The Issue Whether Respondent engaged in unprofessional conduct and, if so, what disciplinary action should be imposed on her nursing license.
Findings Of Fact The Department of Health is the state agency charged with regulating the practice of nursing pursuant to Chapter 464, Florida Statutes. At all times relevant to this proceeding, Respondent was a licensed practical nurse in the State of Florida, holding license no. PN 0986101. Respondent has been so licensed since 1990. At all times relevant to this proceeding, Respondent was employed in the office of Dr. David Flick, M.D., an oncologist. On October 17, 1995, Dr. Flick wrote a prescription for Fiorinal for Katherine Filan, who on that date, was an employee of Dr. Flick. The prescription authorized one refill. On or about January 12, 1996, in response to an inquiry from a pharmacy, Respondent approved a refill of the prescription for Fiorinal for Katherine Filan, without first consulting Dr. Flick. According to Dr. Flick, at all times pertinent to this proceeding, the general policy in his office was that he approved all refills. This policy was unwritten and was not effectively communicated to employees. Respondent and one other licensed practical nurse, formerly employed as a nurse in Dr. Flick's office, provided credible testimony that nurses in Dr. Flick's office were allowed to refill prescriptions, except for narcotics. However, when nurses authorized such refills, the policy was that the refills were to be documented and charted. Respondent believed that her action of authorizing the refill of Ms. Filan's prescription was consistent with the practice and policy of Dr. Flick's office. Moreover, Respondent believed that her approval of the refill was permitted because Dr. Flick had expressly authorized one refill on the original prescription he had written. No evidence was presented that Ms. Filan had refilled the prescription prior to January 12, 1996. After Respondent authorized the refill of the prescription for Ms. Filan, she failed to record the refill authorization on the any medical records. Respondent maintains that her failure to document the refill was inadvertent and was the result of her being extremely busy that day. On the day that Respondent authorized the refill, she was the only chemotherapy nurse on duty, was taking care of patients, and taking incoming nurse's calls. Except for this proceeding, Respondent has never been the subject of a disciplinary proceeding related to her nursing license.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is REOMMENDED that the Department of Health, Board of Nursing, enter a final order dismissing the Administrative Complaint against Respondent. DONE AND ENTERED this 17th day of February, 1999, in Tallahassee, Leon County, Florida. CAROLYN S. HOLIFIELD Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 17th day of February, 1999. COPIES FURNISHED: Sam Power, Agency Clerk Agency of Health Care Administration Fort Knox Building 3, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308 Paul J. Martin, General Counsel Agency of Health Care Administration Fort Knox Building 3, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308 Howard M. Bernstein, Esquire Agency for Health Care Administration General Counsel's Office Medical Quality Assistance Allied Health Post Office Box 14229 Tallahassee, Florida 32317-4229 Michele L. Schrembs DeGrolier, pro se 1501 Carlos Avenue Clearwater, Florida 33755
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following facts are found: By an administrative complaint dated December 15, 1978, respondent was charged with unprofessional conduct in violation of Florida Statutes, Section 464.21(1)(b). The respondent timely requested an administrative hearing which was granted. The envelope which contained the request for hearing was mailed from Buffalo, New York, but the return address was 717 Breakers Avenue #3, Ft. Lauderdale, Florida, with the notation "Note: Address Change." All future correspondence was sent to this address, including the notice of hearing dated May 16, 1979. The hearing was scheduled to commence at 9:30 a.m. At approximately 9:50 a.m., the hearing proceeded without the appearance of the respondent. On July 20 and 21, 1978, the respondent Miller was employed as a registered nurse on the 11:00 p.m. to 7:00 a.m. shift at Cypress Community Hospital in Pompano Beach, Florida. At 3:55 a.m. on July 21, 1978, respondent signed out for 75 milligrams of injectable Meperidine (Demerol), a Class II controlled substance, for patient Frank Mantovi, and then walked into the patient's room with the substance. Another registered nurse on duty, Oletta Jones, observed that the patient was sleeping at the time. Nurse Jones called her supervisor, Anita Johnston, and they awakened the patient and inquired whether he had requested or received any medication for pain. He replied in the negative. The patient appeared oriented and alert, and his vital signs were stable and not indicative of receiving 75 milligrams of Demerol. The administration of Demerol was not charted on the patient's medication record, as it should have been had it been administered. Nurses Jones and Johnston then confronted respondent Miller in the nurses' lounge. At first respondent told them that she had administered the Demerol intermuscularly, but then said she had given it by I.V. push. The doctor's order sheet for patient Mantovi contained a notation for 75 milligrams of Demerol administered intermuscularly as needed for pain every three hours. There is nothing to authorize an I.V. introduction of this medication. It is not acceptable or prevailing nursing practice for a nurse to alter the mode of administration prescribed by the physician. After talking with respondent, patient Mantovi's vital signs were again checked. There was no indication that he had received Demerol. Respondent was then asked to leave the hospital. The pupils of her eyes were observed by Nurse Johnston to be of pinpoint size.
Recommendation Based upon the findings of fact and conclusions of law recited above, it is RECOMMENDED that the Board of Nursing find respondent guilty of unprofessional conduct within the meaning of Florida Statutes, 464.21(1)(b), and suspend her registered nursing license for a period of three (3) months. Respectfully submitted and entered this 14th day of August, 1979, in Tallahassee, Florida. DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 COPIES FURNISHED: Jane M. Miller 717 Breakers Avenue #3 Ft. Lauderdale, Florida 33304 Julius Finegold Esquire 1107 Blackstone Building Jacksonville, Florida 32202 Geraldine Johnson, R.N. Coordinator of Investigation and Licensing 111 East Coastline Drive Suite 504 Jacksonville, Florida 32304 ================================================================= AGENCY FINAL ORDER ================================================================= BEFORE THE FLORIDA BOARD OF NURSING IN THE MATTER OF: Jane Marie Miller 717 Breakers Avenue No. 3 Ft. Lauderdale, Florida 33304 CASE NO. 79-212 As Registered Nurse License Number 66021-2 /
The Issue Whether one or more of the following penalties should be imposed on Elizabeth Worden: revocation or suspension of the Ms. Worden's practice, imposition of an administrative fine, and/or any other relief that the Board of Nursing deems appropriate?
Findings Of Fact Elizabeth Worden is, and has been at all times material hereto, a licensed practical nurse in the State of Florida. Ms. Worden holds State of Florida license number 0739611. Her license lapsed on April 1, 1987, and remained lapsed at least through September 20, 1988. On September 11, 1985, Ms. Worden was arrested and charged with one count of driving under the influence (hereinafter referred to as "DUI") and five counts of possession of controlled substance. On February 24, 1986, Ms. Worden was found guilty of DUI. Additionally, an Order Withholding Adjudication of Guilt and Placing Defendant on Probation was entered based upon a plea of nolo contendere by Ms. Worden to the five counts of possession of controlled substance. Ms. Worden was placed on three years probation for the charge of possession of controlled substance and was placed on a year of probation (to run concurrently with the sentence for possession of controlled substance), ordered to pay a fine, perform community service and had her drivers license suspended for six months for the charge of DUI. During at least part of 1986 and 1987, Ms. Worden was employed as a licensed practical nurse at the Ocala Geriatrics Center (hereinafter referred to as the "Center"). Ms. Worden was one of three licensed practical nurses at the facility during the 11:00 p.m. to 7:00 a.m. shift and was in charge of the patients on one floor of the facility. While on duty at the Center Ms. Worden retired to room 5 in the east wing of the Center almost every night to sleep. She generally went to the room at about 2:00 a.m. and remained in the room until approximately 6:00 a.m. While Ms. Worden slept, she left the certified nurses aides in charge of patient care and assigned duties to the aides which should have been conducted by a licensed nurse. Ms. Worden told the aides to wake her only if a patient needed medication, if another nurse appeared on her floor, and at 6:00 a.m. On three occasions Ms. Worden left the Center while she should have been on duty, leaving certified nurses aides in charge of patient care. On these occasions Ms. Worden was gone from fifteen to thirty minutes carrying out personal errands. Ms. Worden admitted on one occasion to a certified nurses aide that she had consumed a couple of beers before coming to work. Ms. Worden's breath often smelled of alcohol and the room in which she slept also smelled of beer on occasion. During 1987, Ms. Worden entered the Intervention Project for Nurses. She was dismissed from the program in August, 1987, for noncompliance with the program's requirements. On May 18, 1987, Ms. Worden was arrested and charged with DUI and resisting arrest without violence. She was adjudicated guilty of both offenses on July 13, 1987.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Elizabeth Worden be found guilty of having violated Sections 464.018(1)(c) and (g), Florida Statutes, as alleged in Count One and Count Three of the Administrative Complaint. It is further RECOMMENDED that the portion of the Administrative Complaint alleging that Ms. Worden is guilty of having violated Sections 464.018(1)(f) and (h), Florida Statutes, as alleged in the second Count One and Count Three of the Administrative Complaint be dismissed. It is further RECOMMENDED that Ms. Worden's license as a practical nurse be suspended until the later of the end of a five (5) year period from the date of the final order issued in this case or the date that Ms. Worden provides proof acceptable to the Petitioner of her successful completion of a rehabilitation program acceptable to the Petitioner. DONE and ENTERED this 18th day of November, 1988, in Tallahassee, Florida. LARRY J. SARTIN 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 18th day of November, 1988. APPENDIX TO RECOMMENDED ORDER, CASE NO. 88-2548 The Petitioner has submitted proposed findings of fact. It has been noted below which proposed findings of fact have been generally accepted and the paragraph number(s) in the Recommended Order where they have been accepted, if any. Those proposed findings of fact which have been rejected and the reason for their rejection have also been noted. The Petitioner's Proposed Findings of Fact Proposed Finding Paragraph Number in Recommended Order of Fact Number of Acceptance or Reason for Rejection 1 1. 2 3. 3-4 2. 5 3-4. 6 5. 7 7. 8 9. 9 10. 10 10-11. COPIES FURNISHED: Michael A. Mone' Staff Attorney Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Elizabeth Worden 412-A Clark Street St. Charles, Missouri 63301 Bruce D. Lamb General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Lawrence A. Gonzalez Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Judie Ritter Executive Director Department of Professional Regulation Room 504, 111 East Coastline Drive Jacksonville, Florida 32201
The Issue Whether or not Respondent should be disciplined for violations charged under Count I of the Administrative Complaint pursuant to Rule 210- 10.005(1)(e)1. F.A.C. and Section 464.018(1)(f) F.S. [for intentionally or negligently failing to file a report or record required by state or federal law] and pursuant to Rule 210-10.005(1)(e)1. and Section 464.018(1)(h) F.S. [for unprofessional conduct including, but not limited to, inaccurate recording, falsifying or altering of patient records]; under Count II pursuant to Rule 210- 10.005(1)(e)12. F.A.C. and Section 464.018(1)(h) F.S. [for unprofessional conduct including, but not limited to, acts of negligence or gross negligence, either by omission or commission]; and under Count III pursuant to Rule 210- (1)(e)15. F.A.C. and Section 464.018(1)(h) F.S. [for unprofessional conduct including, but not limited to, practicing beyond the scope of the licensee's license, educational preparation or nursing experience].
Findings Of Fact At all times material, Respondent was licensed as a registered nurse in the state of Florida, Board of Nursing license number 84080-2. At all times material, Respondent was employed as a registered nurse/nurse supervisor with North Florida Reception Center (NFRC) Hospital, part of the Florida Department of Corrections. On December 13, 1989, Officer Russell Adler was on duty in 05 dormitory. It was called to Officer Adler's attention and he observed that an inmate, Artis Baker, was crawling around on the floor and was having trouble breathing. At approximately 11:29 p.m. Officer Adler turned over custody of inmate Baker to Officer Willie Hogan for escort to the emergency room. Officer Hogan escorted inmate Baker to the emergency room and went elsewhere while inmate Baker was seen by Respondent, who was the nurse on duty. Shortly thereafter, Respondent returned custody of inmate Baker to Officer Hogan. Officer Hogan testified that the Respondent informed him at that time that he, the Respondent, had given Baker a shot "to calm him down to rest." Hogan escorted inmate Baker back to his dormitory. Officer Adler testified that Hogan told him that Respondent had given Baker "some sleeping medication." However, other witnesses testified that when Respondent was questioned by Dr. Richtine and others after Baker was found dead, Respondent denied that he had medicated Baker. In light of the objective evidence of the autopsy, these contrary so-called "admissions" of Respondent are not sufficient for making a finding of fact that Respondent, did, in fact, administer any drug to Baker. See, Finding of Fact 14. Contrary to NFRC policy, neither inmate Baker's visit to the emergency room nor any medication which may have been administered by Respondent was recorded by Respondent in inmate Baker's patient record. Diane Richtine, M.D., was the on-call physician that night. Contrary to NFRC policy and protocol, Respondent never notified Dr. Richtine that there was an inmate who had presented himself to the emergency room for possible treatment. The foregoing NFRC policies requiring notations in the patient's record and the notification by the on-duty nurse to the on-call physician are contained in a written policy and procedure manual, receipt and reading of which Respondent had acknowledged in writing prior to December 13, 1989, but there was no affirmative proof that these policies or the reports/records required by them are "reports or records required by state or federal law." No statute or Florida Administrative Code rule adopting the Department of Corrections NFRC policy manual was introduced by Petitioner or referenced by any witness. Inmate Baker was returned by Officer Willie Hogan to the dormitory at approximately midnight on December 13, 1989. At 5:55 a.m. on December 14, 1989, Officer Larry Feltner was informed by other inmates that inmate Baker was not responding to the wake-up calls. Officer Feltner checked inmate Baker for a pulse, but was unable to locate one and then called the control room to inform its occupants of the incident. Sergeant Allan Ross and Captain J.D. Wainwright responded. They entered the dormitory and checked inmate Baker for a pulse, and finding none, removed Baker from his bunk and attempted to administer cardiopulmonary resuscitation. The Respondent, David Pearl, then entered the dormitory and while Captain Wainwright and Sergeant Ross were present, checked inmate Baker for life signs and found none. Baker's body was thereafter removed from the dormitory and taken to the NFRC morgue. The Respondent failed to notate inmate Baker's death on his patient records. The first notation of death was made by E. Johnson, R.N., at 8:15 a.m. on December 14, 1989. Patricia K. Bassitt, R.N., was accepted as an expert witness on general nursing practices and record keeping. In her expert opinion, Respondent's failures to notate inmate Baker's visit to the emergency room, to notate his administration of medication to inmate Baker (which administration of medication the expert witness erroneously took to be factually established), and to notate Baker's subsequent death constituted inaccurate keeping of patient records; also in her opinion, Respondent's actions constituted negligent actions and actions below minimum standards of acceptable care. Further, Ms. Bassitt opined that Respondent had acted beyond the scope of good nursing practice, had acted contrary to good nursing practice, and that his actions had been "very lacking." Despite an autopsy performed on inmate Baker, it was not possible to determine the cause of his death. Nothing beyond his regular medications for chronic hypertension was found in his system. No toxic substance, legend drug, or drug which would cause him to sleep was found.
Recommendation Upon the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Board of Nursing enter a Final Order finding Respondent not guilty of the portion of Count I of the Administrative Complaint brought pursuant to Rule 210-10.005(1)(e)1. F.A.C. and Section 464.018(1)(f) F.S. [intentionally or negligently failing to file a report or record required by state or federal law], guilty of the portion of Count I brought pursuant to Rule 210-10.005(1)(e)1. F.A.C. and Section 464.018(1)(h) F.S. [for unprofessional conduct, specifically, inaccurate recording of patient records]; guilty of Count II brought pursuant to Rule 210-10.005(1)(e)12. F.A.C. and Section 464.018(1)(h) F.S. [unprofessional conduct, specifically acts of simple negligence]; and not guilty of Count III brought pursuant to Rule 210-10.005(1)(e)15. F.A.C. and Section 464.018(1)(h) F.S. [unprofessional conduct, specifically practicing beyond the scope of the licensee's license, educational preparation or nursing experience], reprimanding Respondent for his actions, and placing his license on probation for two years with the special condition that he successfully complete courses in charting/assessment in addition to other normally required continuing education courses, together with a $250 administrative fine. RECOMMENDED this 27th day of February, 1991, at Tallahassee, Florida. ELLA JANE P. DAVIS, 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 27th day of February, 1991. APPENDIX TO RECOMMENDED ORDER, CASE NO. 90-4408 The following constitute specific rulings pursuant to Section 120.59(2) F.S. upon the parties' respective proposed findings of fact (PFOF): Petitioner's PFOF: 1-5 are accepted. 6-7 are covered in FOF 6 and 10 and the conclusions of law. 8-19 are accepted. 20-22 are accepted as modified to accurately reflect the witness' testimony and to the extent they are not accepted, they are rejected as contrary to the credible record evidence. Respondent's PFOF: None submitted. COPIES FURNISHED: Tracey S. Hartman, Esquire Department of Professional Regulation Suite 60 1940 North Monroe Street Tallahassee, Florida 32399-0792 David Pearl 1106 1/2 West Princeton Street Orlando, Florida 32804 Judie Ritter Executive Director 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202 Jack McCray, General Counsel Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792
The Issue The issues in this case are whether, before applying for licensure as a registered nurse in Florida, Petitioner had suffered the denial of an application for licensure as a practical nurse in the state of Virginia, and, if so, whether Petitioner's failure to disclose that fact in her Florida application was a knowing misrepresentation; finally, if either or both of the forgoing questions are answered in the affirmative, whether Respondent has grounds to deny Petitioner's pending application for a nursing license.
Findings Of Fact On October 15, 2012, Petitioner Yolette Tema ("Tema") signed an application for licensure as a registered nurse, which she mailed to the Department of Health for review by Respondent Board of Nursing (the "Board"). Item No. 9 of the application sought information about the applicant's disciplinary history. Four subparts (lettered A through D) asked questions that called for a "yes" or "no" answer, which the applicant was to give by marking the applicable check box. The first question ("9A") was: Have you ever been denied or is there now any proceeding to deny your application for any healthcare license to practice in Florida or any other state, jurisdiction or country? Tema answered, "No." In Item No. 10 of the application, there appeared above the signature line the following declarations: I recognize that providing false information may result in disciplinary action against my license or criminal penalties pursuant to Sections 456.067, 775.083, and 775.084, Florida Statutes. I have carefully read the questions in the foregoing application and have answered them completely, without reservations of any kind. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for denial, suspension or revocation of my license to practice as a Registered Nurse or Licensed Practical Nurse in the State of Florida. Tema's signature manifested her agreement with the foregoing declarations. Despite having acknowledged the hard consequences of deceit, Tema's negative answer to the question of whether she ever had suffered the denial of an application for licensure was false. In fact, in June 2011, the Virginia Board of Nursing had denied Tema's application for licensure as a practical nurse, on the ground that she had provided false information in an effort to obtain a license by fraud, deceit, or material omission. Tema had received timely, contemporaneous notice of the Virginia Board of Nursing's final decision, and she was fully aware of that disposition at all times relevant to this case. When she completed the Florida application in October 2012, therefore, Tema knew that her response to question 9A was false. Because the information Tema failed to disclose obviously would have hurt her chances of obtaining a license in Florida, the undersigned disbelieves Tema's explanation for the material omission, which was that she simply made a mistake.1/ Instead, the undersigned infers that Tema intentionally omitted the damaging fact of the Virginia denial in hopes that the Board would not discover it.2/ The Board did, however, discover the Virginia decision while reviewing Tema's application. Based on that past denial and Tema's present failure to disclose it, the Board determined that Tema's Florida application should be denied. The Board's preliminary decision was communicated to Tema through a Notice of Intent to Deny dated February 11, 2014. Determinations of Ultimate Fact Tema is guilty of having an application for a license to practice nursing denied by the licensing authority of another state, which is a disciplinable offense under section 464.018(1)(b), Florida Statutes.3/ Tema is guilty of attempting to procure a license to practice nursing by knowing misrepresentation, which is a disciplinable offense under section 464.018(1)(a).
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Board of Nursing enter a final order denying Tema's application for licensure as a registered nurse. DONE AND ENTERED this 10th day of September, 2014, in Tallahassee, Leon County, Florida. S JOHN G. VAN LANINGHAM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 10th day of September, 2014.
The Issue Whether Respondent committed the violations alleged in the Administrative Complaints and, if so, what penalty should be imposed.
Findings Of Fact Stipulated facts AHCA is the agency responsible for the licensing and regulation of skilled nursing facilities in Florida pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. At all times material hereto, Avante was licensed by Petitioner as a skilled nursing facility. Avante operates a 116-bed nursing home located in Leesburg, Florida. On or about March 28, 2002, AHCA conducted a complaint investigation at Avante. Based on AHCA's findings during the March 28, 2002, complaint investigation, federal tag F281(D) was cited against Avante. On or about May 13, 2002, AHCA conducted a survey at Avante. Based on AHCA's findings during the May 13, 2002, survey, federal tag F281(D) was cited against Avante. Resident E.S. was admitted to Avante on March 11, 2002, with diagnoses including e. coli sepsis, anemia, and schizophrenia with an order for serum albumin levels to be performed "now and yearly." Resident E.S.'s resident chart failed to reflect that a serum albumin test had been performed for Resident E.S. at any time from the date of his admission on March 11, 2002, until March 28, 2002. Avante failed to follow the orders of Resident E.S.'s physician due to its failure to perform a serum albumin test on Resident E.S. at any time between March 11, 2002, and March 28, 2002. Resident R.L. was admitted to Respondent's facility on May 6, 2002 with diagnoses including gastrointestinal hemorrhage, congestive heart failure, coronary artery disease, A-fib, pneumonia, diverticulitis, gout, fracture of right arm, and cancer of the prostate. Resident R.L.'s resident chart reflects that Resident R.L. was neither offered or administered Tylenol by Avante's staff at any time between May 9, 2002, and May 13, 2002. Facts Based Upon the Evidence of Record The correction date given to Respondent for the deficiency cited, Tag F281(D), as a result of the March 28, 2002, complaint investigation was April 28, 2002. Respondent does not dispute the deficiency cited by AHCA as a result of the March 28, 2002, complaint investigation. Thus, facts and circumstances surrounding the May 13, 2002, survey visit to Avante is the source of this dispute. The purpose of the May 13, 2002 survey visit to Avante by AHCA was for annual certification or licensure. In an annual license survey, a group of surveyors goes to a facility to determine if the facility is in compliance with state and federal requirements and regulations. Part of the process is to tour the facility, meet residents, record reviews, and talk to families and friends of the residents. During the licensure visit on May 13, 2002, the records of 21 residents were reviewed. Stephen Burgin is a registered nurse and is employed by AHCA as a registered nurse specialist. He has been employed by AHCA for three years and has been licensed as a nurse for six years. He also has experience working in a hospital ER staging unit and in a hospital cardiology unit. Nurse Burgin has never worked in a nursing home. Nurse Burgin conducted the complaint investigation on March 28, 2002, and was team leader for the licensure survey visit on May 13, 2002, at Avante. He was accompanied on the May 13, 2002, visit by Selena Beckett, who is employed by AHCA as a social worker. Both Nurse Burgin and Ms. Beckett are Surveyor Minimum Qualification Test (SMQT) certified. During the course of the May 13, 2002, licensure survey visit, Ms. Beckett interviewed Resident R.L. As a result of this interview, Ms. Beckett examined Resident R.L.'s medication administration record (MAR) to determine whether he was receiving pain medication for his injured left elbow. As a result of reviewing Resident R.L.'s record, Ms. Beckett became aware of a fax cover sheet which related to Resident R.L. The fax cover sheet was dated May 8, 2002, from Nancy Starke, who is a registered nurse employed by Avante as a staff nurse, to Dr. Sarmiento, Resident R.L.'s attending physician. The box labeled "Please comment" was checked and the following was hand written in the section entitled "comments": "Pt refused Augmentin 500 mg BID today states it causes him to have hallucinations would like tyl for pain L elbow." According to Nurse Starke, the fax to Dr. Sarmiento addressed two concerns: Resident R.L.'s refusal to take Augmentin and a request for Tylenol for pain for Resident R.L.'s left elbow. She faxed the cover sheet to Dr. Sarmiento during the 3:00 p.m. to 11:00 p.m. shift on May 8, 2002. Despite her fax to Dr. Sarmiento, which mentioned pain in R.L.'s left elbow, her daily nurse notes for May 8, 2002, reflect that Resident R.L. was alert, easygoing, and happy. He was verbal on that day meaning that he was able to make his needs known to her. Her daily nurse notes for May 8, 2002 contain the notation: "Pt refused augmentin today. Dr. Sarmiento faxed." According to Nurse Starke, she personally observed Resident R.L. and did not observe any expression of pain on May 8, 2002, nor did Resident R.L. request pain medication after she sent the fax to Dr. Sarmiento. The fax cover sheet also contained the hand written notation: "Document refused by PT. OK 5/9/02" with initials which was recognized by nurses at Avante as that of Dr. Sarmiento. The fax sheet has a transmission line which indicates that it was faxed back to Avante the evening of May 9, 2002. Nurse Starke also provided care to Resident R.L. on May 11, 2002. According to Nurse Starke, Resident R.L. did not complain of pain on May 11, 2002. Theresa Miller is a registered nurse employed by Avante as a staff nurse. Nurse Miller provided care to Resident R.L. on May 9 and 10, 2002, during the 7:00 a.m. to 3:00 p.m. shift. Nurse Miller's nurses notes for May 9 and 10, 2002, reflect that she observed Resident R.L. to be alert, easygoing, and happy. Her notes also reflect that Resident R.L. was verbal on those dates, meaning that he was able to tell her if he needed anything. She did not observe Resident R.L. to have any expression of pain on those dates, nor did Resident R.L. express to her that he was in any pain. Vicki Cannon is a licensed practical nurse employed by Avante as a staff nurse. Nurse Cannon has been a licensed practical nurse and has worked in nursing homes since 1998. Nurse Cannon provided care to Resident R.L. on May 11 and 12, 2002, on the 7:00 a.m. to 3:00 p.m. shift. Her nurse's notes for May 11, 2002 reflect that Resident R.L. was sullen but alert and verbal. Resident R.L. had blood in his urine and some discomfort. Nurse Cannon contacted Dr. Sarmiento by telephone on May 11, 2002, to inform him of Resident R.L.'s symptoms that day. Nurse Cannon noted on Resident R.L.'s physician order sheet that she received a telephone order from Dr. Sarmiento to give Resident R.L. Ultram PRN and Levaquin, discontinue Augmentin, order BMP and CBC blood work, and a urology consult. Ultram is an anti-inflammatory and a pain medication. Ultram is stronger than Tylenol. The notation "PRN" means as requested by the patient for pain. Levaquin is an antibiotic. Nurse Cannon faxed the order to the pharmacy at Leesburg Regional Medical Center. By the time Nurse Cannon left Avante for the day on May 11, 2002, the Ultram had not arrived from the pharmacy. On May 12, 2002, Resident R.L. had edema of the legs and blood in his urine. Nurse Cannon notified Dr. Sarmiento of Resident R.L.'s symptoms. Resident R.L. was sent to the emergency room for evaluation based on Dr. Sarmiento's orders. Additionally, Nurse Cannon called the pharmacy on May 12, 2002, to inquire about the Ultram as it had not yet arrived at the facility. Resident R.L. returned to Avante the evening of May 12, 2002. Alice Markham is a registered nurse and is the Director of Nursing at Avante. She has been a nurse for more than 20 years and has been employed at Avante for a little over two years. She also has worked in acute care at a hospital. Nurse Markham is familiar with Resident R.L. She described Resident R.L. as alert until the period of time before he went to the hospital on May 12, 2002. She was not aware of any expressions of pain by Resident R.L. between May 9, 2002 until he went to the hospital on May 12, 2002. Nurse Markham meets frequently with her nursing staff regarding the facility's residents. During the licensure survey, Nurse Markham became aware of Ms. Beckett's concerns regarding Resident R.L. and whether he had received Tylenol. She called Dr. Sarmiento to request an order for Tylenol for R.L. The physician order sheet for R.L. contains a notation for a telephone order for Tylenol "PRN" on May 14, 2002, for joint pain and the notation, "try Tylenol before Ultram." The medical administration record for R.L. indicates that Resident R.L. received Ultram on May 13 and and began receiving Tylenol on May 15, 2002. AHCA 's charge of failure to meet professional standards of quality by failing to properly follow and implement physician orders is based on the "OK" notation by Dr. Sarmiento on the above-described fax and what AHCA perceives to be Avante's failure to follow and implement that "order" for Tylenol for Resident R.L. AHCA nurse and surveyor Burgin acknowledged that the "OK" on the fax cover sheet was not an order as it did not specify dosage or frequency. He also acknowledged that the nursing home could not administer Tylenol based on Dr. Sarmiento's "OK" on the fax cover sheet, that it would not be appropriate to forward the "OK" to the pharmacy, that it should not have been placed on the resident's medication administration record, and that it should not have been administered to the resident. However, Nurse Burgin is of the opinion that the standard practice of nursing is to clarify such an "order" and once clarified, administer the medication as ordered. He was of the opinion that Avante should have clarified Dr. Sarmiento's "OK" for Tylenol on May 9, 2002, rather than on May 14, 2002. Nurse Burgin also was of the opinion that it should have been reflected on the resident's medication administration record and treatment record or TAR. In Nurse Markham's opinion, "OK" from Dr. Sarmiento on the fax cover sheet does not constitute a physician's order for medication as it does not contain dosage or frequency of administration. Nurse Markham is also of the opinion that it should not have been forwarded to the pharmacy, transcribed to the medication administration record, or transcribed on the treatment administration record. According to Nurse Markham, doctor's orders are not recorded on the treatment administration record of a resident. Nurse Markham is of the opinion that the nursing staff at Avante did not deviate from the community standard for nursing in their care of Resident R.L. from May 8, 2002 to May 14, 2002. Nurse Cannon also is of the opinion that the "OK" by Dr. Sarmiento does not constitute a physician's order for medication. The Administrative Complaints cited Avante for failure to meet professional standards of quality by failing to properly follow and implement a physician's order. Having considered the opinions of Nurses Burgin, Markham, and Cannon, it is clear that the "OK" notation of Dr. Sarmiento on the fax cover sheet did not constitute a physician's order. Without Dr. Sarmiento's testimony, it is not entirely clear from a review of the fax cover sheet that the "OK" relates to the reference to Tylenol or the reference to Resident R.L.'s refusal of Augmentin. Accordingly, Avante did not fail to follow a physician's order in May 2002. As to AHCA's assertion that Avante failed to meet professional standards by not clarifying the "OK" from Dr. Sarmiento, this constitutes a different reason or ground than stated in the Administrative Complaints. Failure to clarify an order is not the equivalent of failure to follow an order. There is insufficient nexus between the deficiency cited on March 28, 2002 and the deficiency cited on May 13, 2002. Accordingly, Avante did not fail to correct a Class III deficiency within the time established by the agency or commit a repeat Class III violation. Moreover, the evidence shows that the nursing staff responded to the needs of Resident R.L. Resident R.L. expressed pain in his left elbow to Nurse Starke on May 8, 2002. Resident R.L. was alert and could make his needs known. He did not express pain or a need for pain medication to Nurse Miller on May 9 or 10, 2002 or to Nurse Cannon on May 11 or 12, 2002. Rather, Nurse Cannon noted a change in his condition, notified Dr. Sarmiento which resulted in Resident R.L. being sent to the emergency room. Resident R.L. returned to Avante the evening of May 12, 2002, and received Ultram for pain on May 13, 2002, when the medication reached Avante from the pharmacy. The evidence presented does not establish that Avante deviated from the community standard for nursing in its actions surrounding the "OK" from Dr. Sarmiento. In weighing the respective opinions of Nurses Burgin and Markham in relation to whether the community standard for nursing was met by the actions of Respondent, Nurse Markham's opinion is more persuasive.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law set forth herein, it is RECOMMENDED: That the Agency for Health Care Administration enter a final order dismissing the Administrative Complaints issued against Respondent, Avante at Leesburg. DONE AND ENTERED this 13th day of December, 2002, in Tallahassee, Leon County, Florida. BARBARA J. STAROS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 13th day of December, 2002. COPIES FURNISHED: Jodi C. Page, Esquire Agency for Health Care Administration 2727 Mahan Drive Mail Station 3 Tallahassee, Florida 32308 Karen L. Goldsmith, Esquire Jonathan S. Grout, Esquire Goldsmith, Grout & Lewis 2180 Park Avenue North, Suite 100 Post Office Box 2011 Winter Park, Florida 32790-2011 Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building 3, Suite 3431 Tallahassee, Florida 32308-5403 Valinda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building 3, Suite 3431 Tallahassee, Florida 32308-5403
Findings Of Fact The Respondent Tobianna W. Huddleston is a registered nurse licensed in Florida, having been issued license number 140220-2. The Respondent's license to practice nursing in the State of New York was revoked on or about December 24, 1982, effective January 3, 1983, by the Commissioner of Education for the State of New York. The Commissioner's revocation was based on a Report of the Regents Review Committee which reviewed a Recommendation of a Hearing Panel which found that the Respondent was incapable of practicing her profession competently and, therefore, constituted a threat to the public.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED: That a Final Order be entered by the Board of Nursing revoking the nursing license of the Respondent Tobianna W. Huddleston. DONE and ENTERED this 28th 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 28th day of October, 1983. COPIES FURNISHED: Julia P. Forrester, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Tobianna W. Huddleston Post Office Box 1124 Danville, Kentucky 40422 Helen P. Keefe, Executive Director Florida Board of Nursing Room 504, 111 East Coastline Drive Jacksonville, Florida 32202 Frederick Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
Findings Of Fact Respondent, a licensed practical nurse, worked the 7 to 3 shift on the south end of the eighth floor of University Hospital, Jacksonville, Florida. She and the nurses with whom she worked were divided into two teams, each of which took responsibility for certain patients. Respondent was on team one. The patient Lena Rogers, who was on eighth floor south on January 21, 1977, was assigned to team two. On the morning of January 21, 1977, respondent reported for work as usual. As a routine matter, the hospital pharmacy had earlier delivered to eighth floor south a box containing 25 ampules of Demerol. Each ampule contained 50 cc of Demerol. Accompanying the box of ampules were three sheets of different colored paper, each of which was stamped with the same number as the box. The green sheet was signed by a nurse on eighth floor south and returned to the pharmacy as its receipt for the Demerol. The yellow control sheet was lost in its entirety. While this is not an every day occurrence, such sheets are lost about once a month at University Hospital, and the evidence was devoid of any indication that the yellow control sheet had been intentionally mislaid. The white sheet, containing 25 shingled charge slips, remained with the box of Demerol. Nurses administering Demerol to patients were expected to fill out one of the slips each time an ampule of Demerol was used, indicating which patient should be billed for the drug. The accepted procedure is for nurses, after administering drugs to their patients, to note that fact on the patients' charts, in the nurse's notes, and on a medication graph. These records are supposed to be updated immediately after medicine is administered but, not infrequently, nurses wait until the end of their shifts to do record keeping. This departure from accepted practice is less frequent, however, in the case of controlled drugs like Demerol. When it is necessary for a nurse to waste drugs like Demerol, accepted practice requires that the wasting be witnessed by another nurse, after which both nurses are to sign the yellow control sheet. On January 21, 1977, respondent Morgan signed 16 charge slips, but crossed through her signature on one of them. The remaining charge slips signed by respondent indicated a patient named Williams should be billed for four ampules of Demerol; that a patient named Fowler should be billed for four ampules of Demerol; that a patient named Fisher should be billed for three ampules of Demerol; and that patients named Rogers and Richards should each be billed for two ampules of Demerol. About half past one on the afternoon of January 21, 1977, Jonti Lute, R.N., who also worked on eighth floor south, noticed that respondent appeared drowsy and as if she were in a daze. Ms. Karen Harris, the house supervisor for the 7 to 3 shift, was on eighth floor south on the afternoon of January 21, 1977, making her rounds. Ms. Harris observed respondent sitting at the nurses station, writing on charts, and occasionally nodding. Respondent's eyes were dry and she was continually wetting her lips with her tongue. When she stood up, she held on to a table for support. As she left the nurses' station, she tripped over her own feet and bumped into a partition. Her speech was slurred. Ms. Harris suggested that respondent accompany her to the hospital employees' clinic. Respondent protested and the director of nursing, Ms, Apol, was summoned. Before her shift ended, respondent went to the employees' clinic where she was examined by Dr. Lipkovich. As part of the examination, respondent gave a urine specimen, 50 cc of which was sent to a laboratory for chemical analysis. Mr. Bush, a chemist, testified that analysis disclosed the presence of Demerol in this sample in a quantity of "25 mg. per cent." By her own admission, respondent injected herself with the contents of one ampule of Demerol, while she was on duty. Respondent testified that she administered some of the remaining Demerol to the patients she had indicated on the charge slips should be billed for the medicine, and wasted the remainder by ejecting it from syringe(s) into a sink. None of the charts of the patients whom respondent indicated should be billed for Demerol on January 21, 1977, contained any indication that Demerol had been administered to the patients on that date. Respondent testified that nobody had witnessed her wasting Demerol on January 21, 1977.
Recommendation Upon consideration of the foregoing, it is RECOMMENDED: That petitioner revoke respondent's nursing license. DONE and ENTERED this 28th day of October, 1977, in Tallahassee, Florida. ROBERT T. BENTON, II Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 COPIES FURNISHED: Mr. Julius Finegold, Esquire 1005 Blackstone Building Jacksonville, Florida 32202 Mr. Frederic A. Buttner, Esquire Barnett Bank Building Jacksonville, Florida 32202 =================================================================
Findings Of Fact Bonnie Isaac, R.N., held License No. 52845-2 as a Registered Nurse. Said license having been suspended for a period of ninety (90) days pursuant to the lawful order of the Board signed February 18, 1976. Said order of suspension was transmitted to and received by Bonnie Isaac on February 27, 1976. Subsequent to the receipt of said order, Bonnie Isaac continued to perform duties which can only be performed by licensed nurses in the course of her employment at Jackson Memorial Hospital, Dade City, Florida. Bonnie Isaac did not return her certificate of licensure and renewal certificate to the Board, but said renewal expired on March 31, 1976 pursuant to law. The license of Bonnie Isaac was not reinstated at the end of ninety (90) days although she requested that her license be returned to her by her letter of June 25, 1976 to the Florida State Board of Nursing. The license of Bonnie Isaac, suspended by lawful order of the Board effective February 27, 1976, had not been reinstated as of the date of hearing.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, the Hearing Officer would recommend that the probation of Bonnie Isaac expressed in Board's order dated February 18, 1976 for nine (9) months following the ninety (90) day suspension of Respondent's license be set aside and the license of Respondent be suspended for one year from the initial date of suspension, February 27, 1976, said license to be reinstated with the full benefits and privileges thereof on February 26, 1977. DONE and ORDERED this 16th day of December, 1976, in Tallahassee, Florida. STEPHEN F. DEAN Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida COPIES FURNISHED: Julius Finegold, Esquire 218 E. Forsyth Street Jacksonville, Florida 32202 Geraldine B. Johnson, R.N. State Board of Nursing 6501 Arlington Expressway Bldg B Jacksonville, Florida 32211 Bonnie C. Isaac, R.N. Route 11, Box 735 A Lakeland, Florida 33801
