The Issue The issue in this case is whether Respondent, Sandra Blankenship, committed the violations alleged in an Amended Administrative Complaint issued by Petitioner, the Department of Health, and, if so, what disciplinary action should be taken against her.
Findings Of Fact The Parties. The Department is the agency in Florida responsible for regulating the practice of midwifery pursuant to Chapters 20, 456, and 467, Florida Statutes (2004).6 Ms. Blankenship is and has been at all times material hereto a licensed midwife in the State of Florida, having been issued license number MW 0091. Ms. Blankenship finished her training in May 1998 and received her Florida midwifery license effective July 7, 1998. Patient S.B. Patient S.B., who was 34 years of age, having been born on January 22, 1964, visited Ms. Blankenship, who was then practicing midwifery at Tree of Life Maternity Services, Inc. (hereinafter referred to as "Tree of Life"), in late December 1998. Patient S.B. went to Tree of Life because she was pregnant and was highly motivated to have an out-of-hospital vaginal birth. The purpose of her visit to Tree of Life was to arrange for prenatal and delivery services. This was not Patient S.B.'s first pregnancy. She had given birth to a son on September 28, 1995. That delivery was made by cesarean section (hereinafter referred to as "C- Section") after a long attempt at vaginal delivery. Patient S.B. was in labor between 24 and 30 hours before the C-Section was performed. Patient S.B. and Ms. Blankenship discussed at length the services Patient S.B. would receive. Patient S.B. was asked questions about her medical history, regular and obstetrical, which she answered. In particular, Patient S.B. informed Ms. Blankenship of the difficult birth of her son, including the fact that he had been delivered by C-Section.7 Following her initial visit, Patient S.B. began receiving prenatal care at Tree of Life on a monthly basis initially and, as her "due date" for her baby's birth approached, more frequently. During the early morning hours of July 9, 1999, Patient S.B. began having labor pains. Accompanied by her husband, Patient S.B. arrived at Tree of Life at approximately 6:00 a.m. She was having moderate contractions, four to five minutes apart, and her cervix was dilated five centimeters. Patient S.B. was monitored every hour after her arrival. From approximately 12:45 p.m. until 3:00 p.m., Patient S.B. relaxed in a tub of water. Part of that time she was noted to be sleeping. Her contractions continued to be moderate. At 3:00 p.m., Patient S.B. exited the tub. Between her arrival at 6:00 a.m. and 7:45 p.m., S.B.'s cervix had dilated as follows: 6:00 a.m. 5 to 6 centimeters 11:00 a.m. 7 centimeters 12:30 p.m. 8 centimeters 3:00 p.m. 9 centimeters 7:30 p.m. 9 centimeters 7:45 p.m. 9 centimeters In order for delivery to occur, the mother's cervix must be dilated ten centimeters, which is referred to as being "complete." Once the mother becomes complete, the baby's head, absent obstruction, should be able to move past the mid-point of the pelvis. A baby's progress is measured, both before and after the mother becomes complete, from the mid-point of the pelvis, which is the narrowest part of the mother's cervix. The location of the baby's head above the mid-point of the pelvis is measured in centimeters and is referred to as "minus stations." Therefore, if the baby's head is two centimeters above the mid- point, it is said to be at "minus-two station." The location of the baby's head below the mid-point of the pelvis is also measured in centimeters and is referred to as "plus stations." Therefore, if the baby's head is two centimeters below the mid- point, it is said to be at "plus-two station." When Patient S.B. became complete is not specifically noted on the Labor Sheet or Progress Notes kept by Ms. Blankenship during Patient S.B.'s attempted delivery. Nowhere did Ms. Blankenship note specifically that Patient S.B. was "complete" or dilated ten centimeters. Neither party proved precisely when Patient S.B. was dilated to ten centimeters, or complete. Dr. Gichia believed that Patient S.B. was complete at approximately 8:00 p.m. Dr. Gichia's opinion was based, in part, upon a note indicating that Patient S.B. was at plus-one station at 7:25 p.m. Dr. Griffin's reliance upon the note, however, is misplaced. It is doubtful how accurate Ms. Blankenship's estimates of the stations reached by the baby were, based upon the fact that she noted that the baby's head had reached a plus- three or plus-four station by 11:30 p.m., but the baby's head was only at a plus-one station when Patient S.B. was later examined in the hospital by Dr. Neil Boland. Dr. Gichia also based her opinion on a note that Ms. Blankenship had had Patient S.B. start pushing at 8:00 p.m. Dr. Gichia concluded that Patient S.B., if she were pushing, was complete and had, therefore, entered what is referred to as "second stage labor." Again, Dr. Gichia's reliance on the 8:00 p.m. note is misplaced. As explained by Ms. Blankenship, Patient S.B. had indicated at approximately 8:00 p.m. that she had the urge to start pushing. Accordingly to Ms. Blankenship, Patient S.B. was still dilated to only nine centimeters, but she believed that, with pushing, she would become complete. After allowing Patient S.B. to make some effort to push, Ms. Blankenship determined that her effort was poor and, therefore, instructed her to stop for a while. While she wrote on her Labor Sheet that she was having Patient S.B. rest for "20 minutes," in fact, Patient S.B. rested much longer, not beginning to actively push again until 9:30 p.m. Although the precise point in time when Patient S.B. became complete was not proved, it can be said that it did take place at some point after 7:25 p.m. and before, or at, 9:30 p.m. This conclusion is supported by Dr. Boland, who assumed that Patient S.B. began second stage labor at 9:30 p.m. rather than attempt to identify a precise earlier point in time.8 Although the accuracy of the stations of the baby's location noted by Ms. Blankenship are questionable and not supported by the weight of the evidence,9 Ms. Blankenship genuinely believed that the baby was at the following stations at the noted times: 7:25 p.m. plus-one station 9:30 p.m. plus-two station 11:30 p.m. plus-three/four station "with pushes" At midnight Ms. Blankenship informed Patient S.B. that, if she did not deliver by 12:30 a.m., July 10th, she would have her transported to a hospital due to maternal exhaustion. Patient S.B. agreed. At 12:25 a.m. a "911 call" was made to arrange to have Patient S.B. transported to a local hospital. She was picked up at 12:30 a.m. Patient S.B. was not attended to by a physician until 1:30 a.m., an hour after leaving Ms. Blankenship's care. Failure to Progress in Descent. Although testimony was offered at the final hearing concerning whether Patient S.B. should have delivered within two hours of beginning stage two labor, the only alleged deficiency in Ms. Blankenship's treatment of Patient S.B. contained in the Administrative Complaint is that "Patient S.B.'s second stage of labor exceeded two (2) hours without progress in descent (the downward movement of the baby)." Due to this alleged deficiency, the Department concluded that Ms. Blankenship violated Florida Administrative Code Rule 64B24-7.008(4)(i)1, when she failed to consult with, or refer or transfer Patient S.B. to, a physician. Ms. Blankenship believed that, based upon her conclusion that the baby had moved from plus-two station at 9:30 p.m. to a plus-three or plus-four station at 11:30 p.m., Patient S.B., after beginning second stage labor, had progressed in descent and, therefore, her referral to a physician was timely. The term "progress in descent," however, is a technical term which in the practice of midwifery requires more than just the movement of the baby which Ms. Blankenship mistakenly believed she was witnessing. Based upon standards established by the American College of Obstetricians and Gynecologists (hereinafter referred to as the "ACOG"), for, among other things, the practice of midwifery, progress in descent after two hours contemplates that, once a mother becomes complete, the baby should be born within two hours or, if not, that the midwife will consult with, or refer or transfer the mother to, a physician. Ms. Blankenship failed to comply with the ACOG acceptable definition of progress in descent. Assuming that Patient S.B. became complete as late as 9:30 p.m., she was not transferred to the hospital until 12:30 p.m., three hours later, and was not seen by a physician until 1:30 p.m., four hours later. While Ms. Blankenship believed that the baby's head was moving downward during this time, that perceived movement did not constitute "progress in descent." Malpractice Insurance. The parties stipulated that Ms. Blankenship did not have malpractice insurance from February 24, 1999, to July 10, 1999, and that she did not inform Patient S.B. that she did not have malpractice insurance while Patient S.B. was in her care. Ms. Blankenship did not, however, intentionally deceive Patient S.B. Rather, she had incorrectly believed that her malpractice insurance had been maintained by a business associate.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered by the Department: Dismissing Count I of the Amended Administrative Complaint; Finding that Sandra Blankenship violated Section 467.203(f), Florida Statutes, as alleged in Count II of the Amended Administrative Complaint; and Suspending Ms. Blankenship's midwifery license for a period of one year from the date the final order and placing her license on probation for two years thereafter. DONE AND ENTERED this 18th day of February, 2005, in Tallahassee, Leon County, Florida. LARRY J. SARTIN 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 18th day of February, 2005.
Findings Of Fact Petitioner, Daniel J. Callahan, is a physician currently licensed to practice medicine in the State of Florida pursuant to Chapters 455 and 458, Florida Statutes. Respondent, Agency for Health Care Administration, Board of Medicine, (Board of Medicine), is the state agency charged with the duty and responsibility to administer Chapter 458, Florida Statutes. Petitioner is the subject of three disciplinary actions brought by the Board of Medicine which are now pending before the Division of Administrative Hearings, case Nos. 93-6020, 93-6021, and 94-3208. The Administrative Complaints filed in these cases set forth allegations of sexual misconduct against Petitioner. The Board of Medicine has filed a motion for official recognition of Rule 59R-9008, Florida Administrative Code, in the disciplinary actions against the Petitioner. Hearing in the disciplinary cases against Petitioner is currently scheduled to begin on March 29, 1995.
Findings Of Fact Tarsha's Little People, Inc. operates a group home facility for young developmentally disabled people who are moderately to profoundly retarded. The facility located in Tampa, Florida, is licensed by the Department of Health and Rehabilitative Services. In addition to being licensed by HRS, TLP also holds a contract with the Department to provide services to HRS clients for a fee. TLP currently provides residential and developmental services to 13 HRS clients. They live in the group homes, attend local schools as appropriate, and receive additional training in daily living skills at TLP. Because of their retardation the clients at TLP require constant supervision to prevent them from harming each other or themselves. Without assistance many of them cannot take care of simple daily needs such as eating, bathing or dressing. Medication Logs Many of the clients at TLP have potent psychotropic medication such as Haldol and Mellaril prescribed for them. These are powerful mood altering drugs which have serious side-effects. Proper monitoring of dosage administration is vital to the therapeutic use of these drugs as the daily dosage is usually increased until the patient's behavior which is being modified changes. Without adequate administration records the physician prescribing the medication will have distorted information on which to rely when determining the proper dosage necessary to achieve a therapeutic level. As part of its residential service TLP administers medication to its residents. As soon as a dose is given the administration should be entered on a medication log. In numerous instances entries were not made by the TLP staff at the time medicine was given or should have been given. This failure to properly record medication has resulted in inaccurate medication logs with serious discrepancies in the amount of drugs administered to TLP residents. The medication logs at TLP show more medication having been dispensed to each client than was sold for that client by Eagle Drug Company, the sole source of medicine for TLP residents. As an example, for client Michael C. TLP records show 374 one milligram doses of Haldol having been administered, but Eagle Drug Company had filled prescriptions for only 300 one milligram pills for Michael C. Similar errors appear in the records of four other clients. It is reasonable to infer that while the inaccurate medication logs show an adequate administration of medicine to TLP clients, the clients have not actually received the medicine in the amounts prescribed for them. The failure to properly record medication posed a substantial danger to the health and well- being of the five clients whole records were introduced here. Eating Supervision and Tooth Brushing During July 1982 an HRS retardation program supervisor visited TLP for an inspection. She observed three deficiencies at the home. At the evening meal the residents were fed, among other foods, large pieces of ham, but each resident was provided only a spoon with which to eat. They were unable to cut the ham into chewable pieces and therefore had to pick the meat up with their hands and gnaw bite-size pieces off. This procedure presented a danger of choking for the residents and failed to provide them with the opportunity to learn the proper use of knives and forks. After dinner the residents customarily brushed their teeth. During the time the HRS retardation program supervisor was there, after each resident brushed his teeth his brush was taken back by a TLP staff member and placed in a single glass of water for all the residents. One client had gums which bled profusely yet his brush was placed in the common glass. The water colored red from his blood. After brushing each client was given a sip of water from another common glass of water. During the residents' bath time, two staff members accompanied two residents at a time to the bathroom while only one staff member remained to supervise the balance of the residents in the home. This is totally inadequate supervision for 13 or 14 retarded clients. If the HRS program supervisor had not been scheduled to visit TLP that evening the evidence indicates that only one staff member would have been scheduled for duty at bath time. There would have therefore been no one available to supervise the residents while that one staff person was giving baths. There is no direct evidence that the use of a common glass of water for drinking and toothbrushes was a regular practice or was an isolated incident at TLP. The scheduling of inadequate staff for client supervision at bath time was however shown to be a regular practice. Brian B.'s Helmet Brian B., one of TLP's clients, suffered from poor muscular coordination. He frequently fell. He wore a helmet to protect his head when he did fall. In January 1982 a chin strip which held on his helmet broke. Brian B. was prone to chew on the strap and thereby weakened it until it failed. On May 26, 1982 a Department staff member became aware that Brian had fallen and injured his head. As a result of his injuries TLP ordered a new chin strap for his helmet but the strap did not arrive until two and one-half months later. In August 1982 immediately before the new strap arrived Brian again fell and caused a gash in his head which required hospital treatment. It was only after considerable prodding from HRS that the new strap was obtained. The new strap did not however alleviate the problem with the helmet as later that year Brian B. was observed wearing the helmet with the strap knotted rather than properly buckled under his chin. He was removed from TLP. When the helmet was taken off his hair was matted and had a strong stench from not being washed. The failure of TLP to promptly remedy the problem of Brian B.'s helmet strap needlessly exposed him the risk of serious head injury. Kevin B.'s French Leave During his residency at TLP between May 1981 and September 1982 Kevin B. escaped from the facility at least five times. On the occasion of his last escape on September 6, 1982 he was picked up by the Tampa Police approximately 19 blocks from the facility. Despite requests from HRS that a behavior modification program to eliminate his propensity to escape be implemented, no effective program was devised by TLP. The facility's efforts to restrain his wander lust by installing dead bolts and bells on his door were easily frustrated by his escaping through the room window. Because of his retarded mental state it was dangerous for Kevin B. to be loose by himself in the community. After his last escape from TLP he was placed in another facility which was later able to sufficiently restrain him and modify his behavior, but not before a few more escape attempts. Loose Floor Covering On June 22, 1982 TLP was notified by the Department that the floor covering in parts of the facility was not safe due to having been ripped up by the clients. The problem was not fixed until mid-September 1982. Several of TLP's clients have gait difficulty. For them torn up flooring is a significant hazard. TLP had some difficulties securing the replacement covering. This fact accounts for some of the delay in making the repairs but this incident, like that of Brian B.'s helmet, is illustrative of TLP's attitude in not taking the initiative to recognize unsafe situations and then remedy them without waiting for a push from the Department. The incident also demonstrates that there are periods of time when TLP clients were not adequately supervised. In order to rip up the flooring they must have had considerable time alone without a staff member being present. Bites, Scratches and Sores The parties presented conflicting evidence on whether the clients of TLP were subject to more incidents of bites, scratches and other sores than were residents in similar facilities in the Tampa Bay area. Such proof is difficult to quantify. Because TLP clients are not exclusively within the control of TLP all the time, the Department was not able to prove that TLP is responsible either directly or indirectly for the minor injuries sustained and exhibited by TLP clients. When the clients attend school or commute to school by bus they can suffer injury. The Department's proof did not eliminate the possibility or probability that many of the injuries to TLP clients occurred in situations, other than those under the supervision of TLP. I therefore find the Department failed to establish that TLP clients experience a disproportionate number of bites, scratches and sores. Ernie J.'s Medication During September 1982 Ernie J., a client at TLP, was receiving the drug Mellaril under a prescription issued by Dr. Shirley Borkowf. Ernie attended school and required the administration of his Mellaril drug during the school day. As was its custom Ernie's school requested from TLP information indicating what medication he should be given at school and the amount of dosage. TLP responded by telling the school he should receive Benadryl, yet TLP sent to schools his proper medication, Mellaril. The school discovered the discrepancy, sought clarification from TLP, and Ernie suffered no harm because of the error. Post Complaint Improvements Subsequent to the filing of the original Administrative Complaint, TLP has made several improvements to its facility. Three adult staff members are now on duty during the busiest hours of the day, between 4:00 p.m. and midnight. The interior of the facility has been painted, pictures have been hung on the walls, and three tree stumps have been removed from the grounds. In April 1983 TLP sought professional advice for improving its medication logs, and on the basis of that advice has instituted procedures for maintaining significantly better medication records which if followed will comply with the Department's standards.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That the Department of Health and Rehabilitative Services enter a Final Order revoking the license of Tarsha's Little People. Inc. to operate a group home facility for developmentally disabled people. DONE and RECOMMENDED this 29th day of February, 1984, in Tallahassee, Florida. MICHAEL PEARCE DODSON 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 29th day of February, 1984.
