter. She was told to check with opposing counsel regarding her request, and later she confirmed that there was no objection. The hearing was cancelled, and Ms. Sagastume was asked to follow up her oral request in writing. No written request was filed. The hearing officer's secretary made several efforts to contact Ms. Sagastume and left messages on her answering machine or with whomever answered her phone. On June 4, 1990, when nothing further was heard from Ms. Sagastume, the amended notice of hearing was mailed, establishing a new hearing date of August 30, 1990. The notice was not returned, nor was any communication received from Ms. Sagastume. She did not appear at the hearing. Instead, she sent a certified letter to Lisa Bassett, then counsel for Petitioner, postmarked August 27, 1990 and received August 29, 1990. The letter requested that the hearing be rescheduled for sometime in November, as she was still working for the Census Bureau. No return address nor telephone number was listed on the letter or envelope. When Respondent did not appear at the hearing, the hearing officer tried to contact her at the telephone number in the file, 407-348-4450, but the number had been discontinued. Mr. Tunnicliff informed the hearing officer that he had not spoken with Ms. Sagastume. The DPR investigator had attempted to reach her by phone, or in person at her house, several times, but was unsuccessful. Ms. Sagastume had returned the call once, but left no telephone number. Since Ms. Sagastume had successfully obtained a continuance in the past, it was deemed that she is aware of the proper procedure and was attempting to avoid the proceeding. Petitioner was prepared to present its case and the hearing commenced at 9:50 a.m. In support of the allegations, Petitioner presented the testimony of Mary Elizabeth Duchaine, Helen Louis Shipley, Jacquette Cockrell, and Patricia Allen Zimmerman. Petitioner's exhibits #1-9 were admitted, which exhibits include the letter from Ms. Sagastume referenced above, patient records, Respondent's license file and a final order and complaint in another disciplinary action against the same Respondent. No transcript was filed and the right to file a proposed recommended order was waived by counsel for Petitioner.
Findings Of Fact During the relevant period, Respondent Atalia Dacosta G. Sagastume was licensed by the State of Florida as a practical nurse holding license number PN 0824781, issued on March 31, 1986. Her address of record was 316 Florida Parkway, Kissimmee, Florida, 34743-6325. Ms. Sagastume was employed by Kissimmee Memorial Hospital as a "pool nurse" in November, 1988. A pool nurse is not a regular employee, but serves on call during times of need, and receives a premium salary with no regular benefits. Pool nurses are considered experienced nurses and are held by the hospital to the same nursing standards as regular staff. Ms. Sagastume received orientation as to hospital procedures at Kissimmee Memorial Hospital all day on November 28, 1988, and on five additional days throughout the next few months. The orientation included methods of appropriate record-keeping, which methods are also standard nursing practice. On January 18, 1989, Ms. Sagastume signed out the narcotic, Demerol, two times on the sign out sheet for Patient "D". Ms. Sagastume was not the attending nurse for this patient and no entries on this patient's chart were made by Ms. Sagastume, as observed by Jacque T. Cockrell, R.N., the Director of Nursing at Kissimmee Memorial at the time of the incident. Ms. Cockrell and another nurse supervisor met with Ms. Sagastume and prepared a counselling report on January 19, 1989. Ms. Sagastume was reminded that she may administer medications only to her own patients and that she must document narcotics on the patient's chart (progress notes) as well as on the narcotics record sheet. At that time the supervisors considered the problem was educational and felt they had remedied it. On February 6, 1989, Ms. Sagastume signed out narcotic medications for two patients, "W" and "M". She altered the times on the signout sheet by simply writing over the entries, rather than by striking through, writing "error", and then correcting the entry as she had been instructed. In addition, on February 6, 1989, Ms. Sagastume signed out narcotic medications to patient "M" four times during her evening shift: 15:05 (3:05 p.m.), 19:00 (7:00 p.m.), 21:00 (9:00 p.m.), and 23:10 (11:10 p.m.). This is unusual, and some notation should have been made that the physician was called about the patient's pain. The notes on the patient's chart do not reflect a need for the medication, particularly since the 7:00 p.m. entry by Ms. Sagastume indicates that the pain was relieved. Ms. Sagastume's careless, improper or incomplete record-keeping violate minimal standards of acceptable prevailing nursing practice. Kissimmee Memorial Hospital discharged Ms. Sagastume on February 20, 1989. A separate administrative complaint in DPR case #89-001399 was filed against this Respondent on March 8, 1990. That complaint alleges other violations of nursing practice standards at St. Cloud Hospital in April, 1989. These violations involved irregularities in narcotics record keeping, as well as the observation of unsteady, erratic behavior and the presence of fresh needle marks on the Respondent's arms. Respondent failed to respond to that complaint and on July 10, 1990, the Board of Nursing entered its Final Order finding that the investigative file supported the allegations of the complaint. The license of Atalia Sagastume was ordered suspended until she personally appears before the Board and demonstrates her ability to safely engage in the practice of nursing. (Petitioner's Exhibit #9).
Recommendation Based on the foregoing, it is hereby, RECOMMENDED: That a Final Order be entered finding Respondent guilty of unprofessional conduct as alleged, and suspending her license to practice nursing, concurrently with the suspension already imposed in DPR case #89-001399. DONE and RECOMMENDED this 4th day of October, 1990, in Tallahassee, Florida. MARY CLARK Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 4th day of October, 1990. COPIES FURNISHED: Atalia Dacosta G. Sagastume 316 Florida Parkway Kissimmee, FL 32743-8413 and 710 Royal Palm Drive Kissimmee, FL 34743 Charles Tunnicliff, Esquire Department of Professional Regulation 1940 North Monroe Street, Suite 60 Tallahassee, FL 32399-0792 Kenneth E. Easley General Counsel 1940 North Monroe Street Tallahassee, FL 32399-0792 Judie Ritter, Executive Director Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202
Findings Of Fact The Respondent Mary Ambroz is a registered nurse having been issued license number 129 070-2. Her last known address is 3304 S.W. LeJeune Road, Coral Gables, Florida. At all material times, the Respondent Ambroz was employed as a nurse at Variety Children's Hospital (now known as Miami Children's Hospital), and Mount Sinai Hospital, in Miami, Florida. On or about June 14, 1981, the Respondent Ambroz was working at Mount Sinai Hospital under the supervision of Cindy Shoard, R.N. On that date, an emergency arose with a patient who suffered a lethal arrhythmia which required Shoard and another nurse to begin emergency procedures including starting an IV and placing vital sign monitors on the patient. The Respondent Ambroz entered the room after Shoard had begun emergency treatment and pushed her aside stating that the patient was hers and she would take over. Shoard asked the Respondent to leave the room. The Respondent did not leave and instead picked up drugs which had been placed by Shoard on a table for administration to the patient after the IV procedure, and attempted to administer the drugs herself. Shoard informed the Respondent that the drugs were to be administered in a different manner from the way which she was attempting, and again asked her to leave the room. The Respondent then left the room and the patient was stabilized. On or about July 7, 1981, while employed at Mount Sinai Hospital, the Respondent was absent without leave four days in a row. This incident resulted in her termination of employment from Mount Sinai. Additionally, while still employed at Mount Sinai, the Respondent failed to properly chart physicians' orders concerning medication on four separate occasions and reported to an oncoming nurse, that an IV bag of a patient in her care had been filled when the Respondent had in fact failed to fill the bag. In August of 1982, while employed at Miami Children's Hospital, the Respondent Ambroz was caring for an extremely ill premature infant, K. Kuehnart, who was being treated by endotracheal tube. The Respondent was aware that the infant was classified as "limited touch" due to her serious condition and the risk that movement could kink or dislodge the tube and cause a life-threatening situation. The Respondent handled this infant without adequate justification and after being repeatedly told not to do so by her supervisor, Mary Mulcahy. Moreover, in her care and treatment of baby Keuhnart, the Respondent Ambroz failed to observe basic aseptic techniques including insuring that the inside of the endotracheal tube remained sterile. On August 17, 1982, the Respondent Ambroz, while under the supervision of Andrea Prentiss, R.N., was caring for a premature infant with a tracheal problem which required that the infant be placed on a ventilator. It was extremely important that this infant be handled minimally and carefully so the tube in the infant's throat would not become dislodged. Despite Prentiss' instructions, the Respondent moved the infant in a manner which caused the tube to become dislodged. A neonatologist was present to reinsert the tube and no permanent damage occurred. However, even following this incident, the Respondent handled the infant contrary to Prentiss' instructions. Subsequently, the infant's mother arrived from out-of-town to visit her child. The mother was instructed to wash her hands and put on a surgical gown before entering her child's room. When the mother entered the room, the Respondent Ambroz refused to allow the mother to touch her baby, brushed her hand away from the child, and stated that the mother had an infected cuticle. Prentiss examined the mother's hands, saw no evidence of infection, and ordered the Respondent to allow the mother to touch her child. Also, during this visit, the Respondent requested that the mother change her child's socks since they were, in her opinion, an ugly shade of green. These incidents upset the baby's mother and resulted in her requesting that Prentiss prohibit the Respondent Ambroz from caring for her baby. The actions of the Respondent Ambroz, while employed at Mount Sinai and Miami Children's Hospital, departed from, or failed to conform to, acceptable and prevailing minimal standards of nursing practice.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED: That the Board of Nursing enter a Final Order revoking the nursing license of the Respondent Mary Ambroz. DONE and ENTERED this 17th day of October, 1983, in Tallahassee, Florida. SHARYN L. SMITH, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 17th day of October, 1983.
The Issue The central issue in this case is whether the Respondent is guilty of the violation alleged in the administrative complaint dated March 14, 1989; 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, the following findings of fact are made: At all times material to the allegations of the administrative complaint, Respondent has been licensed as a licensed practical nurse (LPN) in the State of Florida, license no. PN 35080-1. The Department is the state agency charged with the responsibility of regulating the practice of nursing within the State of Florida. During the month of September, 1988, Respondent was employed as a night-shift LPN at Parkside, a residential treatment facility for psychiatric patients. On or about September 25, 1988, Respondent attempted to administer the morning medication to a resident patient, J.L. The patient refused the applesauce (which contained the medicine) and struck the Respondent across the wrist with great force. J.L. had been scheduled for a pass (an opportunity to leave the grounds) that day, but following the incident described in paragraph 3, Respondent decided to revoke J.L.'s privilege. When Respondent informed J.L. that the pass was revoked, J.L. became very agitated. Respondent summoned a fellow worker, Pressoir Berrouet, to assist and to restrain J.L. At some point in time between the activities described in paragraphs 3 and 4, Respondent went to her personal automobile and retrieved a stunning apparatus which she owns for her self-protection. Respondent took the "zapper" or "stun gun" to the patio area of the facility where Mr. Berrouet had secured J.L. in a chair. While J.L. was not restrained by bonds (physical restraints are impermissible at this type of facility), Mr. Berrouet had his hands on the patient's arms so that she was effectively pinned and unable to exit the chair. By this time, Lilli McCain, a day-shift employee at Parkside, had arrived at the facility. She observed Respondent approach J.L. who was still pinned in the chair on the patio. Ms. McCain observed a "black something" in Respondent's hand and witnessed Respondent touch J.L. with the instrument. She then heard J.L. scream out, "you pinched me." Respondent had purportedly "zapped" J.L. Moments later, Ms. McCain observed a red mark on J.L.'s chest. Mr. Berrouet had his back to Respondent through out the time of the incident described in paragraph 6. Consequently, he did not see the Respondent touch the resident, J.L. He did, however, hear a click noise which immediately preceded the scream from J.L. Respondent was upset at having been struck by J.L. Subsequent to the events described above, she resigned from her employment at Parkside. Respondent admitted to Laurie Shifrel, the nursing supervisor at Parkside, that she had used a "zapper" on the resident, J.L. Respondent also told Deborah Moon, the residential program coordinator for the Henderson Mental Health Center (a company which owns Parkside), that she had used a "zapper" on the resident, J.L. At hearing, Respondent testified that she did not use the stunning apparatus on J.L. but admitted she had taken the instrument onto the property to frighten J.L. The more compelling proof demonstrates, however, that Respondent did use the stunning apparatus on J.L. Parkside policy did not require residents to take medications against their will. If a resident refused medication, the proper procedure was to note that information on the patient chart so that the physician could be informed. Restraints were not used at Parkside to control resident behavior. In the event a resident were to become uncontrollable, the operating procedures required that the nursing supervisor be called to the facility or 911 for Baker Act referral depending on the severity of the resident's misconduct. J.L. did not have a history of becoming physically abusive at Parkside. It is not acceptable nursing practice to strike a psychiatric patient or to use a shocking device to curb undesirable behavior. Such conduct falls below the minimal acceptable standard for nursing care. Further, given J.L.'s history, it would be inappropriate to attempt to scare J.L. by a threatened use of such a device. Respondent was sincerely remorseful that she had brought the device onto the Parkside property. Evidence regarding a proper penalty, in the event a violation were found to have occurred, was not offered at the formal hearing.
Recommendation Based on the foregoing, it is RECOMMENDED: That the Department of Professional Regulation, Board of Nursing enter a final order finding the Respondent guilty of the violation alleged, placing the Respondent on probation for a period of one year, requiring the Respondent to attend and complete such CE courses as may be appropriate, and imposing an administrative fine in the amount of $500.00. DONE and ENTERED this 2nd day of November, 1989, in Tallahassee, Leon County, Florida. JOYOUS D. PARRISH Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalache Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 2nd day of November, 1989. APPENDIX TO RECOMMENDED ORDER CASE NO. 89-2944 RULINGS ON THE PROPOSED FINDINGS OF FACT SUBMITTED BY THE DEPARTMENT: Paragraph 1 is accepted. The portion of paragraph 2 which is addressed in finding of fact paragraph 3, is accepted; otherwise rejected as irrelevant. Paragraph 3 is accepted. Paragraph 4 is accepted. Paragraph 5 is rejected as irrelevant and unnecessary to the conclusions reached herein. Paragraphs 6 through the first four sentences of paragraph 9 are accepted. The fifth sentence of paragraph 9 is rejected as contrary to the weight of the credible evidence. The last sentence of paragraph 9 is accepted. Paragraph 10 is accepted. The first sentence of paragraph 11 is accepted. The remainder of paragraph 11 is rejected as contrary to the weight of the evidence or irrelevant. The first sentence of paragraph 12 is accepted. The remainder of the paragraph is rejected as hearsay, irrelevant, or contrary to the weight of the credible evidence. To the extent the facts are set forth in findings of fact paragraphs 3 through 8, paragraphs 13 through 22 are accepted; otherwise rejected as hearsay, irrelevant, or unnecessary to the resolution of the issues of this case. The first two sentences of paragraph 23 are accepted. The remainder is rejected as irrelevant or hearsay. Paragraph 24 is accepted. Paragraphs 25 through 30 are accepted. RULINGS ON THE PROPOSED FINDINGS OF FACT SUBMITTED BY RESPONDENT: None submitted. COPIES FURNISHED: Lisa M. Bassett Senior Attorney Department of Professional Regulation 1940 North Monroe, Suite 60 Tallahassee, Florida 32399-0729 Jane Frances O'Leary 5295 15th Terrace, N.E. Pompano Beach, Florida 33064 Judie Ritter Executive Director Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, Florida 32202 Kenneth E. Easley General Counsel Department of Professional Regulation 1940 North Monroe, Suite 60 Tallahassee, Florida 32399-0729 ================================================================= AGENCY FINAL ORDER ================================================================= STATE OF FLORIDA DEPARTMENT OF PROFESSIONAL REGULATION BOARD OF NURSING DEPARTMENT OF PROFESSIONAL REGULATION, Petitioner, vs. DPR CASE NO.: 0106973 DOAH CASE NO.: 89-2944 JANE F. O'LEARY, Respondent. /
