00-001006 Department Of Health, Board Of Nursing vs. Billie Mae Twiehaus Holzhauer Status: Closed Recommended Order on Wednesday, August 30, 2000.

Summary: "Pre-initialization" of medication administration records fails to meet minimal standards of care. Records should be completed after medication is administered, not prior to act.

STATE OF FLORIDA

DIVISION OF ADMINISTRATIVE HEARINGS

DEPARTMENT OF HEALTH, )

BOARD OF NURSING, )

)

Petitioner, )

)

vs. ) Case No. 00-1006

)

BILLIE MAE TWIEHAUS HOLZHAUER, )

)

Respondent. )

_____________________________________)

RECOMMENDED ORDER

On June 23, 2000, a formal administrative hearing in this

case was conducted by videoconference in Tallahassee and Ft.

Myers, Florida, before William F. Quattlebaum, Administrative Law

Judge, Division of Administrative Hearings.

APPEARANCES

Fo r Petitioner: Reginald D. Dixon, Esquire

Agency for Health Care Administration

2727 Mahan Drive

Post Office Box 14229

Tallahassee, Florida 32317-4229

For Respondent: Harry A. Blair, Esqu ire

Harry A. Blair, P.A.

2180 West First Street, Suite 401

Ft. Myers, Florida 33901

STATEMENT OF THE ISSUE

The issue in the case is whether the allegations of the

Administrative Complaint filed by the Petitioner are correct and,

if so, what penalty should be imposed against the Respondent.

PRELIMINARY STATEMENT

By Amended Administrative Complaint dated January 24, 2000,

the Department of Health (Petitioner) alleged that Billie Mae

Twiehaus Holzhauer (Respondent) violated Section 464.018(1)(h),

Florida Statutes. The Respondent requested a formal hearing.

The Department forwarded the request for hearing to the Division

of Administrative Hearings, which scheduled and conducted the

proceeding.

At the hearing, the Petitioner presented the testimony of

one witness and had Exhibits numbered 1-3 admitted into evidence.

The Respondent presented the testimony of one witness, testified

on his own behalf and had Exhibit numbered 1 admitted into

evidence. The Transcript of the hearing was filed on August 10,

2000. Both parties filed Proposed Recommended Orders.

FINDINGS OF FACT

1. The Petitioner is the state agency charged with

regulation of the practice of nursing in State of Florida.

2. At all times material to this case, the Respondent has

been licensed as a practical nurse in the State of Florida,

holding license number PN 0741801.

3. At all times material to this case, the Respondent was

employed as a practical nurse at the Harborside Health Care

facility in Naples, Florida.

4. At all times material to this case, Patient F. D. was a

resident of Harborside Health Care. On or about August 17, 1998,

at approximately 11:00 a.m., the Respondent initialed a

medication administration record indicating that the Respondent

had provided a nutritional supplement to F. D.

5. According to the medication administration record, F. D.

was to receive the nutritional supplement at approximately

2:00 p.m.

6. At the time the Respondent placed her initials on the

medication administration record, she had not provided the

nutritional supplement to F. D.

7. At all times material to this case, Patient L. G. was a

resident of Harborside Health Care. On or about August 17, 1998,

at approximately 11:00 a.m., the Respondent initialed a

medication administration record indicating that the Respondent

had provided a nutritional supplement to L. G.

8. According to the medication administration record, L. G.

was to receive the nutritional supplement at approximately 2:00

p.m.

9. At the time the Respondent placed her initials on the

medication administration record, she had not provided the

nutritional supplement to L. G.

10. At all times material to this case, Patient R. T. was a

resident of Harborside Health Care. On or about August 17, 1998,

at approximately 11:00 a.m., the Respondent initialed a

medication administration record indicating that the Respondent

had provided a nutritional supplement to R. T.

11. According to the medication administration record, R.

T. was to receive the nutritional supplement at approximately

2:00 p.m.

12. At the time the Respondent placed her initials on the

medication administration record, she had not provided the

nutritional supplement to R. T.

13. Minimal acceptable standards of prevailing n ursing

practice require that nurses accurately document the provision of

supplements and nourishment to nursing home patients.

14. Minimal acceptable standards of prevailing nursing

practice require that documentation of care provided to patients

be recorded contemporaneously with the provision of the care.

15. The Respondent's documentation of care provided to the

patients identified herein fails to meet minimally acceptable

standards of prevailing nursing practice.

16. The placing of a care provider's ini tials on a

medication administration record indicates that medication has

been administered to patients. "Pre-initialing" of medication

administration records poses a risk of confusion to other care

providers working in the facility and is not an acceptable

practice.

17. The Respondent acknowledges that she initialed each

medication administration record at about 11:00 a.m., several

hours prior to the actual administration of the supplement's to

the patients. She asserts that she did not record the amounts of

supplement each patient consumed (100 percent in all three cases

assuming the records are accurate) until after the patient had

consumed the supplement.

18. The rationale for the Respondent's practice is unclear.

The Respondent suggests that she had "a few moments" at about

11:00 a.m. and so she went ahead and initialed the documents,

knowing that she could complete the charting at a later time.

19. The Respondent's suggestion is the intent of the

practice is to save time; however, any time saved is at best

minimal.

20. If the Respondent's testimony regarding post-

administration record completion is credited, the practice

requires that each record be handled twice to complete a single

task. The Respondent suggests that she returns to each

individual record after administering the supplement and charts

the amount of supplement consumed by writing in a space

approximately one-quarter inch beneath the "pre-initialed" space.

In reality, "pre-initialization" doubles the time required to

complete the documentation and increases the potential for

confusing other care providers involved in patient care and

charting.

21. The Respondent continues to assert that the "pre-

initialization" practice is acceptable. The assertion is clearly

contrary to minimally acceptable standards of nursing practice,

and to common sense.

CONCLUSIONS OF LAW

22. The Division of Administrative Hearings has

jurisdiction over the parties to and subject matter of this

proceeding. Section 120.57(1), Florida Statutes.

23. The Department o f Health, Board of Medicine, is

responsible for disciplinary proceedings against licensed

practical nurses in Florida. Chapter 464, Florida Statutes.

24. The Department has the burden of proving the

allegations against the Respondent by clear and convincing

evidence. Ferris v. Turlington , 510 So. 2d 292 (Fla. 1987). In

this case, the burden has been met.

25. Section 464.018, Florida Statutes, provides grounds for

disciplinary actions against licensees. Section 464.018(1)(h),

provides for the imposition of discipline for "[u]nprofessional

conduct, which shall include, but not be limited to, any

departure from, or the failure to conform to, the minimal

standards of acceptable and prevailing nursing practice, in which

case actual injury need not be established."

26. In this case the evidence establishes that the

Respondent's documentation of care as set forth herein fails to

meet the minimal standards of acceptable and prevailing nursing

practice.

27. Rule 64B9-8.006(3)(I), Florida Administrative Code,

provides a range of disciplinary guidelines for use by the Board

of Nursing in imposing discipline for violation of Section

464.018(1)(h), Florida Statutes, where the violation involves

administrative duties including charting. The rule provides for

a "[f]ine from $250 - $1000 plus from 6 months probation with

conditions and CE courses to two years probation with conditions

and CE courses."

RECOMMENDATION

Based on the foregoing Findings of Fact and Conclusions of

Law, it is recommended that the Petitioner enter a final order

against the Respondent, imposing a fine of $500, requiring

completion of appropriate continuing education in nursing records

documentation in addition to any existing continuing education

requirement, and placing the Respondent on probation for a period

of one year under such conditions as the Board of Nursing

determines are warranted.

DONE AND ENTERED this 30th day of August, 2000, in

Tallahassee, Leon County, Florida.

___________________________________

WILLIAM F. QUATTLEBAUM

Administrat ive Law Judge

Division of Administrative Hearings

The DeSoto Building

1230 Apalachee Parkway

Tallahassee, Florida 32399-3060

[phone] SUNCOM 278-9675

Fax Filing [phone]

www.doah.state.fl.us

Filed with the Clerk of the

Division of Administrative Hearings

this 30th day of August, 2000.

COPIES FURNISHED:

Reginald D. Dixon, Esquire

Agency for Health Care Administration

2727 Mahan Drive

Post Office Box 14229

Tallahassee, Florida 32317-4229

Harry A. Blair, Esquire

Harry A. Blair, P.A.

2180 West First Street, Suite 401

Ft. Myers, Florida 33901

Ruth R. Stiehl, Ph.D., R.N., Executive Director

Board of Nursing

Department of Health

4080 Woodcock Drive, Suite 202

Jacksonville, Florida 32207-2714

Angela T. Hall, Agency Clerk

Department of Health

4052 Bald Cypress Way

Bin A02

Tallahassee, Florida 32399-1703

William W. Large, General Counsel

Department of Health

4052 Bald Cypress Way

Bin A02

Tallahassee, Florida 32399-1703

NOTICE OF RIGHT TO SUBMIT EXCEPTIONS

All parties have the right to submit written exceptions within 15

days from the date of this Recommended Order. Any exceptions to

this recommended order must be filed with the agency that will

issue the final order in this case.