The Issue The issue to be resolved in this proceeding concerns whether the Respondent's license should be subjected to disciplinary sanctions on the basis of the allegations in the Amended Administrative Complaint, which charges that he has violated Sections 464.018(1)(d)5 and 464.018 (1)(j), Florida Statutes. If the charges or any portions of them should be substantiated it must be determined what, if any, penalty is warranted.
Findings Of Fact The Petitioner is an Agency of the State of Florida charged with regulating the practice of nursing, the entry into practice and discipline of licensed practioners, in accordance with Sections 20.165 and 20.43, Florida Statutes and Chapters 456 and 464, Florida Statutes. The Respondent at all times material hereto has been a licensed registered nurse in the State of Florida, holding license No. RN3294352. The license is currently suspended. The Respondent's address of record is 1600 E. DeSoto Street, Pensacola, Florida 32501. Roberta Schaffner, M.D., testified as an expert witness in nursing and psychiatry. She is a Florida licensed, board- certified psychiatrist, who also earned a bachelor of science degree in nursing before becoming a physician. She passed her nursing boards in 1977 and was licensed in Tennessee, Ohio and California. She was on the nursing faculty at Mwami Nursing School in Zambia, Africa in 1977 and 1978. She has extensive experience in the field of nursing as well as psychiatry and was accepted in both areas of expertise. The Respondent saw Dr. Schaffner for evaluation on March 3, 2003. Prior to that evaluation she reviewed some of his prior treatment history and records concerning the incident for which he was arrested, as well as letters from a prior physician who had treated him. Dr. Schaffner asked the Respondent to take two psychological tests following their meeting: the Zung Depression Scale and the Minnesota Multi- Phasic Personality Inventory-II (MMPI-II). The Zung Depression Scale is designed to quantify recent depressive symptoms or level of depression. The MMPI-II is a complex 500 question psychometric test that Dr. Schaffner had scored by the company owning the test. She then interpreted the results. As a result of the Zung test administered to the Respondent, Dr. Schaffner opined that he was not suffering from any significant depressive symptoms, although she did feel that he had had depression episodes at various times. As a result of the MMPI-II psychological test Dr. Schaffner testified that his score did not fit with her pre- existing impression of Mr. Ramme from the interview; it was rather an unusual result. The Respondent did not complete some of the basic identifying information on the test which can affect the scoring. She also testified that some of his responses were very different from what he had told her in the verbal interview a couple of hours before he took the test. Although he had verbally described himself as a loner with only one close friend in California, the MMPI-II gave the specific description that the Respondent was "quite outgoing and social," with a "strong need to be around others. . . is gregarious and enjoys attention." Dr. Schaffner explained the five axes that are used in psychiatric diagnosis (as represented in the "DSM-IV" diagnostic handbook) which are ways to describe different aspects of a person's symptoms and behavior when they have a psychiatric illness. The five specific axes are: Axis I: Thought to be primarily very serious psychiatric illnesses that might have a biologic base. Axis II: Developmental delays and developmental problems, mental retardation and personality disorders. Axis III: Other medical conditions. Axis IV: Recent stressors, economic stressors, major illnesses traumas. Axis V: Global Assessment Functioning (GAF), this is a number from 0-99, used to describe an individual's ability to function. After her evaluation of the Respondent, her consultation with his prior physicians and the reviewing of his records, Dr. Schaffner expressed the following diagnosis: As to Axis I she found a "mood disorder, not otherwise specified," (NOS), stating that the Respondent has a serious and chronic psychiatric condition, is impaired and has difficulties. She was concerned that he may have some cognitive changes over a period of time because he did not present like a professional nurse with regard to the vocabulary he used or his way of discussing things that they talked about. She also found that he might have a schizo-affective disorder, which is a chronic illness associated with mood symptoms as the Respondent has exhibited. People with schizo- effective disorder tend to have a decrease in functioning over time, as Dr. Schaffner believes Mr. Ramme has experienced. As to Axis II she finds a personality disorder with paranoid and narcissistic features as being exhibited by the Respondent. Such a disorder can be characterized by declining cognition ability or ways of perceiving and interpreting other people and events which she believes are consistent with the history displayed by Mr. Ramme, such as his rather turbulent employment history and relationship with other people since 1998. She finds also that this sort of personality disorder is characterized with a range of intensity or appropriateness of emotional responsibility "which deviates from the expectations of the culture in which Mr. Ramme lives and operates." In other words she found that his emotional response or responsibility deviated marketedly from expectations of his culture and that his inter-personal function and impulse control exhibited deviation from normal expectations. Concerning Axis III she found that he had history of hypertension, hepatitis C, hyperlipidemia and pot smoking. Concerning Axis IV she found stress of a moderate level including chronic psychological problems, problems with work functioning, social isolation and financial struggles. Concerning Axis V, she found that he had a current level of functioning of 60 on a scale of 0 to 99. She found that score significantly low and explained that with a higher number an individual is functioning better. When the level of functioning goes down into the 70's range a person can be responding to problems and still functioning pretty well, but below 70's down into the 60's one sees an indication of significant problems. Dr. Schaffner found that the Respondent was having difficulties in functioning in both his social life and his work life. Dr. Schaffner established that the Respondent has a history of impairment and a lack of awareness of his difficulty and a lack of interest in securing and pursuing on-going treatment. This makes him at risk in nursing practice since he would not be in treatment or monitored. The Dr. opined that patients could potentially be at risk if the Respondent should be allowed to practice as a nurse without treatment, close supervision and monitoring. She stated that the Respondent needs further evaluation to see that he has not suffered some cognitive declines. It must be ascertained if he has the intellectual capabilities for nursing information and she found that he needs on-going psychiatric evaluation and treatment, including medication. He would need close monitoring of his nursing performance and perhaps limitations on the type of environment he could practice nursing in, in order to continue practicing nursing in some fashion, according to Dr. Schaffner. Dr. Schaffner also described the Respondent's multiple employment terminations and the effect of those on his ability to practice nursing with reasonable skill and safety. She highlighted an incident of his "poor judgment that's not consistent with professional nursing behavior." This involved the Respondent's termination from employment and his demand for a paycheck immediately upon his termination. Because of the Respondent's refusal to leave the facility where he was terminated that day, security personnel had to be called to forcibly remove him. The Respondent obtained his Florida licensure in 1998 and has had three employment positions since that time in the nursing field. He worked for CDI an agency in Pensacola that staffed the hospital in Panama City. He was terminated from that position when he refused to drive the 90 miles to the hospital to work one evening in a hurricane. His second job was at West Florida Hospital where he worked in the emergency room. Due to some disagreement or verbal altercation or disagreement as to policy he was terminated from that position in September of 1999, after being hired in July of 1999. His third position was with a firm called "Nurses on Call." He had just begun orientation and employment with "Nurses on Call" when he was arrested in June of 2000 concerning the battery charge. This event apparently caused him to lose that job before he actually got started with his duties. Dr. Schaffner also found that the Respondent "does not seem to be aware of the significance or seriousness of a number of his experiences or things that have happened to him. He minimizes the seriousness of his previous psychiatric hospitalizations. . . he has a marked lack of either insight or understanding of the difficulty that he has had in a number of settings." Also, according to Dr. Schaffner, the Respondent is not currently being monitored by any kind of health care professional except concerning his high blood pressure. Dr. Schaffner thus opined that the Respondent is not able to practice nursing with reasonable skill and safety without treatment, monitoring and exhibiting a willingness, on an ongoing basis in the future, to be treated and to continue his treatment. Although she obtained additional information that the Respondent related to her during the hearing, Dr. Schaffner indicated that the additional information would not change her diagnosis of the Respondent nor her opinion concerning his ability to practice nursing. Dr. Schaffner also opined that the Respondent's statements to the effect that he had long periods of "low moods and hopelessness and problems sleeping" were consistent with a major depressive disorder diagnosis. Although the Respondent sought to illicit a definitive diagnosis from Dr. Schaffner in his examination of her, to the effect that he does not have a bi-polar disorder, Dr. Schaffner opined that she did not have enough information to rule that out. A "bipolar disorder" is one of the potential diagnoses under the diagnosis "mood disorder NOS" which she had given him. The Respondent admitted that he had mood problems in the past and that he had "taken some medications." The Respondent also stated that he is ready to do his best and do whatever is necessary to get back into nursing, including necessary treatment. The Respondent states that he had started going to the Lakeview Center in Pensacola, a local mental health center, in 1999, to continue on medications that he had previously taken. Those medications included Restoril, a benzodiazopine for sleep and Zoloft, a Seratonin re-uptake inhibitor, commonly known as a mood drug. The Respondent had taken Zoloft for approximately three and one-half years until he stopped in June of 2000. That is the month when he was arrested for battery and resisting arrest, involving the altercation with his then-girlfriend. The Respondent also admitted to taking Lithium, a medication normally prescribed for bi-polar disorder. It is unclear whether he stopped taking the Lithium prior to or after the arrest. The Respondent has been very candid and remorseful in admitting and discussing the altercation which led to his minor criminal conviction. He additionally has been quite candid and positive in expressing the need and the desire to embark on treatment of his personality disorder, including taking medication if necessary and undergoing evaluation therefore. He is passionate about wishing to continue practicing nursing and has a keen desire to help disabled people. He is confident that he has a large fund of knowledge which would help him to continue to practice highly-skilled nursing and has a strong desire to continue to do so. He is willing to do whatever is best for him in order to get back to practicing his nursing profession.
Recommendation Having considered the foregoing Findings of Fact, Conclusions of Law, the evidence of record, the candor and demeanor of the witnesses, and the pleadings and arguments of the parties it is, therefore, RECOMMENDED that with regard to the violation in Count I that, by Final Order, a written reprimand be accorded to the Respondent and that he be required to submit to the psychiatric evaluation and/or treatment referenced with regard to Count II. It is further RECOMMENDED, with regard to Count II that a Final Order be entered finding the charges substantiated and imposing a two-year suspension of licensure, with the suspension stayed. Concomitant with the stay of suspension, there shall be imposed a two-year probationary period wherein the Respondent must successfully undergo a psychological/psychiatric evaluation and faithfully follow any treatment regimen recommended by such evaluators, including on-going medication, if needed, and accompanied by the successful completion of an IPN program and other continuing education and monitoring conditions, including direct supervision by a registered nurse or physician as may be reasonably required by the Board of Nursing, as conditions on his continued practice. DONE AND ENTERED this 6th day of August, 2003, in Tallahassee, Leon County, Florida. S P. MICHAEL RUFF 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 Clerk of the Division of Administrative Hearings this 6th day of August, 2003. COPIES FURNISHED: Lynne A. Quimby-Pennock, Esquire Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Peter J. Ramme, R.N., pro se 1600 E. DeSoto Street Pensacola, Florida 32501 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 Dan Coble, RN, PhD CNAA C, BC Executive Director Board of Nursing Department of Health 4052 Bald Cypress Way, Bin C02 Tallahassee, Florida 32399-3252
Findings Of Fact Respondent is licensed by Petitioner as a licensed practical nurse, License Number 21725-1 and was so licensed during the years 1974 and 1975. Respondent was first employed by Okaloosa Memorial Hospital Crestview Florida in 1965 as a nurse's aide and remained in this capacity until 1968 when she took a leave of absence to attend classes to obtain her license as & practical nurse. She was employed as a licensed practical nurse at the hospital from September 1969 until August 27, 1975. Her primary duty as an LPN was medication nurse on the 7-3 shift. (Respondent's Composite Exhibit 1) On September 27, 1974, Respondent signed out for 100 mg. of "meperidine inj" at 2:15 P.M. on a hospital Narcotic Administration Record for that drug for Station Number 1. The record reflects that the drug was drawn from hospital stock to be administered to patient Tommy Davis. Demerol is the trade name for meperidine and it is a controlled narcotic analgesic drug. Although the Nurses Bedside Record for the patient for that day should have reflected administration of the drug to the patient by the initials of the Respondent, the record does not show such an entry by her or anyone else. Hospital practice also requires that administration of medication be shown on the nurses progress notes for the patient, but there is no record in such notes for the date in question regarding patient Davis having received the medication in question. (Testimony of Bronson, Mitchell, Petitioner's Exhibits 2, 5). A hospital Narcotic Administration Record for "meperidine, 100 mg., inj." for Station Number 1 reflects that on February 8, 1975 at 2:00 P.M. Respondent withdrew 100 mg. of the drug for patient Roy Bringhurst. However, neither the Nurses Bedside Record nor the nurses progress notes reflect that the drug was administered to the patient by Respondent or anyone else at that time. (Testimony of Bronson, Mitchell; Petitioner's Exhibits 3, 6). A hospital Narcotic Administration Record for "meperidine 75 mg. inj." for Station Number 1 shows that on February 23, 1975, at 1:00 P.M., Respondent signed out for 75 mg. of the drug for patient Mary Corbin. Neither the Nurses Bedside Record nor nurses progress notes for the patient reflect that the drug was administered at that time by Respondent or anyone else. (Testimony of Bronson, Mitchell; Petitioner's Exhibits 1, 4). In early August, 1975, personnel of the hospital pharmacy brought to the attention of the hospital administrator the fact that a large quantity of the drug, Thorazine, was being used at Station 1 in the hospital. Medical records reflected that the drug had been used only four times during a five day period when ten vials had been issued. Each vial would provide about five to ten normal injections. It was further noted that after Respondent went on a ten day leave of absence, no Thorazine was used during that period at Station 1. When Respondent returned on August 19th, she requisitioned two bottles of Thorazine for Station Number 1 from the pharmacy and these bottles were given to her by pharmacy personnel on that date. During Respondent's noon hour absence, the hospital Administrator and Director of Nursing went to the medication room of Station 1 and observed a partially full bottle of Thorazine which had been there for some time and had been issued to the station on August 8th. The bottle also had been observed in the medication room by the Director of Nursing at 6:30 A.M. on August 19th before Respondent started her shift. At that time, it also was noted that the trash can in the medicine room was empty. During the noon hour investigation, it was discovered that an empty bottle of Thorazine was in the trash can and another empty bottle was found in general trash outside the hospital. When Respondent returned from lunch, she was asked to step into the medicine room and there the Administrator asked her what had happened to the two bottles of thorazine. Respondent stated that she had administered one injection to patient Barnes and another to patient Nelson and that a third injection had been given to her son. She was unable to account for the remaining amount that had been drawn earlier that day. She consented to the Administrator examining her handbag and therein was found twelve Thorazine tablets in a medicine cup. When asked about them, Respondent admitted that they came from hospital stock supplies and that she had planned to take them home for use by her husband who suffered from heart trouble. Later that day, patient Nelson told the Director of Nursing that he had not received an injection since early in the morning of August 19th and patient Barnes denied having received any injection of the drug that day. Subsequent to August 19, Respondent provided a written statement to hospital authorities in which she said that she gave Thorazine intramuscularly rather than orally to patient Nelson by mistake and that she gave a Thorazine injection to patient Barnes due to her negligence in not ascertaining that such medication had not been ordered for him. Contrary to the statement she had made concerning her son, in fact, the shot which she administered to him at the hospital on August 19 was penicillin which he had brought from home to the hospital on that day. He was then suffering from a cold. The penicillin had been purchased at a pharmacy by Respondent in June, 1975, for possible future use. (Testimony of Mitchell, Howard, Helms, Carl Godwin, Petitioner's Composite Exhibit 7, Petitioner's Exhibit 8, Respondent's Exhibit 2). Respondent testified as a witness and admitted taking the 12 Thorazine tablets from hospital supplies on August 19, 1975, because her husband was not feeling well and she thought the medication would help him. She conceded that it was wrong for her to take the tablets and offered no other excuse for her action. Although she admitted requisitioning the two bottles of Thorazine on August 19th, she testified that these were not delivered to her but that she saw them in a basket in the medicine room about 10:00 A.M. She further testified that it was entirely possible that she could have made the charting errors, as alleged, due to the fact that frequently she had a large number of patients asking for medication at the same time and she was not able to chart such medication until after her shift had finished. At such times she might have forgotten a particular dosage administered to a patient. She stated that she had ordered the two bottles of Thorazine on August 19th because the Director of Nursing had previously required that two bottles be in stock at Station Number 1 at all times. (Testimony of Respondent). In 1975, it was not uncommon for the hospital's nurses to chart their medication at the end of their shift rather than at the time of administration. Although hospital employees were routinely provided such medications as aspirin or antacid from hospital supplies, there was no authorization for them to take or receive other drugs without a doctor's orders. Although several witnesses testified that there were rather loose practices in the hospital regarding employees receiving medication, no specific instances were cited to establish that taking drugs without permission was the norm. (Testimony of Howard, McLaughlin, Downes, Deaton). In view of the foregoing findings the, following further findings are made: On three separate occasions in 1974 and 1975, while on duty as a medication nurse at the Okaloosa Memorial Hospital, Crestview, Florida, Respondent drew quantities of meperidine (demerol) from hospital supplies for specified patients and failed to chart the administration of such drugs in patient records. On August 19, 1975, Respondent wrongfully took twelve Thorazine tablets from Okaloosa Memorial Hospital supplies for personal use. On August 19, 1975, Respondent received two bottles of Thorazine from the Okaloosa Memorial Hospital pharmacy ostensibly for patient use, but wrongfully disposed of the same in an unknown manner. Respondent enjoys a good reputation as a licensed practical nurse. In fact, the hospital Administrator is of the opinion that she was the best medication nurse in the hospital before she became ill in 1974. Her coworkers attest to her loyalty, honesty, and conscientious work. She enjoys a good reputation in her community where she has lived for a lifetime, and a number of her former patients submitted statements concerning her excellent work while under her care. She has been employed at the Crestview Nursing Convalescent Home, Crestview, Florida, since September 30, 1975 and has performed her duties there in a very commendable manner. Her employer wishes to retain her as a licensed practical nurse due to the fact that she is particularly qualified to handle elderly patients and competent nurses for this type of work are difficult to find. (Testimony of Howard, McLaughlin, Sanford, Downes, Deaton, Baldwin, Respondent's Composite Exhibit 1).
Recommendation That Respondent's license as a licensed practical nurse be suspended for a period of six months, but that the enforcement thereof be suspended for a like period during which time Respondent should be placed on probation. DONE and ENTERED this 24th day of January, 1977, in Tallahassee Florida. THOMAS C. OLDHAM Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1130 American Heritage Building Jacksonville Florida 32202 Ernest L. Cotton & Woodburn S. Wesley, Jr., Esquires 88 Eglin Parkway Fort Walton Beach Florida
The Issue This case concerns the issue of whether the Respondent's license as a registered nurse should be suspended, revoked or otherwise disciplined for submitting employment applications which contained false information and for unprofessional conduct in the performance of her duties as a nurse. At the formal hearing the Petitioner called as witnesses Janet Brown, Wilma Green, E. Jean King, Susan Coffin Brennan, Mary Ann Cottrell, and Mary Sheffield. The Respondent testified on her own behalf and was the only witness called by the Respondent. The Petitioner offered and had admitted into evidence, ten exhibits and the Respondent offered and had admitted into evidence, seven exhibits. Counsel for the Petitioner and counsel for the Respondent submitted proposed findings of fact and conclusions of law for consideration by the Hearing Officer. To the extent that those proposed findings of fact and conclusions of law are consistent with the findings made in this order, the proposed findings were adopted by the Hearing Officer. To the extent that the proposed findings and conclusions of law are not consistent with this order, they were considered by the Hearing Officer and rejected as being unsupported by the evidence or unnecessary to the resolution of this cause.
Findings Of Fact The facts set-forth in paragraphs 1 through 4 below were stipulated to by the parties and are found as facts: At all times pertinent to this proceeding, Respondent was a licensed registered nurse in the State of Florida, having been issued license number 67142-2. Respondent filled out and filed the applications for licensure as a registered nurse, Petitioner's Exhibit No. 1. Respondent did fill out and file the applications for employment as a nurse, Petitioner's Exhibit Nos. 2 through 9. Respondent did falsify her date of birth, age, and date of graduation from nursing school on her applications for employment as a nurse, Petitioner's Exhibit Nos. 2 through 9. This was done by Respondent on the recommendation of an employment agency initially, and was done in order to obtain employment. On or about April 8, 1982, Respondent filled out and submitted an employment application for work as a nurse to Lakeview Nursing Center. (Petitioner s Exhibit No. 2). The application reflected that Respondent obtained her R.N. degree from Bellevue Hospital in 1948. That information is false. The Respondent received her R.N. degree in 1939. On or about March 11, 1983, Respondent filled out and submitted an employment application for work as a nurse to Leesburg General Hospital, Leesburg, Florida (Petitioner's Exhibit No. 3). That application reflects a date of birth of December 24, 1932 and the date June, 1948 as the year Respondent received her nursing degree. This information is false in that Respondent's date of birth is September 29, 1918, and the year she received her nursing degree was June, 1939. On or about January 25, 1982, Respondent filled out and submitted an application for employment as a registered nurse to Sanford Nursing and Convalescent Center, Inc., Sanford, Florida (Petitioner's Exhibit No. 4). That application reflected a date of birth of December 24, 1932 and the year 1948 as the year in which Respondent obtained her R.N. degree. The date of birth and year of graduation are false. On or about May 28, 1980, Respondent filled out and submitted an application for employment as Director of Nursing at Orlando Memorial Convalescent Center, Orlando, Florida (Petitioner's Exhibit No. 5). That application reflected that Respondent graduated from Bellevue Hospital School of Nursing in 1948. That information is false in that she graduated in 1939. On or about February 13, 1980, the Respondent filled out and submitted an application for employment as a nurse to Quality Care, a nursing service (Petitioner's Exhibit No. 6). That application contained a false date of birth of December 24, 1932 and a false year of graduation from Bellevue Hospital School of Nursing of 1948. On or about January 23, 1980, Respondent filled out and submitted to the Physician's Registry an application for employment as a nurse (Petitioner's Exhibit No. 7). That application reflected an age of 47 and date of birth of January 24, 1932. This information is false. On or about January 8, 1980, the Respondent filled out and submitted an application for employment as a nurse to Medox, Inc. That information reflected a birth date of December 24, 1932 and a year of graduation from Bellevue Hospital as 1948 (Petitioner's Exhibit No. 8). This birthdate and year of graduation are false. On or about January 19, 1978, Respondent filled out and submitted an application for employment as a nurse to Dr. P. Phillips Memorial Nursing Home, Orlando, Florida (Petitioner's Exhibit No. 9). That application reflected an incorrect birthdate of December 24, 1932 and reflected that Respondent attended Bellevue Hospital School of Nursing from 1945 to 1948. Respondent actually attended Bellevue Hospital from 1936 to 1939. During March, 1982, Respondent was employed as a registered nurse at Leesburg Regional Medical Center. Janet Gillespie Brown, also a registered nurse, was assigned to act as Respondent's preceptor during Respondent's orientation at Leesburg Regional Medical Center. As her preceptor Ms. Brown trained as well as supervised Respondent's work during her orientation period. During the time she was employed at Leesburg Regional Medical Center, the Respondent used improper procedures in attempting to insert a foley catheter into a female patient. in cleansing the meatus to remove bacteria the Respondent used a scrubbing technique rather than a wiping technique. This was improper antiseptic technique. The Respondent then attempted to insert the catheter by probing. This also was improper. Upon observing these improper techniques Janet Brown instructed Respondent to make no further attempts to insert the catheter and told her to wait whale she obtained a sterile foley kit which she would insert herself. Respondent did not do as she had been instructed and inserted the catheter after Nurse Brown left the patient's room to obtain the sterile foley kit. After Nurse Brown returned and discovered the catheter had been inserted against her instructions, she went outside the patient's room with Respondent and explained to her that the catheter she inserted was contaminated as a result of the probing. Respondent agreed and explained that she had not performed this procedure for awhile. The ability to properly insert such catheters is a basic nursing skill. No infection resulted from the improper insertion of the catheter by Respondent. Also while employed at Leesburg Regional Medical Center the Respondent failed to properly chart food intake of patients in that she charted each item of food consumed rather than charting percentages of food consumed as she had been instructed. Respondent also failed to properly chart the progress of a stroke patient by failing to chart that the patient had been making attempts to verbally communicate. The Respondent failed to properly organize her time, appeared unable to properly assess patient progress by asking appropriate questions and recording the patient's response, and failed to complete daily assignments such as bed baths and picking up food trays. Respondent did not feel capable of starting an IV (intravenous). Although starting an IV was not considered to be a skill required of Respondent by Leesburg Regional Medical Center, Respondent was unable to change the tubing on an IV and this was a skill expected of her. Respondent was also unable to give accurate counts of the remaining amount of solution in patients' IVs. On one occasion Respondent failed to properly chart the time of the doctor's visit and apparently "switched" the time. Respondent increased the IV flow for a patient as requested by the doctor, but charted the doctor's visit as having occurred later than the time at which she increased the IV. While working at Leesburg Regional Medical Center the Respondent failed to meet the minimal standards of acceptable and prevailing nursing practice. During the first part of February, 1982, Respondent was employed as a relief charge nurse at Sanford Nursing and Convalescent Center, Sanford, Florida. Ms. E. Jean King, R.N. was a charge nurse at Sanford Nursing and Convalescent Center and was assigned to assist in Respondent's orientation. While at Sanford Nursing and Convalescent Center, Respondent was observed by Ms. King to be very confused and very disorganized in her work. She could not remember patients' names and in passing out medications failed to medicate some patients. Then asked whether or not a particular patient had been given medication, Respondent became confused and indicated she could not remember whether or not the medication had been given. In taking a phone order from a doctor the Respondent wrote the wrong order on a sheet of paper and could not then remember what medication had in fact been ordered. This necessitated calling the doctor back and having the order repeated. Respondent also administered medications without first taking the pulse and blood pressure of the patient as required. Respondent required much more supervision than the other nurses under Ms. King's supervision. Respondent's performance and nursing practice at Sanford Nursing and Convalescent Center failed to meet the minimal standards of acceptable and prevailing nursing practice in Florida. On January 12 and January 27, 1980, Respondent as an employee of Medox, Inc., was assigned to Florida Hospital in Orlando, Florida. At the time she reported for work Respondent was informed by Ms. Ann Cottrell, R.N. (Head Nurse in Special Care at Florida Hospital) about what her responsibilities would be during her shift as team leader in the progressive care unit. The duties outlined to Respondent included responsibility for the administration of IV medications, antiequivalent drugs, insulin and any other specific procedures not within the job description of the licensed practical nurses. Respondent was also instructed that she was responsible for ordering IV medications that were to be administered for the next twenty-four (24) hours, that she was to make rounds with the physicians and observe and report the patients' conditions, and that at the end of the shift she was responsible for making certain that all charts were signed off, the doctor's orders were signed off, and any pertinent information included in the nurse's notes. During the course of the day Ms. Cottrell checked back with Respondent several times and asked if she understood her responsibilities and whether she was having any problems. Each time Respondent indicated that she knew what she was doing and had done it many times. During the course of the day the Respondent failed to make a complete report on the patients and as a result, the three to eleven shift was unable to determine what had happened during the day with regard to the patients for which Respondent was responsible. Medications had not been charted properly and many of the notes entered by Respondent were irrelevant to the patient's progress. Respondent also failed to insure that EKG strips for which she was responsible had been read. Ms. Cottrell, a registered nurse, was qualified to express an opinion as to the prevailing standards of nursing practice in Florida. She testified that in her opinion the Respondent was not qualified to work in an acute care area as a nurse and that her performance of her duties at Florida Hospital failed to meet the minimal standards of acceptable nursing practice in the State of Florida. This opinion is accepted by the Hearing Officer.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That the Respondent's license as a registered nurse be suspended for a period of three (3) months. It is further RECOMMENDED that upon completion of the three-month suspension period, Respondent be placed on probation for a period of one (1) year working only under the supervision of another licensed nurse and upon such other conditions as the Board may specify. DONE and ENTERED this 29 day of August, 1983, in Tallahassee, Florida. MARVIN E. CHAVIS Hearing Officer Department of Administration Division of Administrative Hearings Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 29 day of August, 1983. COPIES FURNISHED: Julia P. Forrester, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Arthur Baron, Esquire Attorney at Law 14 East Washington, Ste. 623 Orlando, Florida 32801 Helen P. Keefe, Executive Director Florida Board of Nursing Room 504, 111 East Coast Line Drive Jacksonville, Florida 32202 Frederick Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
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
The Issue The issue is whether Petitioner, Melvin Alston, is entitled to insurance coverage under the State of Florida Health Plan for services received at Miracle Hill Nursing Home.
Findings Of Fact Doris Alston, widow of Melvin Alston, is requesting payment for services rendered to Melvin Alston at Miracle Hill Nursing Home. Melvin Alston died on December 31, 1985. Melvin Alston, as a retired state employee, became eligible for coverage under the State Health Plan on July 1, 1985. He was a professor and dean at Florida A&M University from 1946 until 1969, when he retired. Thereafter he became a professor at Southern Illinois University, from which he retired in 1976. Alston was admitted to Tallahassee Memorial Regional Medical Center (TMRMC) in September, 1984, and was transferred to the extended care unit on September 20, 1984, because there were no available nursing home beds. On October 31, 1984, a bed became available at Goodwood Manor, a skilled nursing home facility, and Alston was admitted to Goodwood Manor from the TMRMC extended care unit. Alston remained at Goodwood Manor until August 22, 1985, when Mrs. Alston removed him and placed him at Miracle Hill Nursing Home. While at Goodwood Manor, Alston was receiving essentially custodial care. He had a routine diet and simply needed assistance with his activities of daily living, such as bathing and feeding. He was able to take his medications as they were given to him and he could leave the nursing home on a pass basis. While at Goodwood, Alston's medical orders were reviewed monthly and he was not seen daily by a physician. Alston received the same level of care at Miracle Hill Nursing Home. In skilled nursing facilities, the range of services needed and provided goes from skilled through intermediate levels to custodial. Skilled care includes such services as injections or intravenous medications on a daily basis which must be administered by a nurse. Dr. C. E. Richardson became Alston's physician at Miracle Hill Nursing Home. In the course of his deposition, Dr. Richardson testified that Alston received medical level care at Miracle Hill. However, Dr. Richardson stated several times that he did not know the level of care given to Alston under the definitions of the care levels available. He acknowledged that the levels of care ranged from skilled to custodial. Dr. Richardson also did not know the terms of the benefit document for the State Health Plan. Dr. Richardson only provided the medical care, which was the same no matter what level of nursing care he needed or received. According to Dr. Richardson, Alston was on a fairly routine diet, could engage in activities as tolerated, and could go out on a pass at will. One of Dr. Richardson's orders dated 11/27/85 shows that Dr. Richardson did not order a skilled level of care, but instead checked the level of care to be intermediate. Alston did not receive or need skilled nursing care at Miracle Hill. It is more appropriate to classify the level of care as custodial, as that term is defined in the State Health Plan Benefit Document. Alston's primary insurer was Blue Cross/Blue Shield of Illinois, based on coverage he had from his employment there. Blue Cross/Blue Shield of Illinois denied the claim for services at Miracle Hill because the services were custodial and were not covered by that plan. It also denied the claim because Miracle Hill's services did not fit its criteria for skilled nursing care. William Seaton is a State Benefits Analyst with the Department of Administration and his duties include assisting people who have a problem with the settlement of a claim with Blue Cross/Blue Shield of Florida, which administers the State Health Plan. After the claim was denied by Blue Cross/Blue Shield of Illinois, Mr. Seaton assisted Mrs. Alston by filing a claim under the State Health Plan. Blue Cross/Blue Shield of Florida concluded that no benefits were payable for facility charges at a nursing home and that an extended care or skilled nursing facilities would have limited coverage; however, because Alston was not transferred to Miracle Hill directly from an acute care hospital, no coverage existed. The pertinent provisions of the benefit document of the State Health Plan are as follows: I.G. "Custodial Care" means care which does not require skilled nursing care or rehabilitative services and is designed solely to assist the insured with the activities of daily living, such as: help in walking, getting in and out of bed, bathing, dressing, eating, and taking medications. * * * I.N. "Hospital", means a licensed institution engaged in providing medical care and treatment to a patient as a result of illness or accident on an inpatient/outpatient basis . . . and which fully meets all the tests set forth in ., 2., and 3. below: . . . In no event, however, shall such term include . . . an institution or part thereof which is used principally as a nursing home or rest for care and treatment of the aged. * * * I.AH. "Skilled Nursing Care" means care which is furnished . . . to achieve the medically desired result and to insure the insured's safety. Skilled nursing care may be the rendering of direct care, when the ability to provide the service requires specialized (professional) training; or observation and assessment of the insured's medical needs; or supervision of a medical treatment plan involving multiple services where specialized health care knowledge must be applied in order to attain the desired medical results. * * * I.AI. "Skilled Nursing Facility" means a licensed institution, or a distinct part of a hospital, primarily engaged in providing to inpatients: skilled nursing care . . . or rehabilitation services . . . and other medically necessary related health services. Such care or services shall not include: the type of care which is considered custodial . . . . * * * II.E. Covered Skilled Nursing Facility Services. On or after August 1, 1984, when an insured is transferred from a hospital to a skilled nursing facility, the Plan will pay 80% of the charge for skilled nursing care . . . subject to the following: The insured must have been hospital confined for three consecutive days prior to the day of discharge before being transferred to a skilled nursing facility; Transfer to a skilled nursing facility is because the insured requires skilled care for a condition . . . which was treated in the hospital; The insured must be admitted to the skilled nursing facility immediately following discharge from the hospital; A physician must certify the need for skilled nursing care . . . and the insured must receive such care or services on a daily basis; . . . 6. Payment of services and supplies is limited to sixty (60) days of confinement per calendar year. * * * VII. No payment shall be made under the Plan for the following: * * * L. Services and supplies provided by . . . a skilled nursing facility or an institution or part thereof which is used principally as a nursing home or rest facility for care and treatment of the aged. * * * N. any services in connection with custodial care . . . .
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Department of Administration enter a Final Order denying the request for benefits for services rendered to Melvin Alston at Miracle Hill Nursing Home. DONE AND ENTERED this 24th day of May, 1988, in Tallahassee, Florida. DIANE K. KIESLING 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 24th day of May, 1988. APPENDIX TO THE RECOMMENDED ORDER IN CASE NO. 87-4674 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on the proposed findings of fact submitted by the parties in this case. Specific Rulings on Proposed Findings of Fact Submitted by Petitioner, Melvin Alston 1 . Proposed findings of fact 1-3 and 5 are rejected as being subordinate to the facts actually found in this Recommended Order. Additionally, proposed findings of fact 3 and 5 contain argument which is rejected. 2. Proposed finding of fact 4 is irrelevant to the resolution of this matter. Specific Rulings on Proposed Findings of Fact Submitted by Respondent, Department of Administration Each of the following proposed findings of fact are adopted in substance as modified in the Recommended Order. The number in parentheses is the Finding of Fact which so adopts the proposed finding of fact: 1(1); 4(2); 5(2); 6(11); 8(11); 9(12); 10(3 & 4); 11(5); 12(4); 14(5); 15(7); 19- 21(8 & 9) 23(13); and 24(13). Proposed findings of fact 2, 3, and 16 are unnecessary. Proposed findings of fact 7, 13, 18, 26, and 27 are rejected as being irrelevant. Proposed findings of fact 17 and 22 are subordinate to the facts actually found in the Recommended Order. 2. Proposed finding of fact 25 is unsupported by the competent, substantial evidence. COPIES FURNISHED: James C. Mahorner Attorney-at-Law P. O. Box 682 Tallahassee, Florida 32301 Andrea Bateman Attorney-at-Law Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550 Adis Villa, Secretary Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550
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.
Findings Of Fact Petitioner became a Registered Nurse in 1965 and has been engaged in the nursing profession since that time. She was awarded a Bachelor of Science in nursing in 1975 from Florida International University and is presently enrolled in the masters of nursing degree program at the University of Miami. In 1973 Petitioner enrolled in the Primary Care Nurse Practitioner program at the University of Miami and successfully completed the six months program in December 1973. During this program she received 1,000 hours training. Upon completion of this training, Petitioner was eligible for licensure as an Advanced Nurse Practitioner but did not apply for registration at that time although she worked as a Nurse Practitioner immediately upon completion of the training. From January 1974 to March 1977 Petitioner worked at Jackson Memorial Hospital at Miami as an Advanced Family Nurse Practitioner. During this period she received actual instruction of approximately one hour per day for a total of some 710 hours in duties of Nurse Practitioner in addition to the daily experience gained working as a Nurse Practitioner. In 1977 Petitioner moved to Colorado where she worked as a Nurse Practitioner from October 1977 until April 1978 for the Rocky Mountain Planned Parenthood organization and the Mountain Community Medical Clinic. In the latter position she manned a clinic that was some 30 to 40 miles from the nearest doctor and communicated with the doctor by telephone in diagnosing and treating patients. She worked some 348 hours in this position. Additionally, Petitioner taught in the Nurse Practitioner program at the University of Colorado one to three days per week from January until May 1978. Upon Petitioner's return to Florida in May 1978 she applied for licensure as an Advanced Nurse Practitioner and was denied licensure because the regulations were changed effective March 31, 1978, to require a one-year educational training program in lieu of the six months program completed by Petitioner. The current approved program at the University of Miami provides some 1,105 hours of training similar to the training Petitioner obtained at the earlier course.
Findings Of Fact At all times material hereto, Anthony Martin, Respondent, has been a licensed practical nurse with license number PN 0727851 whose last known address is 4041C N.W. 16th Street, Apartment 109, Fort Lauderdale, Florida 33313. Respondent was contacted at said address by an investigator employed by Petitioner in May, 1984 and he has not notified Petitioner of any change of address. Although notice of the final hearing was duly sent to Respondent at his last known address, he did not appear. Respondent was employed at St. John's Nursing and Rehabilitation Center as a licensed practical nurse from November 30, 1983 until March 8, 1984. During the course of his employment on January 9, 1984 Respondent received a warning notice and a one-day suspension from the Director of Nursing due to a complaint by a coworker who smelled alcohol on his breath while on duty. Respondent's supervisor also smelled alcohol on his breath on that date. Respondent was interviewed by the Director of Nursing who testified that he admitted to having a drinking problem. She referred him to an impaired nurse program for assistance with his drinking problem but he never attended the program. It is contrary to good nursing practice, and is also contrary to the employment policies and standards of St. John's Nursing and Rehabilitation Center to report for duty as a nurse after having consumed alcohol to the extent that it can be smelled on one's breath. Nancy Cox an expert in nursing education testified that such conduct was unprofessional and below minimum nursing standards since the use of alcohol impairs a nurse's ability to respond to nursing care emergencies and to exercise sound nursing judgment. Cox also testified that an indication of an alcohol problem was a belligerent and uncaring attitude in dealing with patients. Respondent's employment records contain complaints from patients about his hostile and uncaring attitude while on duty. On February 7, 1984 Respondent received a second warning notice concerning his lack of proper care to a tracheostomy patient which resulted in a medical emergency. Respondent was on the 3:00 p.m.-11:00 p.m. shift at the time. During his shift, a nurse's aide asked Respondent to assist a tracheostomy patient on two occasions. Respondent looked in on the patient but did not administer suction or any other care. On a third occasion the aide asked Respondent to care for the patient and he did not even look in on the patient. Before leaving the floor at 11:30 p.m. after her shift, the same aide again looked in on the tracheostomy patient and saw that the patient was in distress and in immediate need of care. The aide got her supervisor who found that the patient was blue. Attempts to clear the air passage with suction were unsuccessful, and the patient had to be transferred to a hospital for emergency care. The expert in nursing education, Nancy Cox, testified that Respondent's actions in dealing with this patient were unprofessional and below minimum standards. Cox explained that a tracheostomy patient cannot verbalize his need for care so extra attention must be paid to patient needs by the nurse on duty, particularly for blockages of the airway. Each occasion when Respondent simply looked in on the patient but failed to administer suction, and the one occasion when he totally ignored this patient's needs constituted unprofessional conduct, in Cox's opinion. Petitioner presented evidence of a third incident on February 25, 1984 involving a diabetic-patient and the care rendered to said patient by Respondent which resulted in a third warning notice against Respondent. The diabetic patient vomited around 7:30 p.m. and lapsed into a coma at 9:10 p.m. Respondent did not check this patient's blood sugar level after the vomiting, which he should have according to Cox, nor did he call this to his supervisor's attention. The parties were allowed to submit proposed findings of fact after the hearing pursuant to Section 120.57(1)(b)4, F.S., and a ruling on each proposed finding that was submitted has been made in this Recommended Order, either directly or indirectly, except where proposed findings have been rejected as subordinate, immaterial, unnecessary, irrelevant or unduly repetitious.
Recommendation Based upon the foregoing, it is recommended that a Final Order be issued revoking Respondent's license but providing that he may apply for reinstatement if, within one (1) year from the issuance of the Final Order Respondent submits to, and successfully completes an impaired nurse program to be designated by the Department of Professional Regulation and Hoard of Nursing at his own expense. DONE and ENTERED this 24th day of June, 1985 at Tallahassee, Florida. DONALD D. CONN, 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 24th day of June, 1985. COPIES FURNISHED: Edward C. Hill, Jr., Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Anthony Martin 4041C NW 16th Street Apartment 109 Fort Lauderdale, Florida 33313 Judie Ritter, Executive Director Board of Nursing 111 East Coastline Drive, Room 504 Jacksonville Florida 32202 Fred Roche Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 Salvatore A. Carpino, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee Florida 32301
