Former Board Member Tri City Healthcare District, Charlene Mary Anderson Charged and Guilty of Gross...

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BOARD OF REGISTERED NURSING DEPARTMENT OF CONSUMER AFFAIRS

STATE OF CALIFORNIA

In the Matter of the Stipulated Settlement and Disciplinary Order Against: .

CHARLENE MARY ANDERSON 3360 Monroe Street Carlsbad, CA 92008

Registered Nurse License No. 461728

Respondent.

Case No. 2010-298

STIPULATED SURRENDER OF LICENSE AND ORDER

DECISION AND ORDER

The attached Stipulated Surrender of License and Order is hereby adopted by the

Board of Registered Nursing, Department of Consumer Affairs, as its Decision in this matter.

It is so ORDERED on Qc:t'of&'""fl- 2tel '2o1 '2--- .

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BEFORE THE BQARI) OF R,EGISTE~O NURSING

DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA

In the Matter Qf the Stipulated Settlement and Disciplinary Order Against:

CHARLENE MARY ANDERSON 3360 Monroe Street Carlsbad, CA 92Q08

Registered Nurse License Nq. 4(51728

Re$pondent.

Case No. 2010-298

STIPULATED SURRENDER OF LICENSE AND ORDER

IT IS HEREBY STIPULATED AND AGREED by and between the parties that

the following matters are tme:

PARTIES

1. Louise R. Bailey, M.Ed., R.N. (Complainant) is the Executive Officer of

the Board ofRegistered Nursing, who brought this action solely in her official capacity.

2. Charlene Mary Anderson (Respondent), is representing herself in this

proceeding and has chosen not to exercise her right to be represented by c.ounsel.

3. On or about March 31, 1991, the Board of Registered Nursing issued

Registered Nurse license No. 461728 to Respondent. The Registered Nurse license expired on

August 31, 2012 and has not been renewed.

JURISDICTION ' ' . .

4. On October 19, 2011, the Board of Registered Nursing adopted Proposed

Decision Case No. 2010-298, which became effective on November 18, 2011. The Disciplinary

Order requires, inter alia, the respondent to serve a 3-year probatio~ term that includes Probation

Conditions# 1-25. The Disciplinary Order is attached as exhibit A and incorporated herein by

reference.

5. At all times after the effective date of Respondent's probation, Condition

18 states,

"License Surrender. During Respondent's term of probation, if he

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ceases practicing due to retirement, health reasons or is otherwise

unable to satisfy the conditions of probation, Respondent may surrender

her license to the Board. The Board reserves the right to evaluate

Respondent's request and to exercise its discretion whether to grant the

request, or to take any other action deemed appropriate and reasonable

under the circumstances, without further hearing. 1)pon formal

acceptance of the tendered license and wall certificate, Respondent will

no longer be subject to the conditions of probation.

Surrender of Respondent's license shall be considered a disciplinary action

and shall become a part ofRespondent's license history with the Board. A

registered nurse whose license has been surrendered may petition the Board for

reinstatement no sooner than the following minimum periods from the effective

date of the disciplinary decision:.

(l) Two years for reinstatement ofa license that was·surrendered for

any reason other than a mental or physical illness; or* (2) One year for a license surrendered for a mental or physical illness."

ADVISEMENT AND WAIVERS

6. Respondent has carefully read and understands Disciplinary Order

Case No. 2010-298. Respondent has carefully read, and understands the effects of this

Stipulated Surrender of License and Order and understands that this Stipulated Surrender, if.

accepted by the Board, is considered as formal discipline of her license.

7. Respondent understands that by signing this stipulation she enables

the Board to accept the surrender of her Registered Nurse License without further process.

CONTINGENCY

8. This stipulation shall be subject to approval by the Board ofRegistered

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Nursing. The Respondent understands and agrees that py signing this Stipulated Surrender of

License and Order, she may not withdraw her agreement or seek to rescind the stipulation prior

to the date it becomes effective. If the Board declines to accept this stipulation as its Decision

and Order, the Stipulated Surrender of License and Order shall be ofno force or effect, except

for this paragraph, it shall be inadmissible in any legal action between the parties, and the Board

shall not be disqualified from further action by having considered this matter.

9. This Stipulated Surrender of License and Order is intended by the parties to

be an integrated writing representing the complete, final, and exclusive embodiment of their

agreement. It supersedes any and all prior or contemporaneous agreements, understandings,

discussions, negotiations, and commitments (written or oral). This Stipulated Surrender of

. License and Order may not be altered, amended, modified, supplemented, or otherwise changed

except by a writing executed by an authorized representative of each of the parties.

10. The parties understand and agree that facsimile copies of this Stipulated

Surrender of License and Order, including facsimile signatures thereto, shall have the same

force and effect as the originals.

11. In consideration of the foregoing stipulations, the parties agree that the

Board may; without further notice or formal proceeding, issue and enter the following Order:

ORDER

IT IS HEREBY ORPERED that Registered Nurse License No. 461728, issued to

Respondent, Charlene Mary Anderson, is surrendered and the surrender is accepted by the

Board of Registered Nursing.

12. The surrender of Respondent's Registered Nurse License and the

acceptance of the surrendered license by the Board shall constitute the imposition of discipline

against Respondent. This stipulation constitutes a record of the discipline and shall become a

part of Respondent's license history with the Board.

13. Respondent shall lose all rights and privileges as a Registered Nurse in

California as of the effective date of the Board's l)ecision and Order.

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:----

14. Respondent shall cause to be delivered to the Board both her pocket

license and wall certificate, if one was issued, on or before the effective date of the Decision

and Order.

15. Respondent fully understands and agrees that if she ever files an application for

licensure or a petition for reinstatement in the. State of California, the Board shall treat it as a

petition for reinstatement. Respondent must comply with all the laws, regulations and

procedures for reinstatement of a revoked license in effect at the time the petition is filed, and all

of the charges and allegations contained in Accusation No. 2010-298 shall be deemed to be true,

correct and admitted by Respondent when the Board determines whether to grant or deny the

petition.

16. Respondent shall not apply for licensure or petition for reinstatement for

2 years from the effective date of the Board ofRegistered Nursing's Decision and Order.

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ACCEPTANCE

I have carefully read the Stipulated Surrender ofLicense and Order. I understand

the stipulation and the effect it will have on my Registered Nurse License. I enter into this

Stipulated Surrender ofLicense and Order voluntarily, knowingly, and intelligently, and agree to

be bound by the Decision and Order of the Board of Registered Nursing.

DATED: /{)-Of'-/~

~g_~fl~~ ARYAN~RSON Respondent

ENDORSEMENT

The foregoing Stipulated Surrender of License and Order is hereby respectfully

accepted by Louise R. Bailey, M.Ed., R.N. (Complainant) is the Executive Officer for the Board

of Registered Nursing.

Louise R. Bailey, M.Ed., R.N. · Executive Officer

BOARD OF REGISTERED NURSING

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EXHIBIT "A"

Stipulated Settlement and Disciplinary Order No. 2010-298

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BEFORE THE BOARD OF REGISTERED NURSING


In the Matter of the Accusation Against:

CHARLENE MARY ANDERSON 81 7 N Tremont St Oceanside, CA 92054


Respondent.

Case No. 2010-298

OAH No. 2010010996

DECISION

The attached Proposed Decision of the Administrative Law Judge is hereby adopted by the Board of Registered Nursing as its Decision in the above-entitled matter.

This Decision shall become effective on November 18, 2011.

IT IS SO ORDERED this 19th day of October, 2011.

Pr Board ofRegistered Nursing Department of Consumer Affairs State of California

ident ·

()



In the Matter of the Accusation Against: Case No. 2010-298

CHARLENE MARY ANDERSON, RN Oceanside, CA OAH No. 2010010996


Respondent.

PROPOSED DECISION

Robert Walker, Administrative Law Judge, Office of Administrative Hearings, State of California, hearq.this matter in San Diego, California, on June 20 through June 23, 2011, and July 12, 2011.

Karen L. Gordon, Deputy Attorney General, represented the complainant, Louise R. Bailey, M.Ed., R.N., Executive Officer of the Board of Registered Nursing.

Richard H. Layon, Attorney at Law, represented the respondent, Charlene Mary Anderson.

The record was closed on July 12, 2011.

SUMMARY

Respondent is a registered nurse. During a four month period from May through August of 2006, respondent withdrew 33 narcotic tablets from a medication dispensing device but failed to account for either administering them to patients or destroying them.

Respondent testified that she administered''~verything.[she] pulled out ofPyxis" and is surprised that the documentation is not complete.

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Complainant does not allege that respondent diverted the drugs. That is, complainant does not allege that respondent failed to administer the drugs to patients. Also, complainant does not allege that respondent consumed any of the drugs. The factual allegation is simply that respondent failed to documentwhat she did with the drugs.

Complainant seeks revocation or suspension of respondent's license.

Complainant also seeks cost recovery, and there are issues concerning cost recovery.

In this decision, it is found and determined that there are grounds to discipline respondent's license and that the appropriate discipline is a stayed revocation with probation.

FACTUAL FINDINGS

Background

1. On March 31, 1991, the Board of Registered Nursing is~med registe~ed nurse license number 461728 to the respondent, Charlene Mary Anderson.

2. Respondent began working at Scripps Memorial Hospital in Encinitas in August of 2002. She worked in a postpartum unit. In September of 2006, an investigation disclosed that, in the four month period from May through August of 2006, respondent failed to document the disposition of 3 3 narcotic tablets. In September of 2006, Scripps terminated respondent.

3. Pyxis is the trade name of an automated device for dispensing medication. In order to withdraw a medication, one must enter a personal identification number. The device maintains a record of the medications dispensed. The record includes the name of the patient for whom a medication was withdrawn, the date and time the medication was withdrawn, and the identification code of the person who withdrew it.

4. When a nurse withdraws a medication, he or she has a duty to make a record of what was done with it. Ordinarily, a nurse administers a medication to the patient for whom it was withdrawn and makes a record of having administered it. On occasion, part or all of a medication needs to be destroyed, i.e., wasted. One may need to waste a medication because, for example, a patient refuses to take it or the order is for less than a full dosage. When a nurse wastes a narcotic medication, he or she must have another nurse witness the wastage, and both nurses must document the event.

. 5. In the postpartum unit at Sc~ipps, nl;lrses usually use a computer system called Watch Child to document the administration Ofmeaications. One can obtain printed flow sheets showing the information stored in Watch Child: Nurses can document the administration of medications in nursing notes.

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Failure to Document

6. Documenting the administration or wastage of medication is a critical function. It always is important, but it is particularly important in the circumstance in which the responsibility for a patient shifts from one nurse to another. This happens routinely when nurses change shifts. It does happen on other occasions, however, as when a nurse becomes ill or is given a different assignment because ofstaffing problems. If a nurse administers a medication but does not document having administered it, there is a risk that a nurse who takes over the patient's care may administer the medication again. And with certain medications, overmedication can create serious risks. Thus, before a nurse leaves a patient in the care of another nurse, he or she has a duty to document the administration of all medications.

7. During a four month period from May through August of 2006, respondent withdrew narcotic tablets from a Pyxis but failed to account for either administering them· to patients or wasting them. She withdrew but failed to document the disposition of 23 tablets ofPercocet, which is oxycodone with acetaminophen. She withdrew but failed to document the disposition of seven tablets of Vi co din, which is hydrocodone. She withdrew but failed to document the disposition of three tablets ofTylenol3, which is codeine with acetaminophen.

8. Patients in a postpartum unit commonly experience a high level of pain. All three of these narcotics are used to relieve pain.

9. In September of 2006, the administrative staff at Scripps concluded that they could not rely on respondent to practice safely, and they terminated her.

Respondent's Testimony

10. The following is a paraphrased summary ofpart ofrespondent's testimony. Charting is critical.to a nurse's job. I never knowingly failed to chart. Before it was brought to my attention, I had not realized there was a problem with my charting. I thought I was charting everything. I carried a paper on which I kept track of things I needed to chart. This is a common practice; nurses refer to·such notes as their "brain." I charted a soon as I could. At the end of my shift, I pulled a Pyxis report and reconciled my medication charting. This was my practice and custom, and I do not recall ever failing to follow it. One reason documentation is important has to do with minimizing the risk of over-medication; other nurses need to know what has been administered.

11. Respondent testified that she tried to provide safe care. She said her goal always was to insure safety for her patients.

12. Respondent, with a tone of pride, said her_ former patients who returned to have another child often asked that respondent be assigned to care for them.

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Matters in Mitigation

13. Respondent became a Licensed Vocational Nurse in 1969 and became a registered nurse in 1991. She has been has worked in nursing for42 years. There is no evidence of respondent's having engaged in unprofessional conduct on any other occasion. On one prior occasion at Scripps, an audit showed that respondent failed to document administration or wastage of two tablets ofVicodin. Respondent's supervisor counseled respo:ndent to be vigilant about documentation. While a nurse has a duty to document the administration or wastage of all medications, mistakes can occur, and a failure to document two tablets does not amount to unprofessional conduct.

14. . Respondent testified that, if she did fail to document, there was a combination of circumstances that may have contributed to her failure. It is difficult to anticipate staffing needs in a postpartum uriit because one cannot schedule when babies will be born. At times, a postpartum unit can become extremely busy without anyone having anticipated that. When that happens, supervisors call in other nurses. Also, supervisors often lend a hand and provide direct patient care. Nevertheless, there are times when postpartum nurses carry very heavy loads. Respondent testified that she often had a very heavy load at Scripps. She testified that, in the postpartum unit at Scripps, "they barely met state standards" for staffing ratios, and as things chang~d during a shift, they frequently failed to meet state standards. She implied that that may have accounted for some. failures to document.

· · 15. It was difficult to chart at the end of a shift because it was difficult to access a computer terminal. Respondent did not want to disturb patients by using the terminals in their rooms, and nurses coming on duty needed to use the other terminals·.

Expert Opinion that Respondent Engaged in Gross Negligence

16. Respondent called Cathy Horowitz as an expert witness. Ms. Horowitz holds a nursing degree and a public health nurse degree. She began her nursing career in 1971 in private practice as a childbirth nurse. She has held numerous nursing and public health nurse positions. From 2008 to the present she has been a staff nurse at the Vallejo campus of the St. Helena Center for Behavioral Health, where she cares for .mental health patients confined to a secured facility. She has been a guest lecturer at a number of colleges and universities. Her background and experience are such that she is very familiar with the requirement to document the administration of medications.

17. Ms. Horowitz testified that respondent's repeated failures to document her disposition of narcotics constituted an extreme depruiure from the standard of care. Ms. Horowitz said respondent's repeated failures to document her disposition of narcotics constituted gross negligence that rose to the level of incompetence and constituted an extreme departure from what is required of a nurse. ·- .:

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18. Ms. Horowitz testified that failing to document the administration of medications can result in over-medication, which can cause serious negative consequences. If a nurse administers a medication but fails to document the administration, another nurse may assume the medication was not administered and act on that assumption.

19. Ms. Horowitz testified that if a nurse is put in a situation in which she cannot document the disposition of medications, he or she should report that to a supervisor. If the supervisor fails to provide a satisfactory solution, the nurse should report to an independent authority.

Expert Opinion that Respondent's Conduct did not Fall Below the Standard ofCare.

20. Respondent called Laura Mitchell as an expert witness. Ms. Mitchell holds a Masters of Scienc~ degree in nursing with an emphasis in computer applications. She has been licensed as a registered nurse in California since 1989, and she is c~rtified as a public health nurse. In the 1998 - 1999 school year, Ms. Mitchell taught surgical nursing and obstetrics at Palomar College. She testified that she is a legal nurse consultant. Her background and experience are such that she is very familiar with the requirement to document the administration of medications. ·

21. Ms. Mitchell testified that the postpartum unit at Scripps was always busy and that staffing was either borderline or inadequate.

22. When Ms. Mitchell initially reviewed the evidence in this case, she conclud~d that respondent failed to document the disposition of medications. Subsequently, however, she changed her mind and concluded that, based on the quality of the evidence, she could not determine whether respondent documented the disposition of medications. The following is a paraphrased summary of part of Ms. Mitchell's testimony. A number of things caused her to change her mind. The Watch Child flow sheets that are in evidence as records of the administration of medications contain no vial signs, no information regarding consciousness, no place for a narrative, and no place for a signature. Also, the flow sheets do not bear the name of Scripps; they could have come from any hospital. Scripps policies require documentation but do not specify where one should document. It is possible that respondent

. documented in nurses notes. The flow sheets in evidence have time-specific columns, but time sheets should not be organized that way. They should be organized with one column for each hour. The columns on the' flow sheets in evidence are not of uniform width. The flow sheets do not have places for entries that specifically concern postpartum. It appears that whoever pulled the records was very selective in choosing which patient records to pull. Ms. Mitchell said that, based on all of these things her conclusion changed, and she cannot confirm that respondent failed to document the disposition of medications.

23. Ms. Mitchell's reasons for changing her conclusion are not persuasive. If respondent had documented the administration of medications in nursing notes, she should have obtained those notes and put them in evidence. She has said, however, that she documented,theadministration of medications in Watch Child, and there are numerous

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examples of her having done that correctly. There was no evidence that the Watch Child flow sheets were from some other hospital or that they did not concern respondent's patients. A good number of the things that caused Ms. Mitchell to change her conclusion could not have been more irrelevant.

24. Ms. Mitchell testified that, based on all of the things she reviewed, she concluded that respondent's conduct did not fall below the standard of care. Ms. Mitchell appeared to be hesitant to express this opinion, and her opinion was not convincing.

Rehabilitation

25. Respondent testified that she was sorry about the whole incident. She said that, when she was confronted with computer records that showed a failure to chart, she was appalled. In presenting her testimony, respondent was appropriately contrite.

26. There is no evidence that respondent's attitude about charting has changed, but it is significant that she testified that she recognizes the importance of charting and understands what needs to be done to minimize the risk of failing to chart. As noted above, respondent testified that charting is critical, and she never knowingly failed to chart. She. said she carried a "brain" on which she kept track of things and charted a soon as she could. She said she pulled a Pyxis report and reconciled her medication charting. Respondent's clear understanding of these things is a double edged sword. The fact that she understood these things but, nevertheless, failed to chart raises a question as to whether there is some other problem. On the other hand, the very real risk of losing her license is likely to have caused her to redouble her efforts and be more careful to cio what she clearly understands she is required to do.

Testimonial

27. Madeline Rodriguez, M.D., practices obstetrics and gynecology. Before respondent began working at Scripps in2002, she worked at Tri-City Medical Center in Oceanside. Dr. Rodriguez testified that she recalls respondent's having worked in the postpartum unit at Tri~City. Dr. Rodriguez said she always thought of respondent as being caring and compassionate. Dr. Rodriguez found respondent to be competent.

COSTS

28. Complainant submitted a certification of costs for work performed by the Division of Investigation, Department of Consumer Affairs (Division of Investigation) and for "Expert." Regarding the Division of Investigation, the certification concerns work performed in June of2007, July of2008, and Augustof2009 at a cost of$7,821. Regarding "Expert," the certification concerns work performed in September of 2010 at a cost of · $1,425. .

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29. Complainant also submitted a certification of costs for work performed by the Office of the Attorney General. The certification concerns work performed by an attorney and by a paralegal in 2009 through 2011 at a cost of $3 7,210. Attached to that certification is a form entitled "Matter Time Activity Summary." The certification says that the "summary . . . sets forth the tasks undertaken [and] the amount oftime billed for the activity ...." But that is not true; neither the summary nor the certification contains a description of the tasks performed or the time spent on the tasks.

30. · The total cost recovery sought is $46,456.

31. Business and Professions Code section 125.3, subdivision (a) provides, in part: . .

[T]he administrative law Judge may direct a licentiate found to have committed a violation or violations of the licensing act to pay a sum not to exceed the reasonable costs of the investigation and enforcement of.the case.

32. California Code ofRegulations, title 1, section 1042, subdivisions (b)(3), provides, in part:

[An affidavit] should contain sufficient information by which the ALI can determine the costs incurred in the matter and the reasonableness of such costs, for example, a general description of the tasks performed, the time spent on such tasks, and the hourly rate or other form of compensation.

33. In an award for costs, an essential finding is that the costs incurred were reasonable. Subdivision (b )(3), in providing that a certification should contain the time spent on such tasks, is not referring to the total time spent. It is referring to an enumeration of the time spent on various tasks so that the ALI can make some assessment as to whether the time spent on various tasks was reasonable.

34. In this case, neither certification contains a description of the tasks performed or the time spent on various tasks.

35. There is no doubt that the board incurred some reasonable costs. And no doubt the reasonable costs were substantial. But.neither of the certifications contains sufficient information to support a finding as to the amount of reasonable costs .

. 36. It is found that complainant failed to prove, within the terms of Business and Professions Code section 125.3, subdivision (a), the amount of the reasonable costs.

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LEGAL CONCLUSIONS

CAUSE TO DISCIPLINE RESPONDENT'S LICENSE

1. By reason of the matters set forth in Findings 6, 7, and 17, it is determined that respondent engaged in unprofessional conduct in that she withdrew narcotics but failed to document how she disposed of them. Thus, pursuant to Business and Professions Code section 2761, subdivision (a), there is cause to suspend or revoke her license.

2. Complainant alleges that respondent engaged in unprofessional conduct within the terms of Business and Professions Code section 2762, subdivision (e). That subdivision, however, concerns making improper entries. It does not concern a failure to make entries. It concerns falsifying entries or making grossly incorrect, grossly inconsistent, or unintelligible entries. There was no evidence that respondent did any ofthose things.

3. By reason of the matters set forth in Findings 6, 7, and 17, it is determined that respondent engaged in unprofessional conduct in that she engaged in gross negligence by repeatedly failing to provide nursing care as required. Thus, pursuant to Business and Professions Code section 2761, subdivision (a)(l), and California Code of Regulations, title 16, section 1442, there is cause to suspend or revoke her license.

4. By reason ofthe matters set forth in Findings 6, 7, and 17, it is determined that respondent engaged in unprofessional conduct in that she engaged in incompetence by failing

· to exercise that degree of learning, skill, care, and experience ordinarily possessed and . exercised by a competent registered nurse. Thus, pursuant to Business and Professions Code section 2761, subdivision (a)(l), and California Code of Regulations, title 16, section 1443, there is cause to suspend or revoke her license. ·

DISCIPLINARY GUIDELINES

5. The board's disciplinary guidelines recommend various levels of discipline. For a violation of Business and Professions Code section 2761, subdivision (a), the recommendation depends on what the transgression was, and the descriptions of transgressions are not exhaustive. That is, there are transgressions .that fall within section 2761, subdivision (a), but are not covered by the descriptions oftransgressions in the guidelines. Indeed, that is the circumstance with ·respondent's transgression. There is no guideline for a failure to document.

6. The guideline that is most analogous to a failure to document is guideline (b) for section 2761, subdivision (a). That guideline incorporates section 2762, subdivision (e), through section 2761, subdivision (a). As noted above, section 2762, subdivision (e), concerns falsifying entries or making grossly incorrect,. grossly inconsistent, or unintelligible entries. The guideline for making those improper e~tries recommends· discipline of a stayed revocation with three years of probation.

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PROBATION IS AN APPROPRIATE DISCIPLINE

7. In this case, that guideline identifies the appropriate discipline- a revocation of respondent's license with the revocation stayed and a probationary license issued for three years subject to appropriate conditions.

8. Respondent's failure to document the disposition of narcotics is a very serious matter. If she did not administer the medications to patients, she created a potential for harm by depriving them ofprescribed medications. If she did administer the medications to patients, she created a potential for harm by creating a risk of over-medication. On the other hand, there is no evidence that respondent actually harmed any patient. There is no record of any prior disciplinary action against respondent and no evidence that she has departed from the standard of care on any other occasion. And it has been almost five years since the . incidents of misconduct.

9. Respondent testified that she recognizes the importance of charting and understands what needs to be done to minimize the risk of failing to chart. She testified that charting is critical, and she never knowingly failed to chart. She said she carried a "brain" on which she kept track of things and charted a soon as she could. She said she pulled a Pyxis report and reconciled her medication charting. Thus, respondent understood these things and had appropriate safeguards in place but, nevertheless, failed to chart. This raises a question as to whether there is some problem other than simply a need to be more careful. For example, is there a medical problem that caused respondent not to do things she thought she was doing? Is there a medical problem that caused her to forget to do things she intended to . do? Because the evidence suggests these concerns, protection of the public requires that there be a professional assessment of respondent's ability to practice safely. As one condition of probation, respondent will be required to have a mental health examination, including psychological testing as appropriate, to determine her capability to perform the duties of a registered nurse.

10. No evidence was presented that respondent has practiced nursing since she was terminated from Scripps in September of2006. Because of that, protection of the public requires that respondent's probationary license be suspended until representatives of the board determine whether respondent should be required to enroll in and successfully complete a refresher course or courses as approved by representatives of the board; Protection of the public further requires that, in the event representatives of the board determine that respondent should be required to enroll in and successfully complete a refresher course or courses, the suspensionofrespondent's probationary license be continued

. until respondent successfully completes the required cours.e work.

COST RECOVERY

11. By reason ofthe matters set forth in Findings 28 through 36, the prayer for cost recovery must be denied.

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ORDER

License number 461 728 issued to the respondent is revoked. The revocation, however, is stayed for a period of three years, and respondent is placed on probation. Respondent's probationary license is immediately suspended until representatives of the

·board determine whether respondent should be required to enroll in and successfully complete a refresher course or courses. In the event representatives of the board determine that respondent should be required to enroll in and successfully complete a refresher course or courses, the suspension of respondent's probationary license shall continue until respondent successfully completes the required course work. The probationary license will be subject to the following conditions.

1. Each condition of probation is a separate and distinct condition. If any condition, or any application thereof, is declared unenforceable in whole, in part, or to any extent, the remainder of this order, and all other applications thereof, shall not be affected. Each condition of this order shall separately be valid and enforceable to the fullest extent permitted by law.

2. Respondent shall obey all federal, state, and local laws. Respondent shall comply with all court orders and all conditions of probation or parole. Respondent shall make a full and detailed account of any violation of law to the board in writing within 72 hours of the violation. To permit monitoring cif compliance with this term, respondent shall submit completed fingerprint cards arid fingerprint fees within 45 days of the effective date of this decision unless she previously submitted those as part of a license application.

3. Respondent shall fully comply with the terms and conditions of the board's probation program and shall cooperate with representatives of the board in all matters, including monitoring and investigation of respondent's compliance. Respondent shall inform the board in writing within no more than 15 days of any address change. At all times, including during any period of suspension, respondent shall maintain an active, current license. ·

4. Respondent shall appear in person for interviews or meetings as directed by the board or its representatives.

5. Periods of residency or practice outside of California will not apply to the . reduction of the probationary terni. Respondent must provide written notice to the board within 15 days of any change of residency or practice outside the state. Respondent must provide written notice to the board within 30 days prior to reestablishing residency or returning to practice in California.

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. . . ' 6. Respondent shall submit a list of all states and territories in which she has ever

been licensed as a registered nurse, vocational nurse, or practical nurse. Respondent shall advise the board of the status of e·ach license she has ever held as a registered nurse, vocational nurse, or practical nurse. If, at any time during the period of probation, the status

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of any such licep.se changes, respondent immediately shall advise the board of the change. If, at any time during the period ofprobation, respondent applies for or obtains a license as a nurse, vocational nurse, or practical nurse, she immediately shall advise the board of the application or license.

7. Respondent shall submit or cause to be submitted such written reports, declarations, and verifications as the board requires. These shall contain statements relative to respondent's compliance with the terms and conditions ofth~ board's probation program. Respondent shall immedi(:ltely execute all release of information forms that the board or its representatives require.

8. Respondent shall provide a copy of this decision to the nursing regulatory agency in every state or territory in which she has a registered nurse license.

9. Respondent, at some time during the period of probation, shall engage in the practice of registered nursing in California for a minimum of 24 hours per week for 6 consecutive months or as directed by the board. For purposes of compliance with this condition, "engage in the practice of registered nursing" may include, when approved by the board, volunteer work as a registered nurse or work in any non-direct patient care position that requires licensure as a registered nurse. The board may require that advanced practice nurses engage in advanced practice nursing for a minimum of 24 hours per week for 6 consecutive months or as directed by the board. If respondent has not complied with this condition during the probationary term but has presented documentation of her good faith efforts to comply, the board, in its discretion, may grant an extension of the probation period up to one year in order to provide respondent with a further opportunity to comply with this condition.

10. Respondent shall obtain prior approval from the board before commencing or continuing any employment, paid or voluntary, as a registered nurse. Respondent shall cause to be submitted to the board all performance evaluations and other employment related reports on the board's request.

11. Respondent shall provide a copy of this decision to her employer and immediate supervisor prior to commencement or continuation of any nursing or other health care related employment.

12. · Respondent shall notify the board in writing within 72 hours after she obtains any r1ursing or other health care related employment. Respondent shall notify the board in writing within 72 hours after she is terminated from any nursing or health care related employment with a full explanation of the circumstances surrounding the termination.

13: Respondent shall obtain prior approval fr~m the board regarding respondent's level of supervision or collaboration before commencing or continuing any employment as a registered nurse.

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14. Respondent shall practice only under the direct supervision of a registered nurse in good standing and with no current discipline, unless the board approves of alternative methods of supervision or collaboration. Examples of the levels of supervision or collaboration that the board may require are the following:

(a) The individual providing supervision or collaboration must be present in the patient care area or in any other work setting at all times.

(b) The individual providing supervision or collaboration must be present in the patient care unit or in any other work setting at least one-half of the hours respondent works.

(c) The individual providing supervision or collaboration must have person-toperson communication with respondent at least twice during each shift worked.

(d) If respondent is approved to work in the home health care setting, the individual providing supervision or collaboration shall have person-to-person communication with respondent as required by the board each workday. Respondent shall maintain telephone or other telecommunication contact with the individual providing supervision or collaboration as required by the board during each workday. The individual providing supervision or collaboration shali conduct, as required by the board, periodic, on-site visits to patients' homes visited by respondent.

15. Respondent shall not work for a nurse's registry, a temporary nurse placement agency, or an in-house nursing pool. Respondent shall not work as a traveling nurse or in any private duty position as a registered nurse. Respondent shall not work for a licensed home health agency as a visiting nurse unless the board has approved the registered nursing supervision and other protections for home visits. Respondent shall not work in any other registered nursing occupation in which home visits are required. Respondent shall not work in any health care setting as a supervisor of registered nurses. The board may restrict · respondent from supervising licensed vocational nurses or unlicensed assistive personnel. Respondent shall not work as a faculty member in an approved school of nursing or as an instructor in a board approved continuing education program~ Respondent shall work only ori a regularly assigned, identified, and predetermined work site and shall not work in a float capacity. Ifrespondent is working or intends to work in excess of 40 hours per week, the board may require documentation to determine whether there should be restrictions on the hours of work.

16. Respondent shall provide repr~sentatives of the board with complete information concerning respondent's practice of nursing after September of2006. Representatives of the board shall determine whether respondent can practice safely without enrolling in and completing a refresher course or courses. Respondent's probationary license shall be suspended until representatives of the board have .made this determination. If the

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representatives determine that a refresher course is not required, the suspension shall be lifted · immediately. If, however, representatives of the board determine that respondent should be required to enroll in and successfully complete a refresher course or courses, the suspension of respondent's probationary license shall continue until respondent, at her expense, successfully completes the required course work. Respondent's completion of a course will · satisfy this condition only if, prior to enrolling in the course, she obtained the board's approval of the course. Respondent shall submit to the board the original transcripts or certificates of completion for the course or courses. The board shall return the original documents to respondent after photocopying them for its records.

17, Respondent, at her expense, shall successfully complete a course relative to the practice of registered nursing no later than six months prior to the end of her probationary term. Respondent's completion of a course will satisfy this condition only if, prior to enrolling in the course, she obtained the board's approval of the course. Respondent shall submit to the board the original transcripts or certificates of completion for the course. The board shall return the original documents to respondent after photocopying them for its. records.

18. If respondent ceases to practice due to retirement, health reasons, or because she otherwise is unable to satisfy the conditions of probation, respondent may request permission to surrender her license to the board. The board may evaluate the request and exercise its discretion in deciding whether to grant the request, deny it, or take other action the board deems appropriate. Ifthe board formally accepts respondent's tender ofher license and wall certificate, respondent no longer will be subject to the conditions of probation. Surrender of respondent's license will be considered a disciplinary action and shall become part of respondent's license history. ·A registered nurse whose license has been surrendered may petition the board for reinstatement no sooner than the following minimum periods from the effective date oftheboard's decision to accept the surrender: Two years for reinstatement of a license that was surrendered for any reason other t4an a mental or physical illness or one

· year for a license surrendered because of a mental or physical illness.

19. Respondent, within 45 days ofthe·effective date of this decision, shall have a mental health examination, including psychological testing as appropriate, to determine her capability to perform the duties of a registered nurse. The examination will be performed by a psychiatrist, psychologist, or other licensed mental health practitioner whom the board has approved. The examining mental health practitioner will submit a written report of the assessment and recommendations to·the board. All costs are the responsibility of the respondent. Respondent shall institute and follow all recommendations for treatment, therapy, or counseling.

20. If the examining mental health practitioner determines that respondent is unable to practice safely as a registered nurse, the practitioner shall immediately notify the ·board and respondent by telephone, and the board shall-request that the Attorney General's office prepare a petition to revoke probation or an accusation. Respondent shall immediately cease practice and may not resume practice unless the .board notifies respondent in writing

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that, based on a mental health determination, respondent is permitted to resume practice. During the period of suspension, respondent shall not engage in any practice for which a license issued by the board is required. The period of suspension will not apply to the reduction of the probationary term.·

21. If respondent fails to have the above assessment submitted io the board within the 45-day requirement, respondent shall immediately cease practice and shall not resume practice unless the board authorizes that in writing. The period of suspension will not apply to the reduction of the probationary term. The board may waive or postpone this suspension only if significant, documented evidence of mitigation is provided. Such evidence must establish respondent's good faith efforts to obtain the assessment, and respondent must provide a specific date for compliance. Only one such waiver or extension will be granted.

22. If respondent violates the conditions of her probation, the board after giving respondent notice and an opportunity to be heard, may set aside the stay order a~d impose the stayed discipline.

23. If, during the period ofprobation, a petition to revoke probation or an accusation is filed against respondent's license or the Attorney General's. Office is requested to prepare a petition to revoke probation or an accusation, the probationary period shall not

· expire until the board has acted on the petition or accusation.

24. If respondent successful completes probation, her license will be fully restored.

25.. The prayer for cost recovery is denied.

DATED: July 28, 2011

ROBERT WALKER Administrative Law Judge Office of Administrative Hearings

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KAMALA D. HARRIS Attorney General of California LINDA K. SCHNEIDER Supervising Deputy Attorney General KAREN L. GORDON Deputy Attorney General State Bar No. 137969

110 West "A" Street, Suite 1100 San Diego, CA 92101 P.O. Box 85266 San Diego, CA 92186-5266 Telephone: (619) 645-3037 Facsimile: (619) 645-2061

Attorneys for Complainant



In the Matter of the Accusation Against:

CHARLENE MARY ANDERSON 817 N. Tremont Street Oceanside, CA 92054


Respondent.

Case No. 2010 298

FOURTH AMENDED ACCUSATION

Louise R. Bailey, M.Ed., RN ("Complainant") alleges:

PARTIES

1. Complainant brings this Fourth Amended Accusation solely in her official capacity as

the Executive Officer of the Board ofRegistered Nursing (Board), Department of Consumer

Affairs.

2. On or about March 31, 1991, the Board ofRegistered Nursing issued Registered

Nurse License Number 461728 to Charlene Mary Anderson (Respondent). The Registered Nurse

License was in full force and effect at all times relevant to the charges brought herein and will

expire on August 31, 2012, unless renewed.

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Fourth Amended Accusation

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JURISDICTION

3. This Accusation is brought before the Board ofRegistered Nursing (Board),

Department ofConsumer Affairs, under the authority of the following laws. All section

references are to the Business and Professions Code unless otherwise indicated.

4. Section 2750 ofthe Business and Professions Code (Code) provides, in

pertinent part, that the Board may discipline any licensee, including a licensee holding a

temporary or an inactive license, for any reason provided in Article 3 (commencing with section

2750) of the Nursing Practice Act.

5. Section 27 64 of the Code provides, in pertinent part, that the expiration of a license

shall not deprive the Board ofjurisdiction to proceed with a disciplinary proceeding against the

licensee or to render a decision imposing discipline on the license.

STATUTORY PROVISIONS

6. Section 2761 of the Code states:

The board may take disciplinary action against a certified or licensed nurse or deny an

application for a certificate or license for any of the following:

(a) Unprofessional conduct, which includes, but is not limited to, the following:

(1) Incompetence, or gross negligence in carrying out usual certified or licensed nursing functions.

7. Section 2762 of the Code states:

In addition to other acts constituting unprofessional conduct within the meaning of this chapter [the Nursing Practice Act], it is unprofessional conduct for a person licensed under this chapter to do any of the following:

(a) Obtain or possess in violation oflaw, or prescribe, or except as directed by a licensed physician and surgeon, dentist, or podiatrist administer to himself or herself, or furnish or administer to another, any controlled substance as defmed in Division 10 (commencing with Section 11000) ofthe Health and Safety Code or any dangerous drug or dangerous device as defmed in Section 4022.

(e) Falsify, or make grossly incorrect, grossly inconsistent, or unintelligible entries in any hospital, patient, or other record pertaining to the substances described in subdivision (a) of this section.

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REGULATORY PROVISIONS

8. California Code ofRegulations, title 16, section 1442, states:

As used in Section 2761 ofthe code, "gross negligence" includes an extreme departure from the standard of care which, under similar circumstances, would have ordinarily been exercised by a competent registered nurse. Such an extreme departure means the repeated failure to provide nursing care as required or failure to provide care or to exercise ordinary precaution in a single situation which the nurse knew, or should have known, could have jeopardized the client's health or life.

9. California Code of Regulations, title 16, section 1443 states:

As used in Section 2761 of the code, "incompetence" means the lack of possession of or the failure to exercise that degree of learning, skill, care, and experience ordinarily possessed and exercised by a competent registered nurse as described in Section 1443.5.

10. California Code ofRegulations, title 16, section 1443.5 states:

A registered nurse shall be considered to be competent when he/ she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows:

(1) Formulates a nursing diagnosis through observation of the client's physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team.

(2) Formulates a care plan, in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures.

(3) Performs skills essential to the kind of nursing action to be taken, explains the health treatment to the client and family and teaches the client and family how to care for the client's health needs.

(4) Delegates tasks to subordinates based on the legal scopes ofpractice of the subordinates and on the preparation and capability needed in the tasks to be delegated, and effectively supervises nursing care being given by subordinates.

(5) Evaluates the effectiveness ofthe care plan through observation of the client's physical condition and behavior, signs and symptoms of illness, and reactions to treatment and through communication with the client and health team members, and, modifies the plan as needed.

(6) Acts as the client's advocate, as circumstances require, by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the client the opportunity to make informed decisions about health care before it is provided.

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COST RECOVERY

11. Section 125.3 of the Code provides, in pertinent part, that the

Board/Registrar/Director may request the administrative law judge to direct a licentiate found to

have committed a violation or violations of the licensing act to pay a sum not to exceed the

reasonable costs ofthe investigation and enforcement ofthe case.

DRUGS \

12. "Percocet" is a Schedule II controlled substance pursuant to Health and Safety Code

section 11055, subdivision ((b)(1)(N), and a dangerous drug per Business and Professions Code

section 4022. Percocet is a brand name for the generic drug oxycodone with acetaminophen

and is used to treat pain.

13. "Vicodin" is a Schedule III controlled substance pursuant to Health and Safety Code

section 11 056( e)( 4) and a dangerous drug per Business and Professions Code section 4022.

Vicodin is a brand name for the generic drug hydrocodone. It is also known as

dihydrocodeinone with the non-narcotic substance acetaminophen and is used to treat pain.

14. "Tylenol3" is a Schedule III controlled substance pursuant to Health and Safety

Code section 11055 and a dangerous drug per Business and Professions Code section 4022.

Tylenol 3 is a generic name for codeine with acetaminophen and is a narcotic pain reliever

(analgesic).

FIRST CAUSE FOR DISCIPLINE

(Incorrect and/or Inconsistent Entries in Hospital and/or Patient Records)

15. Respondent is subject to disciplinary action under Code section 2761, subdivision (a),

on the grounds ofunprofessional conduct, as defmed in Code section 2762, subdivision (e), based

upon the following:

Scripps Memorial Hospital

16. Respondent was employed as a registered nurse at Scripps Memorial Hospital from

August of2002 until her termination in September of2006. Between or about May 4, 2006, and

August 29, 2006, while on duty as a registered nurse at Scripps Memorial Hospital, Respondent

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made grossly incorrect or grossly inconsistent entries in hospital and/or patient records, as

follows:

Patient 1 BP

a. On May 4, 2006, at 1028 hours, Respondent removed two Percocet tablets from the

Pyxis1 machine for this patient. No Medication Administration Record (MAR), Nursing Notes,

nor wastage were charted by Respondent. Two Percocet tablets were unaccounted for.

Patient 2 SM

b. On May 16, 2006, at 1828 hours, Respondent removed one Percocet tablet from the

Pyxis machine for this patient. No MAR, Nursing Notes, nor wastage were charted by

Respondent. One Percocet tablet was unaccounted for.

Patient 3 JLH

c. On July 10, 2006, at 0027 hours, Respondent removed one Percocet tablet from the

Pyxis machine for this patient. There was no Physician Order for Percocet for this patient. No

MAR, Nursing Notes, nor wastage were charted by Respondent. One Percocet tablet was

unaccounted for.

Patient 4 KH

d. On July 18, 2006, at 0048 hours, Respondent removed one Percocet tablet from the


Respondent. One Percocet ·tablet was unaccounted for.

Patient 4 KH

e. On July 18, 2006, at 0436 hours, Respondent removed two Percocet tablets from the


Respondent. Two Percocet tablets were unaccounted for.

1 Pyxis is a trade name for the automated single-unit does medication dispensing system that records information such as patient name, physician orders, date and time medication was withdrawn, and the name of the licensed individual who withdrew and administered the medication. Each user/operator is given a "user ID" code to operate the control panel. The user is required to enter a second code "PIN" number, similar to an ATM machine, to gain access to the medications. Sometimes only portions of the withdrawn narcotics are given to the patient. The portions not given to the patient are referred to as wastage. This waste must be witnessed by another authorized user and is also recorded by the Pyxis machine

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Patient 5 AC

£ On August 2, 2006, at 2002 hours, Respondent removed one Percocet tablet from the

Pyxis machine for this patie:pt. No MAR, Nursing Notes, nor wastage were charted by


Patient 5 AC

g. On August 2, 2006, at 2315 hours, Respondent removed Two Percocet tablets from

the Pyxis machine for this patient. No MAR, Nursing Notes, nor wastage were charted by


Patient 5 AC

h. On August 3, 2006, at 0139 hours, Respondent removed two Percocet tablets from the



Patient 5 AC

i. On August 3, 2006, at 0524 hours, Respondent removed two Percocet tablets from the



Patient 6 AP

j. On August 28, 20906, at 1223 hours, Respondent removed two Percocet tablets from



Patient 6 AP

k. On August 28, 2006, at 1531 hours, Respondent removed two Percocet tablets from



Patient 6 AP

1. On August 29, 2006, at 1023 hours, Respondent removed two Percocet tablets from



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Patient 6 AP

m. On August 29, 2006, at 1317 hours, Respondent removed two Percocet tablets from



Patient 7 AS

n. On July 13, 2006, at 502 hours, Respondent removed two Hydrocodone tablets from



Patient 7 AS

0. On July 13, 2006, at 2112 hours, Respondent removed two Hydrocodone tablets from


Respondent. Two Hydrocodone tablets were unaccounted for.

Patient 7 AS

p. On July 14, 2006, at 0046 hours,. Respondent removed two Hydrocodone tablets from

the Pyxis machine for this patient. Respo1;1dent charted in this patient's Medication Chart that one

(1) tablet was administered. There were no Nursing Notes and no wastage charted by

Respondent. One tablet ofHydrocodone was unaccounted for.

Patient 8 LCW

q. On August 8, 2006, at 0018 hours, Respondent removed two Hydrocodone tablets

from the Pyxis machine for this patient. There were no MAR, Nursing Notes nor wastage charted

by Respondent. Two tablets ofHydrocodone were unaccounted for.

Patient .9 SB

r. On July 6, 2006, at 0437 hours, Respondent removed one Tylenol with Codeine tablet

from the Pyxis machine for this patient. There was no Physician Order for Tylenol with Codeine

for this patient. There were no MAR, Nursing Notes nor wastage charted by Respondent. One

tablet of Tylenol with Codeine was unaccounted for.

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Patient 1 0 MM

s. On August 20, 2006, at 1626 hours, Respondent removed two Tylenol with Codeine

tablets from the Pyxis machine for this patient. There were no MAR, Nursing Notes nor wastage

charted by Respondent. Two tablets ofTylenol with Codeine were unaccounted for.

SECOND CAUSE FOR DISCIPLINE

(Gross Negligence)


on the grounds of gross negligence, as defmed by California Code of Regulations, title 16, section

1442, in that she repeatedly failed to provide nursing care as required or failed to provide care or

to exercise ordinary precaution in a single situation which she knew, or should have known, could

have jeopardized the client's health or life, in that between or about May 4, 2006 and August 29,

2006, while employed as a registered nurse, Respondent failed to chart the administration ofor

account for thirty-three (33) narcotic tablets in patients' MARs, Nursing Notes, or wastage as is

more fully described in paragraph 16, above.

TIDRD CAUSE FOR DISCIPLINE

(Incompetence)


on the grounds of incompetence as defmed by California Code ofRegulations, title 16, section

1443, in that she lacked possession of or failed to exercise that degree of learning, skill, care and

experience ordinarily possessed and exercised by a competent registered nurse, in that between or

about May 4, 2006 and August 29, 2006, while employed as a registered nurse, Re$pondent failed

to chart the administration ofor account for thirty-three (33) narcotic tablets in patients' MARs,

Nursing Notes, or wastage as is more fully described in paragraph 16, above.

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PRAYER

WHEREFORE, Complainant requests that a hearing be held on the matters herein alleged,

and that following the hearing, the Board ofRegistered Nursing issue a decision:

1. Revoking or suspending Registered Nurse License Number 461728, issued to

Charlene Mary Anderson Charlene Mary Anderson;

2. Ordering Charlene Mary Anderson to pay the Board of Registered Nursing the

reasonable costs of the inv.estigation and enforcement of this case, pursuant to Business and

Professions Code section 125.3;

3. Taking such other and further action as deemed necessary and proper.

DATED: ---,--{Q_'+)_ID_)~)...:......\_ UISE R. BAILEY, M.ED., RN

E ecutive Officer Board of Registered Nursing Department of Consumer Affairs State of California Complainant

SD2009804891

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Former Board Member Tri City Healthcare District, Charlene Mary Anderson Charged and Guilty of Gross...

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