The Issue Should discipline be imposed by Petitioner against Respondent's license to practice as a licensed practical nurse (L.P.N.)?
Findings Of Fact Findings Established by Request for Admissions: Petitioner is the State of Florida department charged with regulating the practice of nursing pursuant to Section 20.43, Florida Statutes, Chapter 456, Florida Statutes, and Chapter 464, Florida Statutes. Respondent is and has been at all time material to the complaint a L.P.N. in the State of Florida, having been issued license number 9246217. Respondent's address of record is Post Office Box 99, High Springs, Florida 32655-0099. At all times material to this case, Respondent was employed as a L.P.N. by Suwannee Home Care and Medical Personnel, a staffing agency. At all times material to this case, Respondent was assigned to work as a L.P.N. at Alachua Nursing and Rehabilitation in Gainesville, Florida (Alachua). At all times material to this case, Alachua in Gainesville, was a licensed rehabilitation facility as defined in Section 400.021(13), Florida Statutes. At all times material to this case, Patient E.D. was admitted to Alachua (having been admitted) on June 20, 2003, with a diagnosis of status post CVA (stroke). On or about June 21, 2003, Respondent was assigned to care for E.D. on the 3 to 11 p.m. shift, and at the end of the shift, Respondent reported to the oncoming nurse that he assisted with the care of E.D. and that E.D. was okay and in no acute distress. Respondent's nurse's notes regarding the care he provided to patient E.D. do not mention whether he suctioned the tracheostomy care being provided; and do not contain any physical assessment of the patient. Respondent should have performed and documented tracheostomy care, including but not limited to frequency of suctioning, amount of color of sputum suctioned, cleaning of the tracheostomy device, oral hygiene, and method of communication with the patient. Respondent should have performed and documented a physical assessment of the patient that included respiratory rate and effort, color, pulse rate, and exertional level. Respondent should have monitored and followed up on patient E.D.'s vital signs. Additional Facts: Alice Bostick, is a Medical Malpractice Investigator for Petitioner. She was involved in the investigation leading to the drafting of the Administrative Complaint. As part of the process she attempted to notify Respondent of the allegations made against him. On July 15, 2003, she sent a letter of notification to Respondent at an address obtained from a printout of license information associated with Respondent. That address was 13134 North 22nd Street, Apartment 109, Tampa, Florida 33612. The information sent to Respondent was a Uniform Complaint Form and a Nursing Home Adverse Incident Report. The information sent to Respondent was returned as undeliverable and not subject to forwarding, absent a forwarding request made from Respondent to the U.S. Postal Service. Having failed to notify Respondent at the Tampa address, Ms. Bostick took advantage of access which the Petitioner has to the Florida Department of Highway Safety and Motor Vehicles records to locate Respondent's address maintained by the other state agency. The address provided by the other agency was Post Office Box 99, High Springs, Florida 32655-0099. This was the proper address. Utilizing the new address, the same information was dispatched a second time from Petitioner to Respondent. This time it was not returned as undelivered. Instead Respondent contacted Petitioner's office in person and by his remarks made it known that he received the communication from Petitioner concerning the investigation. At times relevant to this case Respondent worked for the Suwannee Valley Nursing Agency. That agency assigned him to work on a shift at Alachua, now the Manor of Gainesville. On June 21, 2003, Respondent worked the 3:00 p.m., to 11:00 p.m., shift at Alachua. One of the resident's in his care at that time was E.D. Resident E.D. was born on May 18, 1920. She had been released from the hospital on June 20, 2003, and transferred to Alachua. She was receiving oxygen. Physician's orders called for tracheostomy care (trach care) to be administered "Q 6 hours." She had a catheter which was last changed on the date of her release from the hospital. The order indicated that the catheter should be changed every Friday beyond that point. The resident was being fed by tube. As Respondent describes it, E.D. was among 30 patients in his care on the shift. Other residents included persons with G-tubes and insulin-dependent diabetics. Respondent was very busy during his shift helping the residents. Another staff member at the nursing home reminded the Respondent that he needed to suction E.D's trach. At some point in time Respondent and the other staff member suctioned the trach. When this function was performed during the shift is not established in the nursing home record pertaining to resident E.D., as that record was presented at the hearing. Therefore it was not shown an entry was made in the resident's record for care confirming the suctioning of the trach. The only reference to patient E.D. made in writing by Respondent presented at hearing, was from nursing notes related to resident E.D. In the nurse's note Respondent made an entry at the end of his shift as to vital signs for the resident, pulse rate 92, respiration rate 24 and a notation that Respondent "Assisted e-care no acute distress noted." Contrary to the nurse's note made by Respondent, resident E.D. was in distress as discovered by Gloria Brown, L.P.N., who came on shift to work from 11:00 p.m. June 21, 2003, until 7:00 a.m. June 22, 2003. Ms. Brown was familiar with the need to suction a trach and to make appropriate entry in the nursing notes in caring for a trach patient. Notes are also made in relation to oxygen saturation for that resident if a doctor's order calls for that entry. Ms. Brown properly expected the prior shift nurse to notify her concerning the resident's condition as to the number of liters of O2 provided the resident and if the resident had a fever. If the resident had a Foley catheter placed reference would be made to that circumstance. Generally if the resident was experiencing a problem, Ms. Brown would expect the outgoing nurse to mention that fact. On June 21, 2003, at 11:45 p.m., as Ms. Brown described in the nursing notes, "On first rounds observed resident E.D. with shallow breathing, skin color grayish, O2 on a 2 liter per trach mask. Attempt to suction, felt resistance. Sat. 24. O2 increased to three liters. Able to palpate pulse. 911 was called. Transported to Shands at UF via 911. Respiratory distress." Resident E.D. was transported to Shands Hospital at 12:00 midnight. When resident E.D. was transported to the hospital she was experiencing respiratory distress. She had a baseline level of consciousness in the alert range. Petitioner presented an expert to comment on Respondent's care rendered resident E.D. in the context of the allegations set forth in the Administrative Complaint. That expert was Meiko D. Mills, R.N., M.N.S., A.R.N.P. Ms. Mills is licensed to practice nursing in Florida. She has a business that involves the preparation for graduates of L.P.N. schools and R.N. schools to take the National Licensing Examination for those fields. Ms. Mills is familiar with trach care. She has had occasion to write nursing notes pertaining to trach care. She is generally familiar with the requirements for nursing notes in the patient record concerning any form of patient care rendered by the nurse practitioner. She was recognized in this case as an expert in the field of nursing related to patient care and L.P.N.s. In providing trach care, Ms. Mills refers to the need for a sterile environment and the part of the trach device that she refers to as a tube, requires a lot of cleaning because of secretions from the patient. She describes the fact that the trach device will form a crust. As a result the center portion of the device sometimes has to be taken out and soaked in sterile water to clean it. The suctioning process associated with trach care involves the use of a suctioning machine in which all the encrustations and saliva are removed. It is possible for a hard mucus plug to form if suctioning is not done appropriately, according to Ms. Mills. Ms. Mills expressed her opinion concerning Respondent's care provided resident E.D., as to a reasonable degree of certainty and whether Respondent met the minimal standards for acceptable and prevailing care and treatment of E.D. She described that care as lacking. Ms. Mills comments that the nursing note that was made by Respondent at the end of his shift was inadequate in describing the kind of care provided to the resident. In particular she describes the lack of reference to the trach issue and the oxygen saturation issue. She perceives that E.D. required considerable attention and that attention is not reflected in the nursing note. As a person responsible for providing care to E.D., who had a trach, Ms. Mills refers to the need for the Respondent to establish a baseline at the beginning of the shift. That baseline is constituted of vital signs and oxygen saturation, as well as a basic assessment of the resident. There was the need to compare the vital signs assessment to the shift before Respondent came on duty to gain an impression of any trends. The observations by Respondent should have been documented in nursing notes beginning with the baseline as to vital signs, oxygen saturation, reference to the condition of the trach, respiratory effort and so forth, and there was the need to go back and reassess over time. As Ms. Mills explains the resident's condition was reaching an abnormal state on the shift before. Without entries concerning the resident's condition, the assumption is made by Ms. Mills, that the patient care and in particular trach care was not performed by Respondent. Ms. Mills refers to a normal pulse rate as 80 to 100, but Ms. Mills cautions her students that a pulse rate close to 100 bears watching. A respiration rate approaching the highest normal demands attention. Anything above that creates concern. Higher readings tend to manifest themselves with shallower breathing by patient at more frequent intervals, given the body's attempt to compensate for a lack of oxygen. To address this condition a baseline oxygen saturation should be established at the beginning of a shift to help set a plan of care. A resident such as E.D. with a pulse rate of 97 and respiration rate of 24 is a person who needs to be closely monitored. There was no record by Respondent reflecting the establishment of monitoring to address these circumstances. The resident's progress should have been noted as to pulse rate and respiration rate several times during Respondent's shift, as Ms. Mills perceives it. Respondent should have also notified the oncoming nurse for the following shift that the patient was not doing well. This was not done. Overall, Ms. Mills feels that Respondent was deficient in his documentation concerning resident E.D. through the nursing notes. The general comment by Respondent that he assisted with care is not sufficient to establish that trach care was performed in Ms. Mills opinion. According to Ms. Mills, some of the vital signs reflected in the resident's record would create the possibility that they were in relation to a mucus plug in the trach. When the Resident E.D. was transported from the nursing home on June 21, 2003, at 11:30 the oxygen saturation at that time was 78 percent and her pulse was 159. In Ms. Mills opinion those values represented the fact that the resident was in distress. Ms. Mills believes that Respondent engaged in unprofessional conduct by acts of omission. Ms. Mills compared the nursing notes made by Respondent to those made by nurses on the prior two shifts at the nursing home. The prior notes were described as good notes talking about the care, while Ms. Mills did not get the same feeling about the notes made by Respondent. Ms. Mills compared the circumstances when Respondent came on shift when resident E.D. had a pulse of 100 and respiration rate of 20 and the change from the respiration of 20 to the respiration rate of 24 at the end of the shift, as indicating that the resident had shallow compensatory respiration because of a lack of oxygen. This leads Ms. Mills to the conclusion that the vital signs look worse and the person was significantly compromised over the day. Whether this circumstance was brought about by the formation of a plug due to a lack of trach care, Ms. Mills is not certain, but the vital signs indicate that the resident was sufficiently compromised to alert a health professional to that possibility. Earlier in the day the resident had a respiration rate of 28 and a pulse of 110. The change in those values over time up through the Respondent's shift did not indicate improvement in resident's condition in Ms. Mills' opinion. Ms. Mills' opinions that have been described are accepted. Based upon the facts found and Ms. Mills' expert opinion, Respondent failed to meet minimal standards of acceptable and prevailing nursing practice in the care provided resident E.D.
Recommendation Upon consideration of the facts found and the conclusions of law reached, it is RECOMMENDED: That a final order be entered finding Respondent in violation of those provisions of law set forth in Counts One through Three, calling for a written reprimand for those violations, imposing an administrative fine of $500.00, and placing Respondent on probation for a period of two years. DONE AND ENTERED this 24th day of May, 2005, in Tallahassee, Leon County, Florida. S CHARLES C. ADAMS 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 24th day of May, 2005. COPIES FURNISHED: Judith A. Law, Esquire J. Blake Hunter, Esquire Department of Health 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 Harvey J. Price Post Office Box 99 High Springs, Florida 32655 Dan Coble, Executive Director Board of Nursing Department of Health 4052 Bald Cypress Way Tallahassee, Florida 32399-1701 R. S. Power, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
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
Findings Of Fact The Respondent, Cindy Louise Jirak, was licensed as a Registered Nurse pursuant to Florida law on May 14, 1979. Her license was last actively renewed to May 30, 1983, and now is in a lapsed status. P. Ex. 1. The Respondent was employed as a licensed Registered Nurse at the Central Florida Regional Hospital in Sanford, Florida, during the six month period up to and including October, 1986. On July 8, 1986, the Respondent was on duty as a licensed Registered Nurse and improperly set up intravenous fluids for a patient. The Respondent set up a previously ordered fluid, stating that the currently ordered fluid was not available. The correct procedure when a currently ordered fluid is not available is to hang a normal saline solution. By hanging the previously ordered solution, the Respondent's procedure was below minimally acceptable nursing practice. On October 6, 1986, the Respondent failed to turn on an intravenous solution pump after hanging an intravenous solution. The patient, therefore, did not receive the fluid that had been hung. The Respondent's action in failing to turn on the pump on October 6, 1986, was below minimally acceptable nursing practice. On August 23, 1986, the Respondent signed out 10 milligrams of morphine (one ampule) to be administered to a patient. Only 6 milligrams had been ordered for that patient. The procedure is to waste the excess before the narcotic is administered, and to have that act of wasting witnessed. The "waste and/or destroyed narcotic disposition record" shows that 4 milligrams were properly wasted since only 6 milligrams had been ordered for this patient. The records show that the 6 milligrams were then refused by the patient, but there is no subsequent entry to show that the 6 milligrams of morphine were properly wasted by the Respondent. The Respondent's failure to record the wasting of the 6 milligrams of morphine on August 23, 1986, was below minimally acceptable nursing practice. On August 22, 1986, the Respondent left two doses of Bumax in her cart with no explanation as to why the medication was not given. She was responsible for administration of that medication to a patient under her care, and the medication had been ordered for the patient. The medication was not given to that patient as ordered on that evening, and the Respondent did not make an entry in the records that the medication had not been administered. The Respondent's failure to administer the prescribed medication, or to chart that failure to do so, is below minimally acceptable nursing practice.
Recommendation It is recommended that the Department of Professional Regulation, Board of Nursing, enter its final order suspending the registered nursing license of Cindy Louise Jirak for a period of two years. DONE and ENTERED this 31st day of August, 1987. WILLIAM C. SHERRILL, JR. Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 31st day of August, 1987. COPIES FURNISHED: Judie Ritter, Executive Director Board of Nursing Department of Professional Regulation Room 504, 111 East Coastline Drive Jacksonville, Florida 32201 Van Poole, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Joseph Sole, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 John Namey, Esquire 22 East Pine Street Orlando, Florida 32801 Cindy Jirak 2718 Dellwood Drive Eustis, Florida 32726 =================================================================
Recommendation That no disciplinary action be taken against respondent Jesus B. Mayor. DONE and ENTERED this 1st day of September, 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 1005 Blackstone Building Jacksonville, Florida 32201 A. M. Schwitalla, Esquire Suite 102, 1333 Coral Way Miami, Florida 33145 Geraldine B. Johnson, R.N. State Board of Nursing 6501 Arlington Expressway - Bldg B Jacksonville, Florida 32211
Findings Of Fact Respondent, Carol O'Donnell (O'Donnell), was at all times material hereto licensed as a registered nurse in the State of Florida, and held license number 1498442. On May 15, 1986, O'Donnell was employed as a registered nurse at Broward General Medical Center, Broward County, Florida, on the 3:00 p.m. to 11:00 p.m. shift. At or about 7:30 p.m., O'Donnell abandoned her employment, without notice or authorization, and thereby left her patients unattended. Although the period that elapsed between the time O'Donnell abandoned her position and the time her absence was discovered was apparently of short duration and there was no proof any patient suffered from her absence, her conduct constituted a departure from and failure to conform to the minimum standards of acceptable and prevailing nursing practice in the community.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Respondent, Carol O'Donnell, be reprimanded, and that an administrative fine of $500.00 be imposed upon her. DONE and ENTERED this 20th day of August, 1987, in Tallahassee, Florida. WILLIAM J. KENDRICK 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 20th day of August, 1987. APPENDIX Petitioner's proposed findings of fact are addressed as follows: 1. Addressed in paragraph 1. 2-4. Addressed in paragraph 2. 5. Addressed in paragraph 3. COPIES FURNISHED: William M. Furlow, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Ms. Carol O'Donnell 109 North Birch Road, #4 Ft. Lauderdale, Florida 33312 Judie Ritter, Executive Director Board of Nursing 111 East Coastline Drive Room 504 Jacksonville, Florida 32201 Van Poole, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750 Joseph A. Sole General Counsel Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32399-0750
The Issue Whether the Respondent committed the acts attributed to her and whether such acts constitute a violation of the statutes and rules.
Findings Of Fact Carolle L. Baya is a licensed lay midwife holding a license issued by the Petitioner. Exhibit 1 is a composite of certified copies of birth certificates of babies at whose births Ms. Baya attended. Ms. Baya was very late on over 17 occasions in initiating the registration of the birth of a child whom she had delivered. On two additional occasions, she was so late that a delayed certificate of birth had to be prepared. Frances Friedl was seen by Dr. Sudesh Metah, M.D., at the hospital on April 9, 1988, at 8:30 a.m., for delivery of her first baby. She had been admitted through the emergency room and referred to obstetrics where Dr. Metah was the on-call doctor. When initially seen at the hospital, Ms. Friedl was in active labor. From the admission notes prepared by the labor and delivery nurse, Ms. Friedl started labor between 5:00 and 6:00 p.m. on April 8, 1988; and her water broke about 12:30 a.m. on April 9, 1988. Ms. Baya stated to Dr. Metah when Ms. Friedl was admitted that she had done a pelvic examination at 3:30 a.m. and had determined that Ms. Friedl was in second stage labor. The patient confirmed this information. Although Ms. Friedl had been and was pushing, the birth of the baby had not and was not progressing. At 8:30 a.m. when the doctor saw her, she was fully dilated and the baby had not descended into the birth canal. Ms. Friedl had remained in second stage labor over four hours before admission to the hospital. Dr. Metah considered two (2) hours of second stage labor long enough, with medications, epidural anesthesia, and with progress towards delivery by the patient. Dr. Metah considered three (3) hours to be the maximum for a woman to remain in second stage labor without medical intervention. Dr. Metah had to rotate the baby, who was in a vertex posterial presentation, in order for the baby to be delivered. The baby was a female, 7 pounds, 5-1/2 ounces, with Apgars of 9-10 or 9-9. 1/ She was born 1-1/2 hours after the mother's admission to the hospital. The baby was delivered as soon as possible at the hospital. Ms. Baya did not transport Ms. Friedl to the hospital until four hours after Ms. Friedl was fully dilated and in second stage labor. Annette Louise Zivkovic was admitted to Memorial Medical Center emergency room with obstetric complications in active labor. Her physician, Dr. Sager, was present when she was admitted. Ms. Baya, her midwife, was also present when Ms. Zivkovic was admitted. Admission notes state that Ms. Baya assisted the patient for three hours but that the patient was unable to deliver. Dr. Sager was present at admission and performed a vaginal examination. He determined that Ms. Zivkovic was dilated to "Station 4." The patient stated that she was very scared and her arms and legs were stiff when she had contractions. The patient was unable to push effectively and assist in delivery. The admission notes indicate she was in active labor three hours before being taken to the hospital. The Labor and Delivery Summary indicates that the patient was admitted at 4:25 p.m. on January 2, 1989. She was delivered at 4:41 p.m. She had been in labor since 1:00 p.m. There is no evidence that Ms. Baya knew that Ms. Zivkovic was staining or that she did not have Ms. Zivkovic assessed. The Petitioner's expert midwife, Ms. Richter, testified. A delay of over two hours in referring a patient who was in active labor and had not delivered was unprofessional conduct. Karen Evans was admitted to the hospital via the emergency room and delivered by C-section by Dr. Wooden because the baby was in fetal distress. When delivered, the baby's head was molded into the pelvis. A bad odor from the uterus indicated interuterus infection. Ms. Evans had a high white blood count which was consistent with an infection. Ms. Evans reported to the doctor that she had been leaking fluid for two weeks. Ms. Evans was admitted to the hospital by the emergency squad, who had been requested by Ms. Baya. The doctor stated that the midwife called the medical squad when she realized that she had a complicated patient in labor with fetal distress. Ms. Evans' labor-began at 10:30 a.m., according to Ms. Baya's reports to the patient; and Ms. Evans was admitted to the hospital at 10:30 p.m. for emergency delivery of the baby by C-Section. The baby was delivered approximately 1-1/2 hours later, at 11:57 p.m. The Petitioner's medical expert's opinion was that Ms. Evans should have been referred when it was determined that her water was leaking and should have been referred to the doctor long before she had been in active labor for 12 hours. There was no evidence that Ms. Baya knew or should have known that Ms. Evans was leaking ambiotic fluid. The baby's head being molded into the pelvis is a sign of prolonged labor. There is evidence that Ms. Baya knew that Ms. Evans had been in active labor for over 12 hours. There is no evidence that Ms. Baya knew that Ms. Evans had unexplained vaginal bleeding. There was no credible evidence that Ms. Baya failed to do metabolic screening on M.K. 2/ failed to provide accurate information on the birth certificate of M.K.'s child; or provided care to M.K., who was at high risk.
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: The Petitioner revoke the license of the Respondent; and The Petitioner suspend the revocation upon demonstration by Ms. Baya that she has taken refresher courses in midwifery and can practice safely and in accordance with all applicable statutes and rules. DONE AND ENTERED this 17th of February, 1992, in Tallahassee, Leon County, Florida. STEPHEN F. DEAN 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 17th day of February, 1992.
The Issue exceptions to this Recommended Order should be filed with the agency that will issue the final order in this case.
Findings Of Fact 1 At all times relevant to the inquiry Respondent has held license no. PN 12946-1 issued by the Board of Nursing in Florida. Petitioner is empowered to discipline that license if Respondent is shown to have violated her responsibilities as a nurse practitioner. Disciplinary action is taken in accordance with Chapter 464, Florida Statutes. Respondent had been referred to Memorial Medical Center a Jacksonville, Florida, hospital to work as a nurse on the 3:00 p.m. to 11:00 p.m. shift of April 9, 1988. This referral was from Consolidated Staffing and Home Health Services, a division of St. Vincent's Health Care System. Jacqueline L. Cumbie who is a registered nurse in Florida and a certified nursing administrator and the administrator and director of the nurses for the referring group was responsible for coordinating the assignment of this nurse. The referral here was consistent with that process. When Respondent reported for work at the hospital she was given a brief orientation by Debra Ellen Bearup, the staff R.N. on the floor where Respondent was assigned. That floor was Two Central, a surgical floor. The orientation included the location on the floor where materials could be found that the Respondent would need to carry out her duties to include an explanation about the medication room, supply room, an explanation of patient charts and the nursing flow sheets where the Respondent would have to do her charting and an indication of where the medications were being held that would have to be administered by the Respondent. In fulfilling this role Ms. Bearup was acting as the charge nurse. The assignment that Respondent had was to care for five patients in rooms 205, 209, 210, 214 and 215. The duties Respondent had with those patients was to assess the patients and to provide them with a level of care that they were supposed to be afforded to include monitoring vital signs, doing cepho-caudal assessment, administering medications, recording anything unusual that transpired and in general caring for the patients. Ms. Bearup's shift began at 7:00 a.m. on that date and ended at 7:00 p.m. Ms. Bearup was not at the hospital when the Respondent left the hospital. Ms. Bearup was not aware of any problems that the Respondent was experiencing in carrying out her duties while Ms. Bearup was in attendance with Respondent at the hospital. At times Ms. Bearup would approach the Respondent and state "are you doing o.k., are there any questions, are you running into anything that you do not understand." Respondent would reply that she was "doing fine." The contact between Ms. Bearup and the Respondent did not include any attempt on the part of Ms. Bearup to verify the treatment provided by Respondent for the benefit of the patients assigned to the Respondent such as looking at the patient charts. Ms. Bearup took the Respondent's word for the fact that things were proceeding as they should. Subsequently, Ms. Bearup did examine the charts of the patients that Respondent was responsible for and discovered that the patient in Room 205 had not had vital signs taken as called for and that Respondent had failed to administer antibiotics at 5:00 p.m. Ms. Bearup also discovered that the patient in Room 209 had not had vital signs taken at 4:00 p.m. and 8:00 p.m. and that medication was not given at 5:00 p.m. for that patient. Related to the patient in Room 209, Ms. Bearup found that the Respondent had not completed charting for the patient. Concerning the patient in Room 210, Ms. Bearup found that the Respondent had failed to take the patient's vital signs at 4:00 p.m. and 8:00 p.m. and had failed to complete the charting on the patient. Concerning the patient in Room 214, Ms. Bearup found that the Respondent had failed to take the patient's vital signs at 4:00 p.m. and 8:00 p.m. and had failed to complete the patient's charting. Concerning the patient in Room 215, Ms. Bearup discovered that the Respondent had failed to complete the charting on this patient. In all instances referred to Respondent was aware of her obligations. Ellen Lederman was a staff nurse who came on duty at 7:00 p.m. April 9, 1988 and whose shift was to end at 7:00 a.m. on April 10, 1988. After Ms. Lederman came on duty she had contact with the Respondent and the Respondent became tearful with complaints of pain in her knees and that she was very tired. Ms. Lederman and Katherine Mitchell, another nurse working on the floor at that time, Ms. Mitchell being since deceased, asked the Respondent if she wanted to go home. The Respondent told them that she would like to go home and the nursing supervisor was called and permission was granted to the Respondent to leave her duties at the hospital. Respondent left shortly after 9:00 p.m. Nurse Cumbie who was accepted as an expert in nursing practice gave the opinion that the performance by Respondent did not meet minimal standards for nursing practice related to the oversights in the patient care that have been previously described.
Recommendation Based upon the findings of fact made and the conclusions of law reached, it RECOMMENDED: That a Final Order be entered which dismisses the Administrative Complaint. DONE and ENTERED this 24th day of February, 1992, in Tallahassee, Florida. CHARLES C. ADAMS, 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 24th day of February, 1992. APPENDIX TO RECOMMENDED ORDER The following discussion is given concerning the proposed facts of Petitioner: The first 10 paragraphs in the proposed fact finding and paragraphs 12 through 14 are subordinate to facts found. Paragraph 11 is not necessary to the resolution of the dispute. COPIES FURNISHED: Roberta Fenner, Esquire Department of Professional Regulation 1940 North Monroe Street, Suite 60 Tallahassee, FL 32399-0792 Olean S. McCall Johnson 12929 Mandarin Point Jacksonville, FL 32223 Jack McRay, Esquire Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Judie Ritter, Executive Director DPR Board of Nursing 504 Daniel Building 111 East Coast Line Drive Jacksonville, FL 32202
The Issue Whether petitioner should take disciplinary action against respondent for the reasons alleged in the administrative complaint?
Findings Of Fact Respondent holds a registered nurse's license, No. RN 1992962, and has at all material times. In May of 1989, as an employee of Kimberly Nurse Travelers, an agency with whom Bay Medical Center had contracted for his services, he worked as a nurse at Bay Medical Center in Panama City, Florida. While working the night shift as the triage nurse on May 12, 1989, respondent helped himself to a Darvocet N-100, a pill he ingested 20 minutes later. At the time and at hearing under oath, he said he took the pill because he had a headache. Darvocet is a prescription drug, and respondent had no prescription for it. But petitioner's own witness conceded that Darvocet "is not considered a drug of choice for people that have a problem with drugs" (T.61) and should not, in the dosage respondent took, "impair someone's judgment and ability to perform." T.66. A co-worker reported respondent, who was in plain view when he took the pill from the cart. Later the night of May 12, 1991, at the behest of supervising personnel, respondent supplied a urine specimen, which tested positive for benzodiazepine, possibly the residue of the 15-milligram Dalmane tablet respondent took the night before, when he was off duty. Respondent's co-workers who testified found no fault with his performance as a nurse, this incident aside. But theft of the Darvocet pill, and its ingestion on duty without a prescription, violated hospital policy and fell below the minimal standards of acceptable and prevailing nursing practice.
Recommendation In the absence of aggravating or mitigating circumstances, Rule 21O- 10.011(2)(j), Florida Administrative Code, authorizes penalties for infractions of Rule 21O-10.005(1)(e), Florida Administrative Code, of reprimand, fine, probation and/or suspension. Nothing was proven in aggravation. In mitigation, it was shown that this was a first offense, apparently an isolated occurrence. It is, accordingly, recommended that petitioner reprimand respondent, and levy an administrative fine against him in the amount of five hundred dollars ($500). RECOMMENDED this 13th day of August, 1991, in Tallahassee, Florida. ROBERT T. BENTON, II 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 13th day of August, 1991. COPIES FURNISHED: Judie Ritter, Executive Director Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, FL 32202 Jack McRay, General Counsel Department of Professional Regulation 1940 N. Monroe Street Tallahassee, FL 323990-0792 Tracey S. Hartman, Esquire 1940 North Monroe Street Tallahassee, FL 32399-0792 Carol C. Murphy, Esquire Post Office Box 1084 Lakeland, FL 33802
The Issue The issues concern allegations set forth in an administrative complaint brought by the Petitioner against the Respondent alleging violations associated with the Nurse Practice Act. See Chapter 464, Florida Statutes.
Findings Of Fact According to the official records held by the State of Florida, Department of Professional Regulation, Respondent holds license no. RN38437-2, which lapsed on March 31, 1989. On that date the license became inactive as envisioned by Section 464.013, Florida Statutes. Karen Gushlaw, a resident of Ocala, Florida, went to a business in that same community known as Cardio-Check, Inc. Ms. Gushlaw and her mother had decided to go there to have physical examinations made. This was based upon an advertisement which the mother had seen in the phone book or the newspaper which advertisement had a coupon associated with it. Once at the Cardio-Check, Inc. premises, Ms. Gushlaw met Ralph McCawley. He introduced himself as Ralph McCawley. He did not indicate his professional position by describing what that position was. The only other person in the building at that time was a secretary. Ms. Gushlaw was taken into an examining room. Respondent conducted a medical history asking questions about Ms. Gushlaw's family. Respondent then left the room and he gave a paper robe to Ms. Gushlaw and told her to take off her shirt and bra and that he would be back. Respondent returned and in the presence of the secretary did a breast examination. He had Ms. Gushlaw sit up on a table and he did a circulation test. He tested her fingers and toes. He took Ms. Gushlaw's blood pressure. He conducted an E.K.G. Respondent told Ms. Gushlaw that the E.K.G. was fine and that she looked fine and healthy but that she needed to lose weight. While at this business premises Ms. Gushlaw gave a urine sample. Respondent sent Ms. Gushlaw to another premises known as the Physicians Lab to have a blood test done. Given that the urine sample that was presented at the office showed blood in it, Ms. Gushlaw went back a week and a half later to give another urine sample. That sample did not show the presence of blood. During the first visit to Respondent's office he never told Ms. Gushlaw what credentials or professional licenses he held. On that date no one in the premises identified themselves as either a registered nurse or a licensed physician. Margaret Hunt is an Investigator for the State of Florida, Department of Professional Regulation. Acting on a complaint Ms. Hunt was assigned to make contact with the Respondent at Cardio-Check, Inc. to ascertain his activities as they pertain to that organization. Ms. Hunt's initial contact with Cardio-Check, Inc. was by telephone in response to a yellow page advertisement in the Ocala, Florida telephone directory. A copy of the advertisement that she saw in arranging for the telephone call may be seen as Petitioner's Exhibit No. 2 admitted into evidence. She used the telephone number provided and would eventually go to the address indicated in that advertisement. When Ms. Hunt made her call a male voice answered the phone. She stated that she was making the call in response to a yellow page advertisement and wanted to know what services were offered and how much money it would cost to have the examination. The voice on the other end said that the cost was $55.00 and that she could get a physical examination, blood testing, urinalysis and also an E.K.G. exam. An arrangement was made for an examination on May 21, 1990, following the telephone conversation which take place on May 17, 1990. Ms. Hunt carried out the appointment. When she arrived at Cardio- Check, Inc. there was a white male sitting in the reception area and a white female there as well. Ms. Hunt identified the fact that she was there for purposes of her appointment. The white female who was a secretary identified herself as Melody Williams. She took certain information from Ms. Hunt and gave Ms. Hunt forms to fill out. One of those forms was a medical history type form requesting general patient information. The other item was related to information about Cardio-Check, Inc. or a release that had to be signed. The white male did not identify himself at that time and left the office. The white male left the office in the presence of a black male. This left Ms. Hunt in the company of Ms. Williams. Ms. Williams referred to the white male who had left as "Ralph." Ms. Williams stated that "when Ralph returns, we can do your exam." Ms. Williams took the information which Ms. Hunt had filled out on the forms. Ms. Williams then stated "you may as well go ahead and get a urine sample." Ms. Hunt went into a bathroom located off the waiting area and gave the urine sample and left it in a cup on the counter upon the instructions by Ms. Williams. Ms. Williams took Ms. Hunt into an examination room and told Ms. Hunt to completely undress except for her panties. Ms. Williams told Ms. Hunt that there was a paper towel that she was told to cover herself with. Shortly thereafter Respondent entered the examining room and sat on a stool at a counter in the room and proceeded to take basic background information in the way of medical history from Ms. Hunt such as her illnesses and her family history. Respondent had not identified himself as being a nurse or a physician nor indicated in any way what his profession was. When Ms. Hunt had called on May 17, 1990 for an appointment, she had asked whom she would be seeing, specifically what physician she would be seeing at her scheduled appointment. The person answering the phone was vague and said "you will be seeing me." In that phone conversation he did not identify himself as Ralph McCawley. He did say that he was a certified practitioner. While in the examining room Respondent took Ms. Hunt to the examination table and proceeded to do a physical exam. He looked at her eyes, ears, nose and throat and used a tongue suppressor. He used a small light to look in her eyes, ears, nose and throat. He took blood pressure using a blood pressure cuff. He checked both Ms. Hunt's arms. He checked her reflexes by tapping her with a small rubber hammer on her knees. He then laid her down flat on her back on the examining table and checked the circulation in her fingers on each hand and checked the toes and ankles. He pressed on her abdomen with his hands doing a manual examination. He asked her to remove her bra and he moved the paper towel down to her waist while he used a stethoscope and checked her heart and chest area. He checked Ms. Hunt's back and sides. In those checks he used a stethoscope. He mentioned that Ms. Hunt had a slight heart murmur. He made further explanation to Ms. Hunt because of her concerns. When she questioned him about the nature of the murmur he said, "you have what is called a slight mitral valve prolapse." When questioned further Respondent stated, "let me listen to your heart some more and then I will explain it." He listened further with the stethoscope and made the comment that she did have a slight heart murmur. Respondent also indicated on this visit that Ms. Hunt's blood pressure was high and needed to be rechecked. Concerning the licenses which Respondent held, no licenses were displayed in the reception area or in the examination room of Cardio-Check, Inc. when Ms. Hunt made her visit of May 21, 1990. When Respondent concluded his physical examination of Ms. Hunt he placed leads on her chest area and arms connected to an E.K.G. monitor. He then turned the E.K.G. machine on and ran a printout. This took a few minutes. Ms. Hunt asked Respondent what the results were and he looked at the tape briefly. He responded "it looks normal." After the examination was concluded and Ms. Hunt was getting dressed, she asked Respondent more about the E.K.G. results given the fact that he had said that she had a heart murmur. At that point Respondent pulled the E.K.G. tape out and put it on the examination table and said, "see it's just normal." He pointed to some of the lines on the E.K.G. tape and said, "it's normal." After that point he took tissue paper on the examination table and drew a picture of a heart and tried to explain to Ms. Hunt what a mitral value prolapse is in lay terms. He told her that the problem could be congenital. She mentioned that as a child she had had tonsillitis. Respondent said, "your heart murmur could be congenital or could be from staph infections relating to tonsillitis that has affected your heart, that may have caused the murmur." In the course of these conversations, on the date of the examination, Ms. Hunt was asking the Respondent what type of educational training he had to have to be doing the work that he was doing. He told her that basically he had fourteen years of post-secondary education and he had mentioned that he had three different degrees, referring to college degrees. He also stated that he had four certifications and that he had taken up to 25 continuing educational credits per year. She asked him, "well, are you a nurse or a physician?" His response was he was a cardio pulmonary practitioner. He mentioned that he had worked in various areas in cardio pulmonary matters to include director of a cardio pulmonary unit at a hospital. He said that his goal was to be a cardio pulmonary surgeon. Ms. Hunt paid $55.00 for the examination. She refused to take the blood test. Respondent stressed that, "this really needs to be done because it checks so many different parameters." He told her that there was a laboratory down the street and they would do the blood testing at that site. As Ms. Hunt was leaving Respondent identified himself as Ralph McCawley. Ms. Hunt saw no one else on the date of her examination for purposes of the examination and no one else was in attendance other than Melody Williams and the Respondent. Ms. Williams' participation in the process was as a female attendant while Respondent conducted the examination. Ms. Hunt was instructed to call back to see the results of the urine screen and she did this. She telephoned on May 24, 1990 and talked to the Respondent. He went over the results of the physical examination. He told her what her pulse was, what her blood pressure was, he told her that he respiration was normal. He told her that her circulation was good and normal. He told her that the urine screen came out fine. He again mentioned that he wanted her to have blood work done. He also said that she should come back into his office as soon as possible. He was trying to get her to come back the next day to recheck blood pressure. He wanted this done because he said that it was high. He said he would recheck it for free. He also offered her a position working as a receptionist replacing Melody Williams who was only filling in temporarily. Several days after the telephone conversation Ms. Hunt returned on June 1, 1990 in the presence of Jim Cooksey another investigator with the State of Florida, Department of Professional Regulation. On this visit Respondent was present and Melody Williams was present. Respondent rechecked Ms. Hunt's blood pressure and said it was a little bit high. At that time he said the reading was 158 over 98. Respondent made further mention about the heart murmur because Ms. Hunt kept asking him, "well, can you refer me to a physician? Is there anyone else I can see about this?" To this remark Respondent stated "it is something you really don't have to worry about. You should have it checked periodically, but it's nothing to be really concerned about." He never provided the name of a physician for referral. Ms. Hunt stated can you refer me to your own physician and Respondent said, "well, I treat myself." Ms. Hunt on the June 1, 1990 visit asked that in view of the literature of Cardio-Check, Inc. that was available stating that there was a medical directory, could Respondent give her the name of a medical doctor or refer her to anyone else associated with Cardio-Check, Inc. Respondent never referred her or gave her any name in response to this inquiry. Ms. Hunt asked for a copy of the EKG and physical examination. These matters were turned over to Ms. Hunt and she in turn gave them to the local state attorney's office. No copies were retained. When Ms. Hunt left the premises on her first visit, she was provided with a brochure and a business card associated with Cardio-Check, Inc. The business card and brochure may be found as Petitioner's Exhibit No. 3 admitted into evidence. Grace Gil is a registered nurse licensed in Florida. She has a B.S. in nursing and a masters degree in nursing. She has been a director of nursing in two hospitals in Miami. She was a faculty member at Central Florida Community College for five years, to include chairman of the nursing department at that community college. She has been director of nursing at HCA Marion Community Hospital in Ocala, Florida. At present she is director of inpatient services at HCA Grant Center Hospital which includes nursing and therapy, and is a psychiatric facility for adolescents and children. Her speciality in nursing practices is medical/surgical nursing and nurse orientation. She has taught courses on nursing ethics and courses preparing students to take the state board examination for licensure as a nurse. She was received as an expert in nursing practice and procedures. In preparing to offer her testimony at hearing Ms. Gil received copies of the investigative reports of the Petitioner, as well as copies of the advertisement and brochures that have been referred to as exhibits, and from those observations has arrived at certain opinions concerning the propriety of Respondent's practice. This summation of her opinion is set out in Petitioner's Exhibit No. 4 admitted into evidence, a report made on December 3, 1990. Ms. Gil also spoke to the issue of the Respondent's conduct in her remarks at hearing. Although the investigative file which Ms. Gil examined was not produced at hearing, from her remarks at hearing and her comments in Petitioner's Exhibit No. 4 it is clear that she was addressing the same incidents with patients as set forth in the findings of fact related to this recommended order. The belief is held that the investigative report coincided with the testimony at hearing of the patients Gushlaw and Hunt and that Ms. Gil was commenting on matters which are the same as reflected in the investigative report as testified to by those patients. Furthermore, Ms. Gil sat through the testimony of the patients Gushlaw and Hunt before offering her remarks about the Respondent's conduct. In her report of December 3, 1990, she found that Respondent's conduct was not in keeping with what is expected of a nurse under the Nurse Practices Act when he conducted physical examinations and made diagnoses based on those findings; and interpretation of E.K.G.s, which is within the realm of a licensed physician. (As evidenced by Petitioner's Exhibit No. 5 admitted into evidence, records of the State of Florida, Department of Professional Regulation, Board of Medicine, Respondent is not licensed to practice medicine in Florida.) Diagnosis of a heart murmur and mitral valve prolapse are matters which are difficult to ascertain in that the prolapse usually requires further diagnostic testing, such as an ultrasound or echocardiogram. The detection of a heart murmur requires the training and experience of a physician. In her remarks set out in the December 3, 1990 report Ms. Gil also faults the Respondent for failing to refer the patients to a physician for conditions which would ordinarily require further evaluation and treatment that is to say, cardiac problems might have required medication and the elevated diastolic blood pressure of Ms. Hunt definitely should have been evaluated by a physician since failure to get the diastolic pressure under control could lead to a variety of cardiovascular problems. Accordingly to the December 3, 1990 report nurse practitioners could be expected to realize that readings on the systolic side of 140 or better and on the diastolic side of 90 or better are indications of hypertension which may or may not be medically significant. As reported in these facts, Ms. Hunt's reading on the second visit exceeded these levels. Ms. Gil also makes mention of the fact that Mr. McCawley was practicing without a nursing license which was in good and current standing which is contrary to acceptable standards for conduct by nurses. In the testimony at hearing there were two areas of major concern by Ms. Gil. The first was the practice of nursing without an active license which is contrary to nurse practicing standards. The second concern was, even if his license had been valid,he exceeded the authorized level of practice by a nurse and did things that constituted the practice of medicine. These items beyond his practice level constituting the practice of medicine were items which a nurse would be aware that he or she is not permitted to do. Ms. Gil was also concerned that some of the findings that the Respondent made in his examinations were items of great potential for harm if they were not adequately studied by way of other tests. More specifically, the conduct of physical examinations is not in the realm of practice of a registered nurse. Further, it was inappropriate to make diagnosis based on these examinations which is not within the realm of practice of a nurse. In her testimony Ms. Gil was especially concerned about the diagnosis of a heart murmur and mitral valve prolapse which requires treatment or nontreatment depending upon what tests would reveal and choice a physician would make in conjunction with those tests. Ms. Gil also said that the interpretation of the EKG is strictly within the realm of a licensed physician. She went on to say that in most hospitals there is a rotating list of physicians who are qualified to interpret E.K.G.s and they are not just persons who are internal medicine specialists, there are usually board certified cardiologists. Back to the remarks about the heart murmur and mitral valve prolapse, Ms. Gil says that it takes a very trained ear to hear a heart murmur and this must be done by an experienced coronary care nurse or a cardiologist to confirm the murmur. The mitral valve prolapse requires further diagnostics testing to include ultrasound or at least an echo-cardiogram or a stress test. It may even require cardiac catheterization depending on how serious the prolapse is. It has not been shown that the Respondent has the necessary experience of a coronary nurse to detect a heart murmur, and even if he had that experience he would not be in a position to decide the significance of that finding and would be required to report to the finding to a physician who would then become responsible. In her testimony Ms. Gil was concerned about the blood pressure reading which is a key indicator of a lot of possible health risks which should be reported to a physician. This referral of the blood pressure problems experienced by Ms. Hunt was not made by Respondent. Ms. Gil's remarks in her December 3, 1990 report as commented on in the fact finding here and her testimony at hearing as commented on in the fact finding are accepted by way of expert opinion.
Recommendation Based upon the findings of facts and the conclusions of law, it is, recommended that a Final Order be entered which dismisses Counts I and III and finds Respondent in violation of Count II and suspends his license for a period of two years and imposes a $1,000 fine. Reinstatement following the service of the suspension should be subject to the requirements of Section 464.018(3), Florida Statutes. RECOMMENDED this 28th day of March, 1991, in Tallahassee, Florida. CHARLES C. ADAMS, Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 28th day of March, 1991. APPENDIX TO RECOMMENDED ORDER, CASE NO. 90-5330 The following discussion is given concerning the proposed facts. Petitioner's Facts Paragraphs 1-21 are subordinate to facts found. Paragraph 22 is not accepted in that it was not shown that Respondent was responsible for the brochure, likewise it has not been shown by competent evidence that the Respondent placed the advertisement in the Ocala yellow pages. Therefore, Paragraph 23 is not accepted. Paragraphs 25-30 are subordinate to facts found, except for Paragraph 27 in the phrase that says that the Respondent told Ms. Hunt that her blood pressure was high because of stress and that she didn't need to worry about it is contrary to the evidence presented and the facts found. No testimony was offered to this affect by Ms. Hunt. COPIES FURNISHED: Tracey S. Hartman, Esquire Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Ralph McCawley Post Office Box 2191 Valdosta, GA 31604-2191 Jack McRay, Esquire Department of Professional Regulation 1940 North Monroe Street Tallahassee, FL 32399-0792 Judie Ritter, Executive Dirtector Department of Professional Regulation, Board of Nursing 504 Daniel Building 111 East Coast Line Drive Jacksonville, FL 32202
Findings Of Fact The Respondent is a registered nurse who began her employment at South Lake Memorial Hospital on August 29, 1977, and was terminated on April 23, 1980. During her employment, the Respondent received four poor evaluations and/or warnings for her nursing practice. The first warning occurred on August 1, 1979. This warning involved allegations of poor nursing performance by the Respondent. These allegations included the Respondent leaving her unit, failing to properly organize her work, failing to properly restrain a patient, wasting time by running too many EGG strips instead of performing her assigned functions, failing to take vital signs timely when coming onto shift, becoming hostile with the Director of Nursing, and failing to obey the direct order of the Director of Nursing to leave the hospital and go home after an argument on July 12, 1979. Although there was no direct evidence as to most of the allegations, the Respondent admitted to late charting, failing to timely take vital signs, spending time working with ECG strips, and failing to obey a direct order to-go home given by the Director of Nursing. The next evaluation occurred on November 26, 1979. The deficiencies in Respondent's practice as alleged by the Director of Nursing were that the Respondent gave a patient whole blood instead of packed cells as ordered by the physician, failed to verify an error in transcription by the ward clerk which resulted in a patient's x-rays being delayed for a day, and improperly charting when the Respondent noted on the nursing notes that at 9:00 p.m. there was no significant change in a patient's condition, when in fact the patient had left the hospital at 8:30 p.m. The lack of direct evidence of these allegations was compensated for by the Respondent's admissions as she testified concerning the circumstances surrounding why the incidents occurred. The third warning occurred on March 19, 1980. The allegations in the warning concerned the Respondent having shouted at a supervisor, abandoning her patients, allowing two I.V.s to run dry, failing to carry out a doctor's orders, and failing to chart. Again, there was no direct evidence of the allegations, however, the Respondent admitted that she left her duty station because of sickness prior to relief arriving in the unit, failed to properly follow doctor's orders, and failed to chart for the time she was present in the unit prior to her reporting to the emergency room. The fourth and final warning, which resulted in termination, occurred on April 23, 1980. The allegations by the Director of Nursing were that the Respondent hung one-fourth percent normal saline solution rather than the one- half percent normal saline solution ordered by the physician, and that the Respondent failed to administer the 5:00 p.m. medication. Again, the allegations were admitted by the Respondent as she attempted to explain why they occurred. The Director of Nursing testified that during each of these warnings, the Respondent's attitude was that she had done nothing wrong and, therefore, could not improve on her performance. The testimony of the Department's nurse investigator was to the effect that the Respondent's actions failed to meet the minimal standard of acceptable and prevailing nursing practice. The investigator also testified that, in her opinion, a nurse with Respondent's poor attitude could be extremely dangerous in a hospital setting. After many years of difficult and stressful work, many nurses suffer from what is commonly referred to as "burn out" and are no longer useful, and can be dangerous in a high stress area of nursing. Respondent testified in her own behalf and offered an explanation for each allegation presented by Petitioner. Respondent testified that relative to the first warning, even though she only had two patients, she did not have adequate time to do her charting during her shift and, therefore, had to stay two hours late. Respondent further testified that on one occasion she had not timely taken her vital signs because the Director of Nursing had delayed her with a needless confrontation. Respondent testified that she did not leave the facility as ordered on August 12, 1979, because she was afraid that she would be abandoning her patients, and could lose her vacation and sick leave benefits. With respect to the November 26, 1979 evaluation, the Respondent testified that she gave whole blood instead of packed cells because the whole blood was incorrectly labeled as packed cells. Respondent further testified that she became aware of the error after the solution had infused, and that had she looked at the solution earlier she would have been able to see that it was an incorrect blood product, and would have been able to correct the problem. As to the incorrect transcription resulting in a patient's x-rays being delayed, the Respondent stated that it was the ward clerk's responsibility, not hers, to transcribe the doctor's orders. With respect to the 9:00 p.m. nursing notes when the patient had left the facility at 8:30 p.m., the Respondent's response was that she had been aware that the patient was gone, but was summarizing the patient's condition during the entire shift up to the point the patient left. Respondent acknowledge that the nursing notes may have been misleading. As to thee warning of termination on March 19, 1980, the Respondent admitted leaving her unit prior to relief arriving. Her explanation gas that she had been attempting for one hour to get assistance, to no avail. Upon questioning, she admitted that she was-only "a little dizzy" and had diarrhea. On that day she did not chart any nursing care given by her while on duty. The Respondent was caring for twelve patients at that time. With respect to the April 23, 1980 termination, Respondent admitted that she hung the incorrect percentage saline solution, but that she did so because a prior nurse obtained the incorrect solution from a supply room. The Respondent then also admitted failing to give out the 5:00 p.m. medication as ordered, but stated the reason for her failure to administer the medication was her inability to obtain help from her supervisor which was necessary because she was overworked. Respondent also testified that during this time period, she went on rounds with a doctor, and also went to dinner. The Respondent testified that she felt she was a good and qualified nurse. Respondent also testified that she had been fired previously from Leesburg General Hospital. The Respondent believes her attitude to be good and indicated that the hospital was overreacting to a few isolated incidents.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That the Respondent's license to practice nursing in the State of Florida, license number 39108-2, be suspended indefinitely. If the Respondent seeks reinstatement, it will be her responsibility to undergo counseling with a psychologist or psychiatrist, for an in-depth evaluation and treatment, the results of which shall be submitted to the Board of Nursing if and when the Respondent wishes to apply for reinstatement of her nursing license. If the Respondent applies for reinstatement of her license, it shall be her responsibility to demonstrate to the Board that she is able to engage in the practice of nursing in a safe, professional, proficient and legal manner. This demonstration shall include but not be limited to a report by her psychologist or psychiatrist, along with a recommendation from him that she be reinstated to the practice of nursing. 1/ DONE and ORDERED this 8th day of January, 1982, 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 8th day of January, 1982.
