Administrative Hearing Commission State of Missouri




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Before the

Administrative Hearing Commission

State of Missouri

STATE BOARD OF NURSING, )

)

Petitioner, )



)

vs. ) No. 10-2364 BN

)

SANDREL ARMSTRONG, )



)

Respondent. )




DECISION

Sandrel Armstrong is subject to discipline for failing to document the administration of narcotics.



Procedure

On December 21, 2010, the State Board of Nursing (“the Board”) filed a complaint seeking to discipline Armstrong. Armstrong received a copy of the complaint and our notice of complaint/notice of hearing on January 11, 2011. She filed an answer on February 14, 2011, 2011.



We held a hearing on July 25, 2011. Stephan Cotton Walker represented the Board. Armstrong represented herself. The case became ready for our decision on November 16, 2011, the date we allowed for Armstrong to file a reply to the Board’s written argument.

Findings of Fact

  1. Armstrong is licensed by the Board as a licensed practical nurse (“LPN”). Her license is current and active, and was so at all relevant times.

  2. Armstrong was employed as an LPN at St. John’s Mercy Medical Center (“St. John’s”), in St. Louis, in the skilled nursing unit.

  3. In August 2009, St. John’s introduced a new electronic medical record system, Epic. The nursing staff, including Armstrong, received training on how to use Epic.

  4. In the Epic system, when a nurse scanned a patient’s identification bracelet (“scanned the patient”), the patient’s list of routine medications would come up on a computer screen. PRN (as needed) medications, such as narcotics prescribed for pain, were on a separate list and did not automatically appear on the screen.

  5. When Armstrong accessed the PRN medication list for a patient, she would go to the Omnicell to remove it. Omnicell is a dispensing machine that holds narcotics. Then she would go back to the patient’s bedside, scan the medication into Epic, and administer it.

  6. Sometimes when Armstrong went back to Epic, the screen was blank. Then she had to scan the patient again, and the patient’s routine medications would come up again. The PRN medicine list did not automatically appear. On occasion, Armstrong forgot to document the administration of those PRN medications because their screen did not appear.

  7. On November 19, 2009, a pharmacy audit was conducted for the period from October 1 through October 31, 2009. The pharmacy audit compared records from the Omnicell and Epic.

  8. Omnicell records show, for each nurse or other system user, the date and time the medication was pulled, the item number, the quantity, and the patient’s name.


  1. Epic records show, for each patient, the nurse who administered the medication, the time the patient was scanned, the quantity of medication given to the patient, and whether the medication was given, refused, or not given.

  2. The pharmacy audit revealed certain discrepancies between the narcotics withdrawn by Armstrong from the Omnicell and those accounted for in Epic.

  3. In all, St. John’s determined that Armstrong had ten administrations of fifteen medications during October that could not be accounted for.

  4. No patients reported that they did not receive their medications from Armstrong. Armstrong never appeared to be impaired at work.

  5. When Rachel Little, director of nursing for the skilled nursing care unit at St. John’s, asked Armstrong about the discrepancies, she could not explain them, except to say that they must be due to the new computer system, and other people had complained about it as well.

  6. Little pulled records for four other nurses working on the same hall as Armstrong and found that 100% of the narcotics they withdrew had been documented.

  7. At St. John’s request, Armstrong submitted to a drug screen. The results were negative.

  8. St. John’s terminated Armstrong’s employment. At the time of her dismissal, she had been employed by St. John’s for ten years. Little considered Armstrong to be a good, competent nurse. Patients liked her, and Little had no concerns about her performance.

Conclusions of Law

We have jurisdiction to hear the case.1 The Board has the burden of proving that Armstrong has committed an act for which the law allows discipline.2 This Commission must

judge the credibility of witnesses, and we have the discretion to believe all, part, or none of the testimony of any witness.3 We consider Armstrong to be a credible witness.

The Board alleges that there is cause for discipline under § 335.066:

2. The board may cause a complaint to be filed with the administrative hearing commission as provided by chapter 621 against any holder of any certificate of registration or authority, permit or license required by sections 335.011 to 335.096 or any person who has failed to renew of has surrendered his or his certificate of registration or authority, permit or license for any one or any combination of the following causes:
* * *
(5) Incompetency, misconduct, gross negligence, fraud, misrepresentation or dishonesty in the performance of the functions or duties of any profession licensed or regulated by sections 335.011 to 335.096;
* * *
(12) Violation of any professional trust or confidence[.]
Evidence

The Board alleges that Armstrong withdrew narcotics ten times and did not document them in Epic. The Board’s evidence to support this is that the Omnicell records show the withdrawal of the narcotics, but there are no Epic records for the same date for the same patient showing that Armstrong administered the medication. We agree that this might show that Armstrong did not document giving the medication, and we admitted both sets of records because Armstrong did not object to them. However, while Little testified that these were records regularly kept by St. John’s, and that one of her responsibilities was to refer to or review the records, the maker of the records did not testify, and no one testified that the records were

complete. At the hearing, in response to questioning on this issue, the following dialogue took place:

COMMISSIONER WINN: And when we look at these pages on Exhibit 3[4], it doesn’t look like 10/17/09 is even on this page at all. It begins at the bottom with 10/20.


THE WITNESS: There must not have been a correlating date for 10/17. I think the reason that this screen is shown is that these were documented on the 10/23 time frame. So this report when it’s given from pharmacy they give these two corresponding sheets.
COMMISSIONER WINN: So are you telling me there was no medication then for that date and that’s why there’s nothing showing up?
THE WITNESS: I’m not able to tell from this.
COMMISSIONER WINN: Actually I had a similar question about . . . the first example you gave was on I think a patient named J.M., but I don’t see her name on Exhibit 3 at all.
MR. WALKER: If I may inquire about both of those, Commissioner?
COMMISSIONER WINN: Sure.
BY MR. WALKER:
Q: Let me go to the M. one which may be, may or may not be easier, as to patient J.M. you were looking for when you printed Exhibit 3 any administration of medicines by Nurse Armstrong; is that correct?
A: Correct.
Q: And because there were no records in the Epic system as part of Exhibit 3 that nurse Armstrong administered medicine to Patient M., there is no corresponding page Exhibit 3?
A: Correct. And I’m guessing that’s why the 10/17. These reports are pulled by pharmacy, and they send them as a packet. They do the Epic check and the Epic, like what’s charted, not

charted, and then we take that part of the investigation and then decide how many medications we’re missing.


* * *
Q: So our testimony is that on Exhibit 3 there would be a corresponding entry on October 17 if Nurse Armstrong had administered medicine to Patient E.?
A: That is correct.
* * *
COMMISSIONER WINN: So then getting back over to the one we were just talking about, and that is oxycodone under L.E., that is a screen shot of every nurse who gave L.E. oxycodone, but it still looks to me like it is limited in time to between 10/20 and 10/24/09. Am I missing something?
MR. WALKER: The reason I think you’re right on that issue, Commissioner, is actually the very next entry . . . that is noted as being in Epic but we don’t have that screen page, sorry, Exhibit 2 notes that it is Epic . . . If we don’t have the record, we don’t have the record. It doesn’t look like we have the corresponding date of that one in our record Exhibit 3?
THE WITNESS: So if you see on page 2 of Exhibit 2, I agree with what the Commissioner is saying that you can’t see every medication through this time frame of 10/1 to 10/3. These were the reports that were given to me from the corresponding pharmacy generated reports.[5]
We have no reason to doubt the authenticity of the records from St. John’s that we took into evidence or the veracity of Little’s testimony. But in this proceeding, the Board has the burden of proof, and Armstrong’s license and livelihood are at stake. It is not enough to simply surmise that missing records denote a failure to administer medication.

In Armstrong’s answer, she wrote “Deny – insufficient knowledge” in response to the Board’s specific allegations that she withdrew narcotics and failed to document them. However,

in a separate written statement, and at the hearing, she did not deny that she might have failed to document the administration of the narcotics as alleged by St. John’s. Instead, she explained how such failure might have come about. Therefore, although the evidence supporting the Board’s allegations is weak, we find that Armstrong did fail to document the administration of narcotics withdrawn from the Omnicell on several occasions at St. John’s in October 2009.6

Professional Standards – Subdivision (5)

The Board alleges that there is cause to discipline Armstrong for misconduct, incompetence, and gross negligence in the performance of the functions or duties of an LPN. Misconduct means “the willful doing of an act with a wrongful intention[;] intentional wrongdoing.”7 We follow the analysis of incompetency in a disciplinary case from the Supreme Court.8 Incompetency is a “state of being” showing that a professional is unable or unwilling to function properly in the profession.9 Gross negligence is a deviation from professional standards so egregious that it demonstrates a conscious indifference to a professional duty.10

In particular, the Board points out that Armstrong admitted she made documentation errors under the Epic system, and that its expert testified that proper documentation of the administration of medications is very important for patient care. We agree with this, but the evidence shows that the Epic system was new to St. John’s and that Armstrong had difficulty using it properly. She made errors, but there is no evidence that she did anything with a

wrongful intent; accordingly, we find no misconduct. We also find no incompetency. We agree that multiple instances of inaccurate documentation of medication administration could evidence incompetency, and we have found this in the past.11 But in this case, the evidence was that Armstrong was an otherwise competent nurse who made the same error a number of times because of her lack of familiarity or understanding of a new documentation system. While the evidence shows that she was trained on the new system, it does not show that she was ever counseled and given a chance to improve. Finally, while we believe that Armstrong was negligent in failing to ensure that the medications were properly entered into Epic, we do not believe that her failures demonstrated a “conscious indifference to professional duty.” No evidence suggests that any patient failed to receive his or her medications or that Armstrong diverted narcotics. We do not find gross negligence.

We emphasize that we agree with the Board that accurate documentation of the administration of medications is an extremely important duty for a nurse, and a nurse who fails to fulfill this duty repeatedly would be subject to discipline. In this case, however, Armstrong made the same error several times during the course of one month due to her lack of familiarity with a new electronic documentation system. It is under these specific and limited circumstances that we find that she is not subject to discipline under § 335.066.2(5).

Professional Trust – Subdivision (12)

Professional trust is the reliance on the special knowledge and skills that professional licensure evidences.12 It may exist not only between the professional and her clients, but also between the professional and her employer and colleagues.13 Although we have found that Armstrong is not subject to discipline under § 335.066.2(5), she had an obligation to ensure that

the administration of narcotics to patients was properly documented, and she owed that duty to her patients and her colleagues. She evidently did not ensure that occurred on a number of occasions in October 2009. The evidence establishes that Armstrong was generally a good and competent nurse, but she violated the professional trust relationship with her patients and colleagues when she did not ensure those medications were properly documented. She is subject to discipline under § 335.066.2(12).

Summary

Armstrong is subject to discipline under § 335.066.2(12).

SO ORDERED on December 21, 2011.

________________________________

KAREN A. WINN

Commissione



1Section 621.045. Statutory references are to RSMo Supp. 2010 unless otherwise noted.

2Missouri Real Estate Comm’n v. Berger, 764 S.W.2d 706, 711 (Mo. App., E.D. 1989).

3 Harrington v. Smarr, 844 S.W.2d 16, 19 (Mo. App., W.D. 1992).

4 Exhibit 3 is the Epic record. Exhibit 2 is the Omnicell record.

5 Tr. at 16-20.

6 The Board also argues that two other instances support discipline of Armstrong’s license: an episode in which Armstrong documented the administration of a Fentanyl patch before she actually withdrew it from the Omnicell on October 2, 2009; and one in which she erroneously documented twice the administration of Percocet tablets on October 23, 2009. Those instances are not set forth in the Board’s complaint, however, and the complaint concerns only failure to document. We cannot find discipline for uncharged conduct, Dental Bd. v. Cohen, 867 S.W.2d 295, 297 (Mo. App., W.D. 1993), so we do not consider those in making our decision.

7Missouri Bd. for Arch’ts, Prof’l Eng’rs & Land Surv’rs v. Duncan, No. AR-84-0239 (Mo. Admin. Hearing Comm’n Nov. 15, 1985) at 125, aff’d, 744 S.W.2d 524 (Mo. App., E.D. 1988).

8Albanna v. State Bd. of Regis’n for the Healing Arts, 293 S.W.3d 423 (Mo. banc 2009).

9293 S.W.3d at 436.

10 Duncan, 744 S.W.2d at 533.

11 See, e.g., State Bd. of Nursing v. Hare, No. 10-2366 BN (Nov. 30, 2011).

12Trieseler v. Helmbacher, 168 S.W.2d 1030, 1036 (Mo. 1943).

13Cooper v. Missouri Bd. of Pharmacy, 774 S.W.2d 501, 504 (Mo. App., E.D. 1989).



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