Findings Of Fact Upon consideration of the oral testimony and documentary evidence adduced at the hearing, the following relevant facts are found: The Respondent is and has been at all times material to this proceeding, a licensed physician in the State of Florida having been issued license number ME 0005920. Between July 26, 1982 and June 28, 1985, Clarence Keener was a patient of Respondent. Clarence Keener is approximately eighty-five (85) years old. Clarence Keener was taking Tuinal, a brand name for a drug containing Schedule II Controlled Substance as listed in Chapter 893, Florida Statutes, when Respondent began treating him. Respondent continued to prescribe Tuinal for Clarence Keener's insomnia. Tuinal is an accepted sleeping preparation, although a hypnotic medication. On January 6, 1984, Respondent began prescribing Ritalin, a brand name for a drug containing Schedule II Controlled Substance as listed in Chapter 893, Florida Statutes, for Clarence Keener's depression and fatigue. Ritalin is an anti-depressant. Respondent prescribed Tuinal and Ritalin at the same time for Clarence Keener from January, 1984 until June, 1985. Tuinal to be taken at night for sleep and Ritalin to be taken in the morning for depression. In his care and treatment of Clarence Keener, Respondent did not perform: (1) a complete physical examination; (2) any lab work, other than urinalysis; (3) a blood chemistry; (4) a chest x-ray or; (5) an electrocardiogram. Respondent failed to include in Clarence Keener's medical records the results of blood counts performed in the office. Respondent's medical records on Clarence Keener did not justify his course of treatment of Clarence Keener, however, the evidence was insufficient to prove that Respondent had failed to substantially document his treatment of Clarence Keener considering that Respondent had not performed a complete physical examination, blood chemistries, or any lab work (other than a urinalysis none of which could be documented since they had not been performed. During the course of treatment, Clarence Keener, told Respondent he had problems with heart irregularity and premature ventricular contractions. Respondent continued to prescribe Ritalin for Clarence Keener even after the patient exhibited hypertension and irregular heartbeats, which are known side effects to the use of Ritalin. Respondent neither attempted to "wean" Clarence Keener from the use of Tuinal for insomnia nor did he attempt to use any other type anti-depressant that was less dangerous than Ritalin. Respondent failed to adequately evaluate Clarence Keener regarding the side effects of Tuinal and Ritalin. Between March, 1978 and June, 1985, Gladys Hooten was a patient of Respondent. Gladys Hooten is approximately seventy-one (71 years old. In March, 1978, when Respondent first began treating Gladys Hooten for nerves, he took her blood pressure, checked her heart and urine. Without performing a complete physical on Gladys Hooten, Respondent began prescribing Valium and Quaaludes. Prior to treating Gladys Hooten, Respondent failed to appropriately evaluate and diagnose her condition. On October 5, 1981, Respondent began prescribing Ritalin for Gladys Hooten. Respondent continued to prescribe Quaaludes and Ritalin at the same time for Gladys Hooten until May, 1984. Respondent never tried to "wean" Gladys Hooten from Quaaludes to see if it would stop her depression. Respondent failed to try other drugs instead of Ritalin to treat Gladys Hooten's depression. In May, 1984, when Quaaludes were removed from the market, Respondent began prescribing Tuinal for Gladys Hooten for insomnia. Respondent prescribed Ritalin and Tuinal at the same time for Gladys Hooten from May, 1984 until June, 1985, Tuinal to be taken at night for sleep and Ritalin to be taken in the morning for depression. In his care and treatment of Gladys Hooten, Respondent did not perform: (1) a complete physical examination; (2) any lab work, other than urinalysis; (3) blood chemistry; (4) chest x-ray or; (5) electrocardiogram. Respondent's medical records on Gladys Hooten did not justify his course of treatment of Gladys Hooten, however, the evidence was insufficient to prove that Respondent had failed to substantially document his treatment of Gladys Hooten considering that Respondent had not performed a complete physical examination, blood chemistries, or any lab work (other than a urinalysis) none of which could be documented since they had not been performed. Respondent's concomitant use of Tuinal and Ritalin for Clarence Keener and Gladys Hooten was inappropriate. Both Ritalin and Tuinal are addictive drugs. Neither Ritalin nor Tuinal should be used over a long period of time as was the case here. The usual time period recommended is fourteen (14 days.) One of the known side effects of Tuinal is depression. Respondent prescribed Ritalin for Clarence Keener and Gladys Hooten for treatment of depression. Respondent's use of Ritalin for treatment of depression for Clarence Keener and Gladys Hooten was inappropriate. Ritalin can be a dangerous drug for elderly patients such as Clarence Keener and Gladys Hooten because one of the side effects is ventricular tachycardia or increased heart rate. Respondent's use of Ritalin and Tuinal for Clarence Keener and Gladys Hooten was inappropriate because he failed to evaluate them properly regarding the drugs and their potential harm for the elderly. There was credible evidence that drugs less dangerous to elderly person were available for use by Respondent in his treatment of Clarence Keener and Gladys Hooten. In treating Clarence Keener and Gladys Hooten, Respondent failed to practice medicine with that level of care, skill and treatment which is recognized by a reasonably prudent similar physician as being acceptable under similar conditions and circumstances. Respondent has been practicing medicine for approximately forty (40 years without any apparent blemish on his record. Respondent did not prescribe either Ritalin or Tuinal in excessive or inappropriate amounts for either Clarence Keener or Gladys Hooten in his treatment of them. Respondent's testimony that because of Clarence Keener's and Gladys Hooten's age and their financial status his treatment of them without a battery of expensive test was reasonable and that their quality of life had improved through his treatment was credible. However, the more credible and persuasive evidence was that Ritalin and Quaaludes or Ritalin and Tuinal in combination as in this situation was contraindicated and could have caused some serious problems notwithstanding that neither Clarence Keener nor Gladys Hooten suffered any bad effects from Respondent's treatment.
Recommendation Based upon the Findings of Fact and Conclusions of Law recited herein, it is RECOMMENDED that Respondent be found guilty of a violation of Section 458.331(1)(h)(q) and (t), Florida Statutes. For such violation, considering the mitigating circumstances surrounding the violation, it is RECOMMENDED that the Board suspend Respondent's license for a period of one (1) year, stay the suspension and place Respondent on probation subject to terms deemed appropriate by the Board. It is further RECOMMENDED that Count One and Count Five be DISMISSED. Respectfully submitted and entered this 28th day of July, 1986, in Tallahassee, Leon County, Florida. WILLIAM R. CAVE 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 Adminisrative Hearings this 28th day of July, 1986. APPENDIX TO RECOMMENDED ORDER IN CASE No. 86-0633 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties in this case. Rulings on Proposed Findings of Fact Submitted by the Petitioner 1-8. Adopted in Findings of Fact 1 through 8 consecutively. 9. Rejected as not comporting with the substantial competent evidence in the record in that the medical records were complete but did not support the course of treatment. 10-24. Adopted in Findings of Fact 10 through 24 consecutively. Rejected as not comporting with the substantial competent evidence in the record in that the medical records were complete but did not support the course of treatment. Adopted in Finding of Fact 26. Adopted in Finding of Fact 4 and 5. Adopted in Finding of Fact 27. Adopted in Finding of Fact 28. 30-36. Adopted in Findings of Fact 28 through 34 consecutively. 37-38. Adopted in Finding of Fact 35 as modified. Rulings on Proposed Findings of Fact Submitted by the Respondent Rejected as argument or a statement of what the Administrative Complaint alleged. The first sentence rejected as not supported by substantial competent evidence in the record. The second and third sentences are rejected as immaterial and irrelevant. Rejected as not supported by substantial evidence in the record or as argument. Rejected as argument. COPIES FURNISHED: Leslie Brookmeyer, Esquire Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301 John H. Shackelton, M.D. 6404 Arlington Road Jacksonville, Florida 32211 =================================================================
The Issue This is a license discipline case in which the Petitioner seeks to take disciplinary action against the Respondent on the basis of charges set forth in a three-count Administrative Complaint. The Administrative Complaint charges the Respondent with violations of paragraphs (m), (q), and (t) of Section 458.331(1) Florida Statutes.1
Findings Of Fact At all times material to this case, the Respondent, Donald A. Tobkin, M.D., has been licensed, and continues to be licensed, to practice medicine in the State of Florida. His license number is 30942.5 Sometime during the month of December 2004, the Police Department of Hollywood, Florida, (HPD) received information from a confidential informant that the Respondent was soliciting drug-prescribing business and was writing inappropriate and excessive prescriptions for controlled substances. On the basis of that information, the HPD initiated an undercover operation to investigate the information received from the confidential informant. As part of the undercover investigation, on the evening of January 20, 2005, at approximately 9:56pm, an HPD female detective named Nicole Coffin made a telephone call to the Respondent's telephone. The Respondent answered the telephone and identified himself by name. Detective Coffin pretended to be a person named Melissa Beech. She pretended to be a person who was seeking to obtain OxyContin, which is a Schedule II controlled substance. During the entire undercover investigation, Detective Coffin pretended to be a drug-seeker while interacting with the Respondent. On the telephone she told the Respondent that she wanted a prescription for OxyContin and also told the Respondent that a girl somewhere on Federal Highway had given her the Respondent's card and had told her she could call the Respondent if she needed a prescription. Detective Coffin, in her role as Melissa Beech, did not initially describe any medical complaint to the Respondent; she just said she wanted a prescription for OxyContin. In response to the request for a prescription for OxyContin, the Respondent told the make-believe drug-seeker that he could provide the requested prescription, but that they would have to have a "medical reason" for such a prescription. The Respondent then asked the make-believe drug-seeker if she had ever been in an automobile accident. The make-believe drug-seeker answered "yes," because that is the answer she thought would provide a basis for a "medical reason." The Respondent then proceeded to ask the make-believe drug-seeker a long series of leading questions which, if answered "yes," could provide the appearance of a "medical reason" for the requested prescription for OxyContin. This series of questions was for the purpose of establishing a contrived "medical reason" for the prescription sought by the make-believe drug-seeker. There never was, and there never appeared to be, any real "medical reason" for the prescription sought by the make-believe drug-seeker. The sole purpose for the many questions asked by the Respondent, and for the Respondent's written notations related to those questions, was to create the illusion, or the false impression, that there was a "medical reason' for the prescription when, in fact, there was no such reason. The detective who was pretending to be a drug-seeker answered "yes" to all of the leading questions asked by the Respondent. She answered "yes," even when that was not a truthful answer, because she was trying to give the answers she thought the Respondent wanted to hear.6 The Respondent's leading questions included questions asking about such things as whether the make-believe drug-seeker had ever had an automobile accident, whether she had suffered a herniated disk as a result of that accident, whether she had had an MRI, whether she had had any subsequent accidents, whether she had tried any other drugs to relieve pain, whether she had used Oxycontin in the past, and whether in the past the Oxycontin had relieved her pain. During the course of the first telephone conversation between Detective Coffin and the Respondent a number of significant matters were not discussed. The Respondent did not discuss the possibility of surgical treatments to treat the back pain described in response to the Respondent's questions. The Respondent did not discuss the necessity of reviewing the MRI or X-rays that supposedly would confirm the "herniated disc" he had inquired about. The Respondent did not discuss the necessity of obtaining future MRIs, X-rays, or other diagnostic tests to evaluate the "severe back pain" supposedly described by Detective Coffin in her role as Melissa Beech. The Respondent did not mention that she would need to have any follow-up visits with the Respondent. During the course of the first conversation between Detective Coffin and the Respondent, she told the Respondent that she had previously been obtaining Oxycontin "off the street" and that she was seeking a prescription from the Respondent because her street source had "dried up." She also told him that she had previously taken Valium and Percocet. During the course of the first telephone conversation Detective Coffin, pretending to be a drug-seeker, told the Respondent that she suffered from back pain as a result of the make-believe automobile accidents. She did not say that she was currently experiencing pain at the time of that telephone conversation. During the first telephone conversation the Respondent did not ask the make-believe drug-seeker any questions about her menstrual cycle, about whether she was pregnant, or about whether she had had any prior pregnancies or had ever had any children. However, in his written notes the Respondent included notations that purport to be answers to those unasked questions. Similarly, the Respondent did not ask the make-believe drug-seeker any questions about her consumption of alcohol, but included in his notes notations that purport to memorialize the answer to that unasked question. The Respondent's "history" notes also report that he warned the make-believe drug-seeker that OxyContin tablets should not be crushed or broken, even though he did not include any such warning in his telephone conversation with the make-believe drug-seeker. During the first telephone conversation, Detective Coffin was never asked about, and never provided any information about, whether other physicians had either prescribed OxyContin for her or had refused to prescribe OxyContin for her. The only prior sources of OxyContin she mentioned to the Respondent were non-prescription illegal sources on the street. The Respondent never discussed with Detective Coffin the possibility or necessity of a more structured medical treatment plan for addiction. The Respondent never discussed with Detective Coffin the possibility or necessity of a more structured medical treatment plan to treat a complaint of "severe pain." During the course of the first telephone conversation, the Respondent agreed to provide a prescription to the make- believe drug-seeker for a total of sixty-two 80-milligram OxyContin tablets. It was agreed that the make-believe drug- seeker would pay $100.00 for the first prescription and that the Respondent would provide similar prescriptions in the future for $50.00 per prescription. Towards the end of the first telephone conversation the Respondent told the make-believe drug-seeker that he had another matter to attend to and that she should call him later to arrange the time and place for the two of them to meet later that same evening. During the course of the first telephone conversation, which lasted for approximately 14 minutes, the Respondent made written notes of the answers given by the make-believe drug-seeker. Those notes were prepared in such a manner as to resemble the types of notes customarily made by physicians who are making a medical record of information elicited from a patient. A number of the details recorded in the Respondent's notes of the first telephone conversation were inconsistent with the information provided by the make-believe drug-seeker. Specifically, those notes contained a significant amount of information that was never uttered by the make-believe drug- seeker. The fictitious and false history details memorialized in the Respondent's notes are intentional falsehoods. Later that evening, at approximately 12:20am on January 21, 2005, Detective Coffin, still pretending to be the drug-seeking person named Melissa Beech, placed a second telephone call to the Respondent. She spoke with the Respondent for about three minutes on this occasion. Most of the second conversation consisted of providing the Respondent with information about the location where Detective Coffin would be waiting for him and information about where the Respondent should park when he arrived. Law enforcement officers of the HPD attempted to record both of the telephone conversations between the Respondent and Detective Coffin. Both of those attempts were unsuccessful. There is no recording of either of the telephone conversations. Sometime later that evening, during the early morning hours of January 21, 2005, the Respondent met the make-believe drug-seeker at the motel or efficiency apartment. He entered the room where the make-believe drug-seeker was pretending to be staying. Prior to his arrival, two cameras had been concealed in the room by the HPD police officers. During the entire time the Respondent was in the room the two cameras were attempting to record everything he said and everything he did, as well as everything said or done by the detective pretending to be the drug-seeking person named Melissa Beech. After entering the room, the Respondent spoke with the make-believe drug-seeker and asked her additional questions related to her request for a prescription for OxyContin. He made some written notes that purported to be summaries of her answers. During the course of the meeting with the make-believe drug-seeker the Respondent provided her with a document titled "Patient's Acknowledgement," which she signed, but did not read. That document contained information about the patient-physician relationship, about what was expected of the patient, and also memorialized the patient's informed consent to the treatment she was requesting from the Respondent. The Respondent also conducted a brief physical examination of the make-believe patient and made written notes that purported to be a memorialization of what he had observed during the course of his examination. The Respondent's examination of the make-believe drug-seeker included the following: check of pulse and blood pressure, check of reflex responses at several joints, and check of chest sounds with stethoscope. The Respondent performed a deep tendon reflex test on Detective Coffin by striking her wrists, elbows, and knees with a medical hammer. Detective Coffin's feet remained on the floor during this test. A deep tendon reflex test cannot be performed properly with the subject's feet touching the floor. Such a test performed in such a manner will not produce reliable results. The Respondent indicated in his written notes that he had examined Detective Coffin's head, eyes, ears, nose, and throat. However, the Respondent did not perform any examination at all of Detective Coffin's head, ears, nose, or throat. The Respondent perhaps performed a partial examination of Detective Coffin's eyes, but did not perform an adequate examination of her eyes. The Respondent indicated in his written notes that Detective Coffin's pupils were equal, round, and reactive to light and accommodation. However, the Respondent did not conduct any examination of Detective Coffin's eyes that was sufficient to support a conclusion that they were equal, round, and reactive to light and accommodation. The Respondent included in his written notes that Detective Coffin's chest and lungs were clear to auscultation and percussion. The Respondent did not examine Detective Coffin in a manner that could determine whether her chest and lungs were clear to auscultation and percussion. Therefore, the Respondent did not have any basis for writing that the detective's chest and lungs were clear to auscultation and percussion. The Respondent included in his written notes an observation that Detective Coffin's abdomen was soft. The Respondent never touched or otherwise examined Detective Coffin's abdomen. The Respondent had no factual basis for writing that Detective Coffin's abdomen was soft. In his written notes the Respondent indicated that Detective Coffin experienced pain upon lifting her leg thirty degrees. Detective Coffin never raised either leg in the Respondent's presence and never complained of pain in his presence. There was no factual basis for the subject notation. The Respondent never conducted a Rhomberg examination on Detective Coffin, but he included in his written notes an observation that a Rhomberg test was negative. There was no factual basis for such a notation. The Respondent included in his written notes an observation that he had examined Detective Coffin's gait. However, the Respondent never performed an adequate and sufficient examination of Detective Coffin's gait. The Respondent did not conduct a range of motion test of Detective Coffin. The Respondent never asked Detective Coffin to lift her leg towards her chest. Nor did he ask her to touch her toes. The Respondent never asked her to manipulate her body in any way. At no time during the encounter between Detective Coffin and the Respondent did Detective Coffin state that she was experiencing pain. At no time during that encounter did she behave or move in any manner that would suggest she was experiencing pain. To the contrary, Detective Coffin crossed and uncrossed her legs, alternatively slouched and sat up straight in her chair, and made other movements that would indicate to a reasonable prudent physician that she was not experiencing any pain at all. The Respondent never discussed with Detective Coffin the necessity of obtaining further MRIs, X-rays, or other forms of diagnostic testing. He never discussed any need to obtain and review any prior medical records. The Respondent never asked Detective Coffin to sign a medical records release document that would have authorized the Respondent to obtain prior medical records. The Respondent's written notations regarding his examination of the make-believe drug-seeker contain false information because, among other things, the notations contain the results of tests and examinations the Respondent did not perform. Such false notations are intentional falsehoods. The Respondent never discussed with Detective Coffin the need for a follow-up appointment. The Respondent never asked Detective Coffin for any form of identification. Under the circumstances presented in this case, a reasonable prudent physician would have performed a range of motion test and a leg-raising test, neither of which were performed by the Respondent. Under the circumstances presented in this case, a reasonably prudent physician would have established a treatment plan that would have included a schedule for follow-up visits, a review of prior medical records, and plans for future diagnostic tests. The Respondent did not establish any type of treatment plan. The prescription provided to Detective Coffin was inappropriate, unjustified, and excessive because the physical examination was inadequate, the medical record was falsified, and the patient never exhibited any sign of being in pain. Under the circumstances presented in this case, the Respondent's act of providing a prescription to a total stranger with no medical justification for doing so was an action taken other than in the course of the Respondent's professional practice. Ultimately, the Respondent wrote and delivered a prescription to the make-believe patient. The prescription was for sixty-two 80-milligram tablets of OxyContin. This was a 31- day supply if the OxyContin was taken as directed; one tablet every 12 hours. The Respondent wrote several warnings at the bottom of the prescription document. The warnings included such things as the fact that OxyContin impairs driving ability and may cause drowsiness, loss of balance, and/or loss of coordination. The Respondent also wrote on the prescription: "Must swallow whole and do not crush or break." Other law enforcement officers of the HPD were listening to and observing the events inside the room. Shortly after the Respondent handed the prescription to the make-believe patient and received the one hundred dollars from her, other law enforcement officers rushed into the room, arrested the Respondent, and seized various items of the Respondent's personal property, including the medical record he had been preparing regarding his care and treatment of the make-believe patient. With regard to obtaining information about the characteristics of, and the proper use of, specific drugs, medical doctors customarily rely on the information contained in the Physician Desk Reference (PDR) and on the information contained in the manufacturer's package insert that often accompanies a drug. The package insert for OxyContin includes the following information: (Following an initial caption reading WARNING) OxyContin Tablets are a controlled-release oral formulation of oxycodone hydrochloride indicated for the management of moderate to severe pain when a continuous, around-the- clock analgesic is needed for an extended period of time. * * * (Following caption reading CLINICAL PHARMACOLOGY) Oxycodone is a pure agonist opioid whose principal therapeutic action is analgesia. *** With pure opioid agonist analgesics, there is no defined maximum dose; the ceiling to analgesic effectiveness is imposed only by side effects, the more serious of which may include somnolence and respiratory depression. * * * As with all opioids, the minimum effective plasma concentration for analgesia will vary widely among patients, especially among patients who have been previously treated with potent agonist opioids. As a result, patients must be treated with individualized titration of dosage to the desired effect. The minimum effective analgesic concentration of oxycodone for any individual patient may increase over time due to an increase in pain, the development of a new pain syndrome and/or the development of analgesic tolerance. * * * OxyContin Tablets are associated with typical opioid-related adverse experiences. There is a general relationship between increasing oxycodone plasma concentration and increasing frequency of dose-related opioid adverse experiences such as nausea, vomiting, CNS effects, and respiratory depression. In opioid-tolerant patients, the situation is altered by the development of tolerance to opioid-related side effects, and the relationship is not clinically relevant. As with all opioids, the dose must be individualized . . . because the effective analgesic dose for some patients will be too high to be tolerated by other patients. (Following caption reading WARNINGS) OxyContin 80 mg and 160 mg Tablets ARE FOR USE IN OPIOID-TOLERANT PATIENTS ONLY. These tablet strengths may cause fatal respiratory depression when administered to patients not previously exposed to opioids. * * * Concerns about abuse, addiction, and diversion should not prevent the proper management of pain. The development of addiction to opioid analgesics in properly managed patients with pain has been reported to be rare. However, data are not available to establish the true incidence of addiction in chronic pain patients.
Recommendation On the basis of the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be issued in this case to the following effect: Dismissing Counts One and Two of the Administrative Complaint; Concluding that the Respondent is guilty of having violated Section 458.331(1)(q), Florida Statutes, as charged in Count Three of the Administrative Complaint; and Imposing a penalty consisting of an administrative fine in the amount of ten thousand dollars ($10,000.00) and the revocation of the Respondent's license to practice medicine. DONE AND ENTERED this 26th day of June, 2006, in Tallahassee, Leon County, Florida. S MICHAEL M. PARRISH 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 26th day of June, 2006.
The Issue The issue for determination is whether Respondent, a licensed practical nurse, committed violations of Chapter 464, Florida Statutes, sufficient to justify the imposition of disciplinary sanctions against her license. The resolution of this issue rests upon a determination of whether Respondent failed to properly document the dispensing of certain medications topatients; whether she engaged in or attempted to engage in the possession of controlled substances as set forth in Chapter 893, Florida Statutes, for other than legitimate purposes; and whether such action by Respondent constitutes unprofessional conduct in the practice of nursing.
Findings Of Fact Respondent is Doris Brewer. She is a licensed practical nurse and holds license number PN 0537621. At all times pertinent to these proceedings, Respondent was employed at Memorial Hospital of Tampa, located in Tampa, Florida. Respondent's employment with Memorial Hospital of Tampa began in January of 1988 and continued until her termination on November 29, 1988. During her employment and prior to occurrence of the incidents which form the basis for charges set forth in the administrative complaint, Respondent was cited on two occasions by her superiors for deficient performance related to medical record keeping and dispersal of medications to patients. One of those incidents occurred on March 1, 1988, when Respondent failed to follow directions in the administration of medication and received a verbal warning. She was again disciplined on September 15, 1988, receiving a written warning for failure to properly document the administration of controlled substance medications to patients. On November 19, 1988, Respondent signed out a controlled substance, Tylenol #3, for patient B.N. at 3:45 a.m. and again at 5:00 a.m. The medical administration record documents only one dose of the medication was actually given to the patient at approximately 5:10 a.m. The patient's nursing chart or "notes"do not reflect that the pain medication was subsequently provided to the patient by Respondent. Respondent also signed out Tylenol #3 for patient R.B. at 1:45 a.m. and 5:00 a.m. on November 19, 1988. Respondent charted this medication dispersal on the medication administration record. Again, Respondent failed to document administration of the drugs to the patient in the patient's nursing chart or "notes." On November 27, 1988, Respondent signed out Vicodin, a controlled substance, for patient D.G. at approximately 12:00 a.m. and 4:00 a.m., but did not document this action in the medication administration record or in the patient's nursing notes. Respondent testified in mitigation of the charges in the administrative complaint that she was guilty of "poor documentation"; had appropriately administered the subject drugs in each instance; and had not diverted the drugs to the illicit personal use of herself or anyone else. Failure of a nurse to document or "chart" administration of medication to patients in the patient's chart or nurse's notes constitutes a violation of acceptable standards of prevailing nursing practice. By her own admission at the final hearing, Respondent committed this offense. Respondent's failure to properly document administration of the controlled substance medications in each of the three alleged instances constitutes inaccurate recording of patient records for which she was responsible during the period of time when she was on shift and administering medications to thepatients B.N., R.B., and D.G.
Recommendation Based on the foregoing, it is hereby RECOMMENDED that a Final Order be entered by the Board of Nursing finding Respondent guilty of unprofessional conduct in violation of Section 464.018(1)(h), Florida Statutes (1989) and Rule 210-10.005(1)(e)1., Florida Administrative Code. IT IS FURTHER RECOMMENDED that such Final Order place Respondent's license on probation for a period of two years upon reasonable terms and conditions to be established by the Board, including a condition that Respondent enroll in and successfully complete continuing education courses, as may be determined by the Board, in the subject area of proper documentation of administration of patient medications. DONE AND ENTERED this 15th day of June, 1990, 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 15th day of June, 1990. APPENDIX TO RECOMMENDED ORDER 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.-17. Adopted in substance, though not verbatim. Rejected; hearsay. 19.-21. Adopted in substance, though not verbatim. 22. Rejected; hearsay. 23.-25. Adopted in substance. 26. Rejected; hearsay. 27.-29. Rejected; unnecessary. 30. Adopted by reference. 31.-33. Rejected as to patients claims; hearsay. 34.-35. Adopted in substance. Respondent's Proposed Findings. None submitted. COPIES FURNISHED: Tobi C. Pam, Esq. Department of Professional Regulation The Northwood Centre, Suite 60 1940 N. Monroe St. Tallahassee, FL 32399-0750 Doris Brewer 319 Northwood Drive Lutz, FL 33549 Kenneth Easley, Esq. General Counsel Department of Professional Regulation The Northwood Centre, Suite 60 1940 N. Monroe St. 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
