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.
Findings Of Fact At all times pertinent to the allegations contained herein, Respondent Lawrence J. Sleurs, was a registered nurse in Florida under License Number 1248372, which was issued on February 21, 1987, and which expires on March 31, 1989. Respondent was originally licensed by endorsement on June 1, 1981 and was licensed for the renewal bienniums from June, 1981 through March, 1989. The Board of Nursing is the agency responsible for licensing registered nurses in Florida. At all times pertinent to the allegations contained in the Administrative Complaint the Respondent was employed as Director of Nursing at the Hillsborough County Developmental Center in Tampa, Florida, having been hired to that position by Julia Pearsall, the Administrator of the facility. Starting in July, 1987, numerous employees at the facility reported to the Administrator that Respondent was not performing his duties in an appropriate fashion. A consultant, Addle Colgan, employed by Medical Services Corporation, was called to evaluate Respondent's performance and conducted a series of evaluations of the facility as it related to Respondent's performance as Director of Nursing in June, July, and August, 1987. During the course of these various interviews, she determined that Respondent had failed to record appropriate records or take appropriate steps regarding several grand mal seizures of a particular patient during the latter part of June and the early part of July, 1987; that he had failed to exercise appropriate managerial skills in providing appropriate nursing help; that his medical record-keeping was less than satisfactory; that his drug control operations were substandard; and, that numerous other areas of nursing practice as accomplished by Respondent were below standards. In her report dated July 16, 1987, Ms. Colgan recommended that Respondent be put on probation for a period of observation followed by reevaluation. This information and the failures in his performance were discussed with the Respondent by Ms. Colgan and he indicated his awareness of them and his belief that he could do better. It was obvious, however, that he could not do so. On July 25 and 26, 1987, Respondent again failed to orient a licensed practical nurse as required; he failed to relieve one nurse, requiring her to work approximately 20 hours straight; and his mismanagement caused the nurse in charge to commit multiple medication errors due to her fatigue, lack of orientation, and the receipt of improper directions from Respondent. As a result, on July 30, 1987, Respondent was interviewed by Ms. Colgan and Ms. Pearsall at which time he verified what he had advised the nurse in question; his failure to document medication errors or to notify a physician; his failure to read policy and procedures regarding medication errors; and his lack of awareness of immediate and future scheduling needs. Considering the seriousness of these offenses and the fact that Respondent had not improved over the period of probation, at 2:30 PM on July 30, 1987, he was relieved of his duties as Director of Nursing and discharged from employment with the facility. The personnel file pertaining to Respondent and the investigative file concerning his alleged misconduct were forwarded to Mary L. Willis, a registered nurse consultant and expert in the field of nursing competence for evaluation. Having reviewed the entire file, she is satisfied that Respondent's skills were poor and he interfered with the nurses under his supervision in the details of their duties. As a result of his activities, she questions his managerial skills, his preparation for the job of Director of Nursing, his knowledge of care of seizure patients, and his lack of understanding and experience with medications. Taken together, these defects convince her that the care rendered by Respondent during the period in question did not come up to minimal standards as it relates to seizure patients. She is also convinced that the level of skill demonstrated by Respondent in this case was less than that of a practical nurse. In addition, it is her opinion that his charting of medications failed to achieve minimal technical standards in that he ignored basic principles involved in the administration of medication. Ms. Willis has many serious doubts regarding Respondent's preparation to serve as a Director of Nursing. She cannot understand, in light of the fact that he initially complained of the hours required of a Director of Nursing and because of the fact that he lived in Lakeland and while working in Tampa, why he accepted the position in the first place. Taken together, it is her opinion and it is so found, that Respondent's performance of duty as Director of Nursing and as a registered nurse, during the period June - July, 1987, failed to conform to the minimal standards of acceptable and prevailing nursing practice in Florida.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that the Respondent Lawrence J. Sleurs, R. N., be reprimanded, that he be placed on probation for one year under such terms and conditions as the Board may specify, and that he pay an administrative fine of $500.00. RECOMMENDED this 16 day of February, 1989 at Tallahassee, Florida. ARNOLD H. POLLOCK, 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 Administrative Hearings this 16 day of February, 1989. COPIES FURNISHED: Judie Ritter, Executive Director Department of Professional Regulation Board of Nursing Room 504, 111 East Coastline Drive Jacksonville, FL 32201 Charles F. Tunnicliff, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Lawrence J. Sleurs, R.N. 2047 Somerville Drive Lakeland, Florida 32801
The Issue The issue for determination is whether Respondent, a licensed registered nurse, committed violations of Chapter 464, Florida Statutes, sufficient to justify the imposition of disciplinary sanctions against her license. Resolution of that issue rests upon a determination of whether Respondent has been found guilty of a crime relating to the practice of nursing or the ability to practice nursing; or, whether Respondent has failed tocomply with minimal standards of acceptable and prevailing nursing practice to the extent that her action amounts to unprofessional conduct.
Findings Of Fact Respondent is Rita Joy Gibbons. She is a licensed registered nurse and holds license number 1144992, which is currently under suspension. On December 10, 1987, at approximately 5:30 p.m., Respondent was involved in an automobile accident involving property damage to other vehicles and personal injuries to herself. She was subjected to criminal charges when the State Attorney for the Fourth Judicial Circuit filed an information in the County Court of Duval County, Florida. The information charged Respondent with the offense of Driving Under The Influence, a violation of 316.193, Florida Statutes (1987). The information further specifically alleged that Respondent drove or had actual physical control of a motor vehicle while under the influence of intoxicating beverages to the extent that her normal faculties were impaired. On July 11, 1988, Respondent pled no contest to the charged offense. The County Court adjudged Respondent to be guilty of the offense, placed her on probation for three months, credited her with three days of time served in the county jail of Duval County, Florida, and required her to pay a $500 fine. At the time of the accident, Respondent was employed as a nurse by Visiting Nurses Association Continuous Care (VNA Continuous Care), located in Jacksonville, Florida. When the accident occurred, Respondent was late for duty with her employer, VNA Continuous Care. Her work shift for that day was to have begun at approximately 4:30 p.m. and continued until midnight. Representatives of Respondent's employer received a telephone call that Respondent had been in an accident and would not be available for work. Respondent's employment was terminated by VNA Continuous Care on January 4, 1988, shortly after the accident, for misconduct on the job and her failure to appear for work. Respondent's license was suspended on April 15, 1991, in conjunction with sanctions imposed against her in another matter, Department of Professional Regulation, Board of Nursing Case No. 89-013688. The suspension is to last until Respondent appears before the Board of Nursing and demonstrates ability to engage in the safe practice of nursing. Among other charges, Respondent was charged in that case with failure to adhere to minimal standards of professional conduct.
Recommendation Based on the foregoing, it is hereby recommended that a Final Order be entered dismissing the Amended Administrative Complaint. RECOMMENDED this 21st day of May, 1991, in Tallahassee, Leon County, Florida. DON W.DAVIS 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 21st day of May, 1991. APPENDIX TO RECOMMENDED ORDER, CASE NO. 90-2915 The following constitutes my specific rulings, in accordance with Section 120.59, Florida Statutes, on findings of fact submitted by the parties. Petitioner's Proposed Findings. 1.-8. Adopted in substance, though not verbatim. 9.-10. Rejected; not supported by the evidence; statement of ultimate fact. Rejected, she was terminated for misconduct and abandonment of her job. Rejected; legal conclusion; ultimate fact which, while true if the nurse does assume her duties, is inapplicable to the present situation. Respondent's Proposed Findings. None submitted. COPIES FURNISHED: Lois B. Lepp, Esquire Department of Professional Regulation The Northwood Centre, Suite 60 1940 N. Monroe Street Tallahassee, FL 32399-0792 Rita Joy Gibbons 6937 Cherbourg Avenue North Jacksonville, FL 32305 Jack McRay, Esquire General Counsel Department of Professional Regulation The Northwood Centre, Suite 60 1940 N. Monroe Street Tallahassee, FL 32399-0750 Judie Ritter Executive Director Board of Nursing Department of Professional Regulation 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32201
Findings Of Fact Respondent B. Delores Lane Eckard holds a Florida license as a registered nurse, No. 1091372. She has been so licensed since September 10, 1979. Petitioner's Exhibit No. 1. Before she was fired in July of 1983, respondent worked twelve-hour night shifts in the surgical intensive nursing unit at Baptist Hospital in Pensacola. A burn victim, Marc MacInvale, was among the patients respondent attended, during the shift that began at seven o'clock on the evening of June 15, 1983. Because of the extent of his burns, Mr. MacInvale had been placed in a private room, and hospital staff observed "reverse isolation" techniques. In or on his nightstand, Ms. Eckard found two, ten milligram ampules of Valium. Knowing that it was against hospital policy for the ampules to be there, she picked them up, intending to return them to the medication cart. She put them in her pocket for safekeeping, while she finished tasks in Mr. MacInvale's room. After she got home from work, on the morning of June 16, 1983, she undressed and went to bed. When she awoke and gathered up her clothes for washing, she discovered that the ampules were still in the pocket of her uniform. She was aware that a nurse had been fired two weeks earlier when Valium had been discovered in her locker at Baptist Hospital; and she decided against notifying the hospital or anybody she worked with of the whereabouts of the Valium. Instead, she placed the ampules in a clear plastic bag together with a piece of paper with Marc MacInvale's name on it and put the clear plastic bag in her "work purse," with the intention of returning the Valium to the hospital, when she next went to the hospital. In these circumstances, failure to report promptly that she had removed a patient's medicine from his room and that he did not receive it fell below minimal standards of acceptable and prevailing nursing practice, according to uncontroverted testimony. The clear plastic bag with the ampules and the piece of paper with "Marc MacInvale" written on it were still in Ms. Eckard's purse when she was arrested in the early morning hours of June 17, 1983, for driving under the influence of intoxicants. Celebrating with friends at a restaurant in anticipation of her June 18 birthday, she had drunk two glasses of wine and a "brandy manhattan," but had ingested no other intoxicating substances, before setting out for home. After her arrest, she demonstrated poor coordination and balance, slurred speech and difficulty in understanding. After twice registering less, the breathalyzer registered 1.0. Formal charges were apparently filed, and, on October 19, 1983, respondent pleaded nolo contendere. Petitioner's Exhibit No. 2. The police examined the contents of respondent's purse on June 17, 1983, and an assistant state's attorney eventually inquired of William Allen Foster, Baptist Hospital's director of security, whether Valium had been prescribed for Marc MacInvale. Norma Jean Vaughan, respondent's supervisor, confronted her, after she learned that Ms. Eckard had been arrested with Valium in her purse. Respondent volunteered blood and urine samples for analysis. The results of analysis were negative, but Baptist Hospital terminated her employment nevertheless. At the time, things were not going well on the domestic front, either. Ms. Eckard's husband had beaten her, and they were separated. In despair, she recorded the following: "Begin a good-bye tape. Um, I don't want anybody feeling sorry for me. I just want everyone to know why - I never thought that I would come to this point in my life. Cir- cumstances have, uh, made it so that I have, and the decision has been made and is irrevocable. In my forty-three years, I've spent the first (voice shaky, clearing throat) well, five years, with a divorced mother. Then, I spent until I was eleven in an orphanage. This taught me a lot of compassion, if, nothing more. Through my teen years, I had various stepfathers; many were - had means and, uh, were very good to me. I married young and was very happy - raised three chil, well, two children, and, uh, thought I did a decent job. Thought our marriage was well organized and pretty happy, overall. We had everything under control. We saved our money. We made good investments. Everything was going our way. I decided after the children were grown that I wanted to be a nurse. I could do what I wanted to do now. My job with the children was over as far as their, their primary needs were concerned. They had other interests in their lives, and I accepted my displacement. I went to nursing school and, uh, worked very hard to make the grades that I did. I went far and beyond what I had to do to advance my knowledge in medicine and to prepare myself to be the best nurse that I could be. I've worked five years in nursing and, uh, even though I worked Surgical Floor, many people feel like all you do is change bandages, do your job and that's it. The emotional needs of the patient are completely ignored. They hurt, you give them pain meds or you tell them, 'That's too bad; you can't have any pain medicine for another so many hours. And then, that's it. There's no, there's no, uh, efforts to make them more comfortable during that waiting period where they, where they're suffering so much. Or maybe they feel that nobody loves them. Nobody cares. They feel the isolation (pause) the, like no one's with them. They're in an alien environment. A lot of this is ignored by a lot of nurses. I was in reverse isolation when I was burned, and I spent three months in a wheelchair. I know what it is to be alone in an isolation room and, uh, the nurses saying, 'Oh, my God, do I have to dress that again?'. You know. Nobody, it's not a very pleasant thing, but I know the feeling of isolation. I know the feeling of not feeling wanted even though you are. Uh, and I've tried to take, in my nursing, the total body into, to mind to try to fill the needs of the total person, not just the colostomy. It's not a colostomy patient. It's not, it's not a cardiac, and uh, and uh, an abdominal mass, a tumor or whatever. It's a person to me. The compassion that my patients and the families feel that I've afforded has been given freely because I do care about that person as a human being. I have found though (choked up - brief pause - then voice somewhat shaky), now that my life has essentially fallen apart. The marriage that I thought would last forever, you know. Now, we're in our middle years and the kids are grown and we're making good money and we can afford nice things, uh, we can have a nice bank account. We can go places and do things, but then you find that this doesn't happen - that somewhere along the, that time of getting there, that you've lost what originally drew you together. Those dreams of making it there. You've made it. Where is there to go? (Big sigh.) I guess, and with my husband's illness, he can't help, I guess, what he said to me. I never thought anyone would want to hurt me. I've been fairly well protected all my life. I'm not a worldly person as far as the streets are concerned or, or what goes on in this world. I'm well versed in politics and, and in things like that, but my world consists of my work and my home. Now, I come home to an empty house, and I have no goal as far as nursing is concerned. That's been taken away from me also. So - and I feel sort of deserted because, with the exceptions that I've made for other people and for the hospital, things that, things that I would like to change that, that bother me have never been changed and never will be. Those are accepted. Uh, doctors that harm my patients - that has had to be accepted - reported and nothing really accomplished by it. That person is still there. (Click. Recorder apparently turned off and then back on. Clearing throat and then continuing in a somewhat deeper tone of voice.) Yet, when I, as a nurse, inadvertently make an error without malice or without forethought, and with every intention of correcting my error, my only thought was protecting my job - a job that I love dearly, that I was afraid of losing. This was the only reason it wasn't reported to you by myself. Then, I am terminated. And the only other reason for my existence is taken away from me. This is not to make you feel guilty. I know you have your job to do. I know there have been exceptions made. I know of one girl in particular where her whole life was a damn exception, and she has actually come close to killing patients, and it could be proven by records, etc. by actual observations. And yet, she's welcomed with open arms when she comes back. She left in a world of glory. It's as one of our other nurses said, 'She could fall in a bucket of (pause) and come up smelling like a rose very time.' My assets are frozen now. I have no means of support other than my job. I have no other place I want to go or would go. I've thought it over, and I know where my place in life lies and I know what my future holds. It holds nothing at this point because I can't make that decision to divorce my husband or to have him come back here. Those are my options at this point for survival. Those decisions I cannot make. The decision to work - the only reason I had any medication at all was the fact that I had been beaten half to death, and I was forced to go to Dr. - to the doctor simply as a, because I needed the slip to come back to work. At that point, he saw that I was just falling apart as far as my nerves were concerned, simply because my system couldn't adjust to the beatings that I had, had been inflicted upon me. He suggested that I take something until I got over that hump. I've never taken medication before, and, uh, as I told you, I told him I didn't want anything heavy because my system was just not used to medication and anything that I took, even an aspirin, one aspirin, would cure a headache. So, uh, my system is super sensitive to medication apparently. Therefore, he prescribed what he did and, uh, I took it. It's the lowest dosage he could have give - that he could give me. Uh, he said I could take up to 30 milligrams without any harm. The maximum I took was 10, and this was only, you know, when I was really upset and, or felt that I was not in control. For instance, like when I had to meet with my husband or things like this due to the legal matters, or uh, other business interests that we had that brought us together. I'm not making this tape to defend myself. I don't think any defense really is necessary because I've done nothing really wrong. I made an error in judgement, and I've paid dearly, both financially, emotionally, etc...I've lost everything for one error in judgement. I would hope that this would never happen to anyone else because it leaves you with very few options in your life. So, I appreciate your support as far as your confidence in my nursing care. (Click. Recorder apparently turned off and then back on.) I appreciate the fact that you didn't take my license away. I guess that would have been the ultimate defeat. Um (pause) at this point, as I said, um, I have no options. I feel that you're put on this earth for a purpose. My purpose has ended." She mailed the tape recording to Baptist Hospital where various people listened to it on July 8, 1983. Mr. Foster tried to reach respondent by telephone, but got a busy signal. He then called the police department. Three policemen appeared at her home to find her talking to a friend on the telephone. At least one of the policemen stayed to talk for an hour or two, then left and called Mr. Foster. He told Mr. Foster he did not think that Ms. Eckard "needed to be Baker Acted," but said that he would look in on her again later in the day. On December 4, 1983, Ms. Eckard was arrested a second time for allegedly driving under the influence of alcohol, but the state's attorney's office did not pursue these charges. The arresting officer testified at the hearing in the present case. Neither his testimony that she was driving nor his testimony that she was intoxicated has been credited.
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 respondent's license as a practical nurse should be disciplined for the reasons cited in the administrative complaint.
Findings Of Fact Based upon the entire record, the following findings of fact are determined: At all times relevant hereto, respondent, Ruthie Mae Owens Brooks (Brooks or respondent), was licensed as a practical nurse having been issued license number PN 0877941 by petitioner, Department of Professional Regulation, Board of Nursing (Board). She has been licensed as a practical nurse since 1987. There is no evidence that respondent has been the subject of disciplinary action prior to this occasion. When the events herein occurred, respondent was an agency nurse for Underhill Personnel Services, Inc., an agency that furnished nurses to various health care facilities, including Methodist Medical Center in Jacksonville, Florida. She was employed at all times as a licensed practical nurse. On November 17, 1990, respondent was scheduled to work the 11 p.m. - 7 a.m. shift at Methodist Medical Center. Although her duty shift began at 11:00 p.m., respondent arrived a few minutes late and reported directly to the medical-surgical- orthopedic wing instead of signing in at the nursing office as required by hospital rules. After reporting to her work area, respondent went to the assignment board to review her assignment for that evening. Her specific duties that evening were to care for five patients in the medical-surgical-orthopedic wing. While respondent was at the assignment board, a registered nurse, Lynn Ivie, came to the board to ascertain her assignment. At that time, Ivie reported that she smelled a "strong odor of alcohol" on respondent's breath. However, Ivie said nothing at that time since she wanted to give respondent the benefit of the doubt. Around midnight, one of respondent's patients awoke in his room with severe chest pains. Both Ivie and respondent immediately went to the room. Although Ivie instructed Brooks to get a vital signs machine (also known as the Dynamap), Brooks ignored the instruction and "wiped the patient's face with a wet cloth". Ivie then brought the machine into the room and respondent was instructed by Ivie to take the patient's vital signs (blood pressure, temperature and pulse). This merely required her to place an attachment around the patient's arm and push a button to start the machine. The operation of the machine is considered a basic nursing skill. According to Ivie, respondent could not focus on the machine and did not seem to remember how to operate it. After waiting a few moments with no response from Brooks, Ivie finally took the patient's vital signs herself. During this encounter, Ivie again smelled alcohol on respondent's breath and concluded that her inability to assist in the care of the patient and to operate the machine was due to alcohol. Within a few moments, the patient was transferred to the intensive care unit (ICU) on another floor. Before accompanying the patient to the ICU, Ivie instructed respondent to chart the incident and action taken in the nurse's notes and then meet her in the ICU with the completed notes. These notes should be completed in an expedited manner so that the nurses in the ICU wing can utilize them in providing follow-up care to the patient. However, respondent did not chart the incident nor bring the notes to the ICU. Indeed, she failed to chart the notes on any of the patients assigned to her that night. By failing to chart any notes that evening, respondent contravened the requirement that a nurse file a report or record (nursing notes). Around 1:30 a.m. on November 18, Ivie and Joyce Biddix, the nursing supervisor, went to the room of one of the patients assigned to respondent and found the patient, a confused elderly male, sitting nude in a chair with the bed stripped of all linens. He had previously been tied to the bed to prevent him from falling. The linens were soiled with urine and were lying in a heap on the floor. Although respondent had taken the patient out of the bed, disrobed him, and removed the linens, she had left him unattended in the room and had not returned. Biddix called down the hall for someone to bring fresh linens and observed respondent "floating" down the hall saying "I can't find the linens" in a "singsong" voice. When she got closer to respondent, Biddix smelled alcohol on respondent's breath. It may reasonably be inferred from the evidence that respondent's conduct with this patient was unprofessional and constituted a departure from acceptable and prevailing nursing practice. After being confronted by Biddix regarding the alcohol, respondent told her she had drunk one beer with her meal around 10:30 p.m., or just before reporting to duty that evening. However, she denied she was intoxicated or unable to perform her duties. Respondent was then told to leave work immediately. The incident was later reported to Underhill Personnel Services, Inc. and that agency contacted the Board. After an investigation was conducted by the Board, an administrative complaint was filed. At hearing, respondent did not contest or deny the assertion that by reporting to work with alcohol on her breath, she was acting in an unprofessional manner and deviated from the standards of acceptable and prevailing nursing practice. In this regard, she acknowledged that she had drunk alcohol (which she claimed was only one tall beer) with her meal around 10:30 p.m., or just before reporting to duty. However, she contended that all of her previously scheduled shifts at the hospital had been cancel led and she assumed her shift that evening might also be cancelled. In response to the allegation that she could not operate the vital signs machine, respondent offered a different version of events and suggested that the machine in the patient's room was inoperative. Therefore, it was necessary for Ivie to bring a Dynamap into the room and Ivie took the vital signs without respondent's assistance. She justified leaving the elderly patient alone without clothes in his room on the grounds there was no clean gown, the patient was not combative, and she was only gone from the room for a few moments. Finally, she contended that she charted the notes for one of her patients but did not chart the others because the remaining patients were removed from her care by Ivie and Biddix when she was sent home at 1:30 a.m. However, these explanations are either deemed to be not credible or, if true, nonetheless do not justify her actions. Although there was no testimony concerning the specific issue of whether respondent is unable to practice nursing with reasonable skill and safety by reason of use of alcohol, taken as a whole respondent's conduct on the evening of November 17, 1990, supports a finding that her capacity was impaired that evening by virtue of alcohol. Accordingly, it is found that respondent was unable to practice nursing with reasonable skill and safety by reason of use of alcohol.
Recommendation Based upon the foregoing findings of facts and conclusions of law, it is, RECOMMENDED that respondent be found guilty of violating Subsections 464.018(1)(f), (h), and (j), Florida Statutes (1989), and that her nursing license be suspended for six months but that such suspension be stayed upon respondent's entry into and successful completion of the Intervention Program for Nurses. Respondent's failure to remain in or successfully complete the program will result in the immediate lifting of the stay and imposition of the six-month suspension. Thereafter, said license shall not be reinstated until such time as respondent appears before the Board and can demonstrate that she can engage in the safe practice of nursing. DONE and ENTERED this 16th day of December, 1991, in Tallahassee, Florida. DONALD R. ALEXANDER 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 16th day of December, 1991. APPENDIX TO RECOMMENDED ORDER CASE NO. 91-5033 Petitioner: Partially adopted in finding of fact 1. Partially adopted in finding of fact 3. Partially adopted in finding of fact 8. Partially adopted in finding of fact 3. 5-6. Partially adopted in finding of fact 4. 7-10. Partially adopted in finding of fact 5. 11-14. Partially adopted in finding of fact 6. 15-16. Partially adopted in finding of fact 7. 17-18. Partially adopted in finding of fact 8. COPIES FURNISHED: Roberta L. Fenner, Esquire 1940 North Monroe Street, Suite 60 Tallahassee, Florida 32399-0792 Ruthie Mae Owens Brooks 1604 S.W. 40th Terrace, #A Gainesville, Florida 32607 Jack L. McRay, Esquire 1940 North Monroe Street, Suite 60 Tallahassee, Florida 32399-0792 Judie Ritter, Executive Director 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202
The Issue Whether Respondent's license to practice nursing in the state of Florida 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 Teresa Iva Smith Lobato (Lobato) was licensed as a Registered Nurse in the state of Florida, holding license number RN-1655102, and was employed by the Bayfront Medical Center (Bayfront) located in St. Petersburg, Florida as a Registered Nurse. On May 13, 1990 Lobato was to work the 7:00 a.m. to 3:00 p.m. shift, and upon arriving for work was told that she was being "floated" from the Coronary Care Unit (CCU) where she regularly worked to the Progressive Care Unit (PCU) where she had never worked. Bayfront had a policy whereby nurses were "floated" from one unit to another, and at the time Lobato was employed by Bayfront she was made aware of this "floating" policy. Floating means that a nurse is assigned temporarily to a unit other than the nurse's regularly assigned unit. On May 12, 1990 Lobato was aware that she was to be "floated" on May 13, 1990, but had informed the Acting Director of CCU that she would rather cancel her work assignment than be "floated". However, upon arriving for work on May 13, 1990, and being told that she was being "floated" to PCU she accepted the assignment on PCU although she was not pleased about the situation. Bayfront has a policy that requires the outgoing nurse to audiotape a report for the oncoming nurse regarding the condition of the patients and any events occurring during the outgoing nurse's shift or if no tape is made to give report verbally to oncoming nurse. Upon arriving at PCU Lobato, along with PCU Charge Nurse (CN), listened to the audiotaped reports from the outgoing nurse on the following patients D. L. L., A. S., E. H., C. L. S., and H. K. As the morning progressed, Lobato became more and more displeased with her assignment, and let her displeasure be known to the PCU Charge Nurse. However, Lobato did not ask to be relieved from her assignment, although there was testimony that she indicated to the CN that she wanted to go home. Although the record is not clear as to the time the following events occurred, the sequence of those events are as follows: Around 9:00 a.m. Lobato was offered help by the CN but declined; Around 9:30 Lobato went on break, and again was offered help but declined; While on break Lobato talked to the Assis- tant Director of Nursing (ADON) about her under- standing of not being required to "float", and became upset with the ADON's response; After returning from break Lobato was again offered help by the CN which she accepted. The CN brought Michelle Nance, Medical Surgical Technician, and two RNs whose first names were Jessica and Melinda to the unit to assist Lobato. Around 10:30 a.m. Lobato and the CN dis- cussed Lobato's patient assignments, and Lobato advised the CN that everything was done, in- cluding all a.m. medication, other than the missing vasotec doses, and that she had some charting to do. Also, the patient's baths had been completed. Shortly after Lobato and the CN discussed her patients' assignments, the ADON came to the unit to determine what was troubling Lobato. The ADON and Lobato met and there was a confrontation wherein Lobato advised the ADON that she was quitting and the ADON advised Lobato that she was fired. After Lobato's confrontation with the ADON, Lobato left the unit and Bayfront without completing the balance of charting her patients' notes, and without giving the CN a report of the patients even though the CN requested her to do so. Lobato's reasons for not giving the CN a report was that she had discussed the patients with the CN throughout the morning, and that the CN knew as much about the patients as did Lobato at that time, and therefore, she had made a verbal report. Lobato's reasons for not completing the charting of her patients' notes was that when the ADON fired her on the spot the ADON accepted full responsibility for the patients, and Lobato's responsibility to both Bayfront and to the patients assigned to her ceased at that time, notwithstanding her understanding of the importance of charting so that appropriate care could be given to the patients on the next shift. By her own admission, Lobato left Bayfront around 10:30 a.m. on May 13, 1991 before the end of her shift without completing the balance of charting her patients' notes and without giving a report to the CN, other than the ongoing report given during the morning. Earlier while Lobato was still on the unit working the CN had obtained two registered nurses (RN) and a medical surgical technician to assist Lobato. One of the nurses whose first name was Jessica (last name not given) was the RN assigned to Lobato's patients by the ADON when Lobato left and she received a report on the patients from Janice Ritchie, CN. (See Respondent's exhibit 1, and Petitioner's exhibit 1 and Janice Ritchies' rebuttal testimony.) Although Lobato's failure to chart the balance of her patients' notes and make a report to the CN before she left may have caused some problems, there was no showing that any patient failed to receive proper care or suffered any harm as a result of Lobato leaving. While some of the patients may not have received all their medication before Lobato left, the record is not clear as to whether the medication was made available to Lobato to administer or that she was shown where the medication was located in the floor stock. The patient is the nurse's primary responsibility, and the minimal standards of acceptable and prevailing nursing practice requires the nurse, even if fired (unless prevented by the employer from performing her duties), to perform those duties that will assure the patient adequate care provided for after her absence. In this case, the failure of Lobato to compete the charting of her patients' notes and the failure to make a report to the CN, notwithstanding her comments to the CN upon leaving, was unprofessional conduct in that such conduct was a departure from and a failure to conform to minimal standards of acceptable and prevailing nursing practice.
Recommendation Based upon the foregoing, it is recommended that the Respondent be found guilty of violating Section 464.018(1)(h), Florida Statutes, and that she be given a reprimand. RECOMMENDED this 31st day of May, 1991, in Tallahassee, Florida. WILLIAM R. CAVE 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 RECOMMENDED ORDER, CASE NO. 90-7828 The following contributes my specific rulings pursuant to Section 120- 59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties in this case. Rulings on Proposed Finding of Fact Submitted by the Petitioner 1. Adopted in Finding of Fact 1. 2. Adopted in Findings of Fact 1 and 2. 3.-4. Adopted in Findings of Fact 3 and 4, respectively. 5.-6. Adopted in Finding of Fact 4 and 5. 7.-8. Adopted in Finding of Fact 5. 9. Adopted in Findings of Fact 6 and 7. 10. Adopted in Finding of Fact 7. 11.-12. Rejected as not being supported by substantial competent evidence in the record, but even if this testimony was credible it is not material or relevant to the conclusion reached. Adopted in Finding of Fact 8, as modified. Rejected as not being supported by substantial competent evidence in the record, but even if this testimony was credible it is not material or relevant to the conclusion reached. Rejected as not being supported by substantial competent evidence in the record. Adopted in Finding of Fact 8, as modified. Rejected as not being supported by substantial competent evidence in the record. 18.-20. Adopted in Finding of Fact 9 and 12, as modified. Adopted in substance in Findings of Fact 9 and 12. Rejected as not being supported by substantial competent evidence in the record. See Findings of Fact 10, 11, 13 and 14. Adopted in Finding of Fact 11. Rejected as not being supported by substantial competent evidence in the record. 25.-27. Adopted in Findings of Fact 3, 15 and 15, respectively. Paragraph 28 is ambiguous and, therefore, no response. Rejected as not being Finding of Fact but what weight is to be given to that testimony. Rulings on Proposed Findings of Fact Submitted by the Respondent 1.-2. Rejected as being argument rather than a Finding of Fact, but if considered a Finding of Fact since there was other evidence presented by other witnesses. The first sentence is rejected as not being supported by substantial competent evidence. The balance of paragraph 3 is neither material nor relevant. Neither material nor relevant, but see Findings of Fact 6, 7, and 8. Rejected as not being supported by substantial competent evidence in the record, but see Findings of Fact 6, 7, and 8. Neither material nor relevant since the Respondent assisted in selecting those items to be included in Respondent's exhibit 1. First sentence adopted in Finding of Fact 8. The balance of paragraph 7 is argument more so than a Finding of Fact, but see Findings of Fact 12 and 14. More of an argument than a Finding of Fact, but see Findings of Fact 7(c), 12 and 14. 9.-11. More of an argument as to the credibility of a witness rather than a Finding of Fact. More of an argument than a Finding of Fact but see Findings of Fact 7(d) and 13. More of a restatement of testimony than a Finding of Fact, but see Findings of Fact 8 and 9. More of an argument than a Finding of Fact, but see Finding of Fact 10. More of an argument than a Finding of Fact, but see Findings of Fact 7(e) and 9. Not necessary to the conclusions reached in the Recommended Order. 17.-19. Rejected as not being supported by substantial competent evidence in the record, but see Findings of Fact 9 and 12. 20. More of an argument as to the credibility of a witness rather than a Finding of Fact. 21.-23. More of an argument than a Finding of Fact. COPIES FURNISHED: Lois B. Lepp, Esquire Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, FL 32399 Teresa Iva Smith Lobato 6870 38th Avenue North St. Petersburg, FL 33710 Judie Ritter, Executive Director Board of Nursing 504 Daniel Building 111 East Coastliinne Drive Jacksonville, FL 32202 Jack McRay, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792
Findings Of Fact At all times pertinent to the issues herein, the Petitioner, Board of Nursing, was the state agency in Florida responsible for the licensing of registered nurses and the regulation of the nursing profession in this state. Respondent, Maria S. Melegrito was licensed as a registered nurse under license number RN 1138222. During the month of March, 1992, L.B. was a patient at HCA New Port Richey Hospital suffering from congestive heart failure and a decubitus ulcer on his coccyx. He was in and out of the hospital frequently during the month. During this period, Respondent called Mrs. B. on the phone and solicited being hired to care for him at home when he was released from the hospital. Respondent is alleged to have indicated she was L.B.'s favorite nurse. At first Mrs. B. declined, but on or about March 12, 1992, K.B., the patient's wife, after checking on Respondent's credentials with her husband's physician, contracted with the Respondent to provide home health care to L.B. upon his discharge from the hospital. The arrangements were made through Maximum Care, Inc., a home health nursing agency of which Respondent was a cofounder. In a telephone conversation with K.B. on March 12, 1992, the day prior to L.B.'s discharge from the hospital, Respondent assured K.B. that Respondent would supply cardiac trained registered nurses around the clock to care for L.B. K.B. understood from this conversation that a cardiac trained registered nurse would be waiting at the patient's home when he arrived there after discharge. No contract was signed between Respondent and L.B., his wife, or their daughters. That same day, March 12, 1992, Respondent, in a conversation with B.C., one of L.B.'s daughters, indicated that Respondent would be taking care of the patient; that she would relieve the family members of their responsibilities in caring for him. Respondent indicated she was a cardiac care specialist and that she would be present at the patient's home the following days, with all necessary medical equipment, when the patient arrived from the hospital. B.C. also understood Respondent to represent that she would provide certified nursing assistants, (CNA's), and that she was familiar with the patient's condition because she had been his personal nurse while he was in the hospital. In a conversation with G.P., the patient's other daughter, Respondent said she would provide private nurses around the clock; that home health aides and CNA's would be present to assist the family in caring for the patient; and that Respondent would personally be present at the home with the necessary oxygen equipment to greet the patient upon his arrival from the hospital. According to hospital records, L.B. was discharged to the care of his wife, K.B., and his daughter, B.C., at 10:20 AM on March 13, 1992, and the evidence indicates that the discharge form was signed by K.B. The party arrived at the home shortly thereafter, but Respondent was not present there when the party, including the patient, arrived. By the same token, the oxygen ordered by the patient's physician also was not there. Shortly after the patient and his family arrived home, Ms. B and one daughter went to the drug store. When they came back, they were met outside by K.B.'s grandson who kept K.B. outside while the daughter went in. It appears that while they were gone, L.B. suffered a cardiac episode. His daughter, B.C., laid him on the floor so that he would not aspirate his vomitus, but he appeared to have no pulse, no audible heartbeat, was not breathing, and appeared to turn blue from lack of oxygen. One of the family members attempted to contact the Respondent but was unable to do so. Finally, the family called the patient's physician who in turn called the oxygen supply house and directed that oxygen be delivered to the patient's home. Though the discharge form reflects the physician ordered oxygen for the patient, no evidence was presented as to who was to arrange for it. At approximately 1:00 PM the same day, Respondent contacted the family indicating she would "be right there." When family members told Respondent the patient had suffered a cardiac episode, she instructed them to leave him on the floor. Notwithstanding her promise to be right there, Respondent, according to the family, did not arrive at the patient's home until sometime after 3:00 PM. When she arrived she did not have with her oxygen, a stethoscope or a blood pressure cuff. Using the equipment owned by C.P., the patient's other daughter, also a nurse, Respondent took the patient's blood pressure while he was laying prone on the floor. She found it to be 60 over 40. Respondent tells a different story. While not disputing the allegation of her pre-need solicitation of the patient's family for her services, she contends that she was not advised of the immediate need for them until she received a call from one of the daughters at approximately 12:30 PM on March 13, 1992, indicating that the patient was to be discharged. She claims she immediately asked if there was anything needed for the patient's care and was told all was taken care of. She also claims she was told the patient would be at his home within 10 to 15 minutes. On cross examination, Respondent indicated the verbal agreement she had with the patient's wife called for her to be called when the patient got home and she would come, assess the patient and then decide if she or her firm could provide the services required. It is her contention that her initial visit to the patient's home on March 13, 1992 was for the purpose of rendering a patient assessment, and she ended up staying for five hours until she could arrange for follow-on nursing care to be present. This assertion is rejected, however. She had already indicated she knew the patient and was his favorite nurse in the hospital. She would have already been familiar with his condition. Ms. Melegrito further claims she arrived at the patient's house at 1:25 PM to find the patient on the floor with a blood pressure cuff on his arm and oxygen being supplied. Respondent claims it is usually the discharge nurse or the social worker who makes the arrangements for oxygen to be delivered to the patient's home, and it was not her responsibility to do so. There was no direct evidence to contradict this assertion, but it was the physician who ultimately arranged for the delivery of the oxygen. 11 Notwithstanding the allegation that the Respondent did not arrive until after 3:00 PM, the initial visit nursing notes, dated March 13, 1992, reflect in one place she arrived at 2:00 PM; in another place, that she arrived at 1:24 PM; and in a third place that she arrived at 3:00 PM. In its totality, the best evidence suggests that Respondent arrived sometime between 1:00 and 3:00 PM, neither as late as the family claims nor as early as she claims. There is some substantial question as to whether Respondent performed a proper initial assessment of the patient or devised a care plan for him when she arrived. An initial visit nursing note, prepared by the Respondent and bearing date of March 13, 1992, lists the patient's temperature, his pulse rate and his blood pressure. It also discusses a history of the patient's condition and certain initial observations of him. The second page of the form indicates that certain items were covered including a description of the patient's grip, his cardio-pulmonary status, the condition of his skin, his abdomen, ENT status and comments regarding his diet and genito-urinary status. The third page of the form described the patient as being fearful, anxious, restless, confused and disoriented, suffering from headaches, vertigo and blackout spells. He is described as having irregular breath with pale, dry, pallid skin, dry mouth and several difficulties in the cardio-vascular area. The body drawing on the form reflects he has an open bed sore at the base of the spine, and the intervention portion of the form indicates that the patient was found on the floor upon the Respondent's arrival, unconscious. His pressure was down and there was no palpable pulse. Patient was cyanotic and had appeared to have suffered another syncope syndrome. Nonetheless, Respondent noted that the patient's vital signs came back enough for him to regain consciousness, but notwithstanding, he was in the terminal stage of a cardiac condition and the instructions given by the family were not to resuscitate him in the event he should again reach the stage of unconsciousness. The parties agree that the Respondent gave the patient a sponge bath even though, at the time, he may not have been soiled. The family claims he was clean, but Respondent contends she bathed the patient to clean fecal material, urine and sweat from him and the bed clothes. Notwithstanding the Respondent's notation that the patient was confused or disoriented, neither his wife nor his two daughters considered him to be so, and after the patient was placed back in bed and cleaned up, according to the family members, Respondent spent the remainder of the afternoon at the patient's home on the telephone, trying to find a nurse to cover the next shift. Initially, she was unable to do so, and B.C. claims Respondent approached her to work as an aide and deliver patient care to her father. B.C. refused to do so. Respondent admits to a discussion with B.C. about hiring her to care for the patient but claims the discussion was in response to a question by the daughter, not a solicitation by Respondent. Respondent was apparently successful in securing a relief nurse because she was relieved at 5:00 PM by Dorothy Reisebeck, a licensed practical nurse, (LPN), who was not a trained cardiac nurse. According to Ms. Riesebeck she had been told by Respondent that the patient had been discharged from the hospital after minor surgery, and that she, Riesebeck, need only monitor him, check his oxygen, and make him comfortable. Notwithstanding Respondent's claim that she prepared an assessment of the patient and gave an adequate report to her relief, Ms. Riesebeck claims that Respondent failed to provide her with a care plan, an assessment sheet for the patient, or a list of the patient's medications and proper dosages. She also indicates Respondent did not inform her that the patient was suffering from congestive heart failure and was terminally ill. When fully advised of the patient's true condition, Ms. Riesebeck did not feel adequately prepared to care for him. Nonetheless, she remained on the scene until she was relieved at 7:30 the following morning. In this regard, Ms. Riesebeck claims she had been led to believe by Respondent that she would be relieved at 10:00 PM the prior evening, March 13. When she was relieved it was by another LPN, Ms. Holloway, who also had no cardiac care experience. When Ms. Holloway arrived, she also looked for the assessment sheet on the patient which should have been there, but was told by Ms. Riesebeck that one did not exist. They tried without success to contact Respondent and while Ms. Riesebeck and Ms. Holloway were on the scene, the patient suffered another acute cardiac episode. The family understood that since Ms. Holloway, who arrived at 7:30 AM, had worked all the previous night at the hospital, she would be there for only three or four hours until relieved by someone that Respondent had found to do so. Her shift was to end at 11:00 AM, but she was not relieved until Respondent appeared at 3:00 PM on March 14, 1992. Respondent's arrival did not appear to be for the purpose of providing nursing care. She was, upon arrival, dressed in high heels, makeup, jewelry and a flowered dress. A man was waiting for her in the car outside the house, and it was obvious to everyone that Respondent was neither dressed for nor prepared to perform a shift providing care for this patient. It was clear she had no intention of staying for that purpose. Before the Respondent left, however, she began arguing with Ms. Holloway, which culminated in Ms. Holloway leaving. Respondent then began arguing with both of the patient's daughters, and attempted by telephone to find someone else to cover the shift. Respondent appeared to be very disturbed. She was screaming at people on the telephone and reacting to her conversations by slamming the receiver down. Before the Respondent had arrived that day, because they were having problems getting the patient's medications and a morphine IV set up, the family called the patient's physician and requested that the Respondent be replaced by Hospice. Someone other than the Respondent, presumably the physician, was able to contact a pharmacy which sent IV equipment and morphine, saline, and demerol solutions to the patient's home. These medications had been ordered by the physician for the patient's pain after he was called by the patient's daughter. Respondent was present when the pharmacy order arrived and requested that the delivery person set up the IV. That individual refused, however, indicating she was not authorized to do so by the physician. Consistent with the family's request, somewhat later a representative of Hospice arrived, and upon the arrival of that individual, the patient's wife discharged the Respondent. With this, the Respondent became very angry and began screaming, banging on the table and slamming things around. All of this served to disturb and upset the patient. Because of this, it was necessary for family members to calm him down. After the argument with the family, Respondent took the bag containing the patient's medications, the medication record kept by the patient's wife over the prior year, and the patient's hospital prescriptions, and told one of the daughters that the medications were hers because she had paid for them. Respondent then departed the home with the gentleman in the car. The daughter called the police and reported the theft. Respondent did not return the morphine, the saline solution and a bottle of 100 Valium tablets. Ms. Sangster, A Registered Nurse Practitioner for 24 years, evaluated Respondent's performance in this matter for the Department. According to her, a home health nurse is supposed to go into the patient's home and assess his physical status to see what care is needed at home and to assess the ability of the nurse to provide those needs. This function also includes working with the patient's family and to help them in understanding the care required so that family members can administer medications when the nurse is not present. Ordinarily, patients retain a home health agency which has an arrangement with the hospital, on referral by a physician, or directly. Before the patient is discharged the agency should have contacted the patient, and upon discharge an agency representative should go to the patient's home as quickly as possible to meet with the patient and the family. The home health agency is responsible to the family, and the nurse on duty is also responsible to provide the needed care. If the nurse sees that the needs are greater than her skills, she must notify the agency to get some with the requisite credentials. The standard of care applicable to home health nurses requires the practitioner to: Report to provide care on time. Stay with the patient as long as required. Perform all tasks assigned. Perform all tasks needed. Do a complete physical assessment of the patient at the first visit. Administer proper medications on time. Perform all procedures required. Document all activities performed. Provide necessary information to the successor shift personnel either verbally or in writing. If the assigned nurse cannot report on time or stay as long as scheduled, then the home health agency is responsible to provide a substitute. The nurse must advise the home health agency in advance and leave a report for the replacement. The nurse on duty must not leave until the replacement arrives. The initial physical assessment establishes the starting point for future patient status. It is a part of the care plan. It must be done the first time the nurse goes into the home for the initial home visit. It is usually done by a registered nurse or, if a licensed practical nurse does it, a registered nurse must evaluate and approve it. Standard practice requires that all patient contact be documented to include what services are to be provided, and entries in the record should be made when a particular service is rendered or as soon thereafter as is possible. Ms. Sangster reviewed the investigative file in this case. All nurses providing treatment to this patient under the terms of the agreement were to be registered nurses who had cardiac training. This was not what Respondent provided. In addition, the physician's order sheet indicates oxygen was to be delivered to the patient's home and that Maximum Care was to provide the home health care. It is the home health agency's responsibility to insure that what is needed for the patient's care is available if not present on the arrival of the patient. Here, in Ms. Sangster's opinion, since Respondent was the first agent of the home health agency to arrive at the patient's home, it was her responsibility to call and arrange for the oxygen to be delivered. She failed to do this. Ms. Sangster examined all the patient's records with the home health agency. Ordinarily such documents will describe the patient's condition, appearance and level of activity. Much of this information is in the records prepared by Respondent. However, Ms. Sangster found many inconsistencies in the assessment. These related to how the patient was described by two different people who observed him. Respondent describes the patient as confused and disoriented, suffering from blackouts, swollen and pale, but with a good appetite and normal urine. She does not, however, indicate how that confusion should be handled. Another individual notes that the patient activity is normal and he is alert, with normal respiration, temperature and skin, a clear chest, and can speak and hear without difficulty. The family contends the patient was neither confused or disoriented. The Respondent's assessment notes reflect the decubitus on the patient but do not indicate how it will be treated or how any anticipated problem the patient might have should be handled. The form is a three page document. Only the first page reflects the patient's name. Ms. Sangster notes that many of the "yes" or "no" blocks checked on the second page do not have explanatory comments, and it is so found. Based on her evaluation of the entire care package provided to this patient by the Respondent, Ms. Sangster concluded that Respondent's actions in this case did not meet required standards because: There was a lack of documentation to support the actions taken, and that documen- tation present was both inconsistent and incorrect. She failed to provide that care contracted for 24 hours per day, that is, care by cardiac trained registered nurses. She left the patient alone with his family, which constituted - The abandonment of the patient and his family, She failed to insure the required equipment was on hand. She did an improper and inadequate patient assessment. She failed to place the assessment she did in the patient's file. She failed to conduct herself with professionalism in her relationship with the patient and his family. She failed to address safety issues, and As a result of all the above, she placed her patient in great harm. The allegation of abandonment is of great import. Abandonment, defined as either the nurse's failure to show up on time or to leave her patient before relief, is viewed as very serious in the nursing community. The home health nurse must, if she cannot provide coverage, make sure that her agency knows her limitations. Since in this case the Respondent was at least in part owner of the agency, she had a multiple responsibility. She should have arranged for someone to be present at the patient's home when he arrived; insured the necessary oxygen equipment was present; and done an immediate assessment of the patient, while he was on the floor, and communicated the patient's status to his physician. Ms. Melegrito claims she did all that was necessary for this patient considering he was a terminal patient with a "do not resuscitate" order on record. She insists he was never neglected. The wife was briefed on the patient's medications because, Respondent claims, she wanted to administer the medications herself. Respondent got the impression that the patient's wife was resistant to her caring for the patient. Respondent claims the action taken against her is racially motivated based on the fact she is the only brown skinned person being charged. Aside from the fact there is no evidence to support this assertion, she overlooks the fact she was the most qualified person involved and her credentials placed upon her a higher standard of performance than that placed on the other two nurses. Her contention is without merit.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that Respondent, Maria C. Melegrito's license as a registered nurse in Florida be suspended for three years, following the expiration of which it be placed on probation for an additional period of three years, under such terms and conditions as may be prescribed by the Board of Nursing, and that she pay an administrative fine of $1,000. RECOMMENDED this 28th day of November, 1995, in Tallahassee, Florida. ARNOLD H. POLLOCK, 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 28th day of November, 1995. COPIES FURNISHED: Miriam S. Wilkinson, Esquire Department of Business and Professional Regulation 1940 North Monroe Street Tallahassee, Florida 32399-0792 Maria C. Melegrito Federal I.D. number 08343-018 Federal Prison Camp Pembroke Station Danbury, Connecticut 06180 Jerome W. Hoffman General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32309 Judie Ritter Executive Director Board of Nursing Daniel Building, Room 50 111 East Coastline Drive Jacksonville, Florida 32202
