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Case Studies

The case studies listed below are actual cases that have come before the Board.  Although disciplinary action taken by KBN is a matter of public record, the identity of the nurses are not revealed.

The Anonymous Complaint

One of the most challenging aspects of conducting a complaint investigation is when the complainant supplies no information about her/his identity when filing a complaint against a licensee.  This is particularly problematic when the complaint contains serious nursing practice allegations.  The nurse investigator has no one from whom to obtain concrete details surrounding the allegations.  These details can make the difference in determining whether a complaint is retaliatory in nature and may be harmful to the nurse’s reputation versus a complaint with merit where patient and/or public safety has been compromised. 

Anonymous complaints do not afford the nurses the opportunity to confront the accuser, to ask questions, and/or refute information provided by the complainant.  On the other hand, the complainant may wish to request anonymity in writing and the reasons for the request.  In these situations, KBN makes every attempt to withhold the name of the complainant.

CASE:

In the case of Nurse M, an anonymous complainant made a complaint alleging Nurse M failed to administer requested pain medication to 6 patients, falsified medication administration documentation, and refused to follow the patients’ treatment orders.  The complainant stated the nurse was terminated for these actions and gave the nurse’s employment location. 

The complainant was afraid of “retaliation” by Nurse M and gave no contact address or phone number.  In addition, the complainant did not supply full patient names or specific dates when the incidents occurred.  Consequently, medical records could not be obtained to verify allegations through documentation review and patient/provider interviews.  The employer had no knowledge of the allegations, but acknowledged Nurse M had been terminated for attendance issues.

RESULT:

This complaint was dismissed due to lack of evidence and cooperation from the complainant.

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Falsification of Medical Records & Administration of Medication Without a Physician’s Order

CASE:

Nurse BB has been licensed with the Kentucky Board of Nursing since 1999.  She holds a Bachelor’s prepared registered nurse license.  Nurse BB was employed as a full time, night shift charge nurse on a Cardiac Unit at a hospital in Kentucky.  Nurse BB wrote a physician’s order in a patient’s chart for “Ativan 1 mg IV push now” per verbal order from the physician.  However, Nurse BB never actually spoke to the physician to obtain the order and she subsequently administered the medication. The patient’s condition deteriorated and required transfer back to the Intensive Care Unit. 

Nurse BB admitted openly to her employer and Board staff that she indeed wrote the order.  However, Nurse BB also indicated that this was “common practice” in this unit.  She indicated that the physicians in the unit made it very clear that they were not to be bothered for such things as Tylenol or other simple matters.  The nurses were told to “use good judgment.”  Needless to say, Nurse BB was terminated from her position at the hospital.  Upon the hospital’s direction, Nurse BB self-reported the occurrence to the Board.  The hospital filed a formal complaint with the Board indicating Nurse BB was terminated for falsification of medical records and administration of medication without a physician’s order.

From an Investigator’s standpoint, this case exhibited a clear violation of the Kentucky Nursing Laws.  Due to the mitigating circumstances and the nurse’s report that this was “common practice” in that unit, the case was taken to the Credentials Review Panel (CRP) of the Board.  This panel is composed of three (3) Board members who review cases and provide direction to Board staff for final resolution of pending complaints.  After an extensive review of Nurse BB’s investigative file, CRP recommended a reprimand be issued on Nurse BB’s license for the seriousness of her inappropriate nursing actions.  The Board believed that Nurse BB worked in an environment that somewhat cultivated her inappropriate nursing actions.  However, the Kentucky Nursing Laws clearly hold each nurse accountable for her/his own actions.  Specifically, KRS 314.021 (2) reads, “All individuals licensed under provisions of this chapter shall be responsible and accountable for making decisions that are based upon the individuals' educational preparation and experience in nursing and shall practice nursing with reasonable skill and safety.”  Nurse BB clearly falsified medical records and practiced outside of her scope as a Registered Nurse by writing physician orders and administering medication without a legitimate order. 

RESULT:

Nurse BB was issued a Reprimand and had to pay a civil penalty of five hundred dollars ($500) to the Board in addition to attending the Board sponsored “Nursing Leadership Program”.  A referral was made to the Kentucky Board of Medical Licensure regarding the physician who had “expectations” that nurses practice outside of their scope and function.  A referral was also made to the Office of Inspector General related to the facility’s expectations of the medical and nursing staff.

Nurse BB was placed in a “No Win” situation.  If she called the physician she would suffer the consequences, since she did as he expected, she lost even more.  So for any nurse who finds him/herself in this situation; remember that you worked hard for your license and you need to protect it.  Advise the physician it is not within your scope, function and training to prescribe medications. Follow your chain of command when placed in these types of situations.  Any nurse who complies with these requests, not only places her/his license in jeopardy, but places the patient and facility at risk.

For practice related issues, contact Pamela C. Hagan, APRN Practice/Education Consultant, at 502-429-3311 or toll-free at 1-800-305-2042, ext 3311.

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The Drug Diverter 1

One of the most serious and disturbing complaint for the Board to investigate is when a complainant suspects that a nurse is diverting narcotic medications from their patients for their own personal use or for the use of others.  The allegations may indicate that a patient did not receive their narcotic medication and that the nurse is potentially addicted to the narcotic medication.

Drug abuse and drug diversion now rank among the top concerns of healthcare managers and human resource professionals and continues to be a growing problem in the healthcare industry. Drug diversion in facilities has the potential to put patients at risk as well as drain a facility’s budget. Diverters/abusers get their “fix” while patients suffer pain. In addition, health care workers have also become more creative in how they steal drugs and hide their addictions. Some employers do not require drug screening as a condition of employment, while others fail to have policies in place for random “for cause” drug screens.

Drug diversion by nurses is not only a violation of the Nursing Law it is also a violation of the Criminal Penal Code. Holding a nursing license is a privilege, not a right.  When a nurse receives her/his nursing license, they become a professional and must act accordingly. However, drug addiction is a disease and needs to be addressed with the nurse in an appropriate manner. The Board may take disciplinary action against a nurse who is found to have diverted drugs from their employer and/or make a referral to the Kentucky Alternative Recovery Effort (KARE) for Nurses Program, an alternative to discipline program.

CASE:

Nurse A has been a trusted employee at her facility for over ten (10) years.  Nurse A  also became addicted to Opiates after she was in a car accident three years ago that fractured a bone in her back.  She was prescribed Opiates by her primary care physician.  Nurse A started to take more than the required dose of medication and before long she was taking up to twenty pills on a daily basis.  Her physician was trying to wean her off the medication and was prescribing less and less of the medication, although her dependency was growing stronger.  Her only means of getting her “fix” was at work.  Nurse A would ingest her patient’s Demerol and give them Tylenol instead. She would chart the medication as given or wasted.  Nurse A would ask Nurse B to initial the medication as wasted, when in fact Nurse B had not witnessed the medication wasted.  Nurse B trusted Nurse A as a friend and co-worker; someone who she had worked with for over six years.  The facility started an internal investigation after several patients denied receiving their medication. An audit of the medical records revealed a pattern of discrepancies in the documentation and administration of narcotic medication by Nurse A.  The investigation revealed Nurse A’s cover up. Upon questioning, Nurse A admitted to the diversion. Nurse A and Nurse B were terminated from employment and reported to the Kentucky Board of Nursing.

VIOLATIONS:

  • KRS.013(4)(d) Has negligently or willfully acting in a manner inconsistent with the practice of nursing.
  • KRS.013(4)(f) Abuse use of controlled substances, prescription medications, or alcohol.
  • KRS.013(4)(g) Has misused or misappropriated any drugs placed in the custody of the nurse for administration, or for use of others.
  • KRS.013(4)(h) Has falsified or in a negligent manner making incorrect entries or failed to make essential entries on essential records.

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The Drug Diverter 2

CASE:

Nurse CC was licensed by the Kentucky Board of Nursing in 2002 as a licensed practical nurse.  He was employed full time, night shift in the Emergency Room (ER) of a hospital in Kentucky.  Nurse CC’s employment with the facility was pretty uneventful until the morning of his last shift.  He was allowed to leave early because he appeared sleepy.  Unfortunately, on his way home, he was involved in a single car accident and returned to the ER via a police escort for blood testing.  Vials of Demerol were found in Nurse CC’s car.   Needless to say, his ER visit was followed by a jail visit and subsequent termination from employment as a LPN for diversion of controlled substances for his own use.  A formal complaint was sent to the Board and an administrative complaint was entered for his misdemeanor conviction, Operating a Motor Vehicle Under the Influence of Alcohol/Drugs.  It does not stop there.

The facility conducted audits of their automated medication dispensing system and charts of patients cared for by Nurse CC over a six (6) month timeframe.  The results indicated discrepancies that increased over time and indicated a dramatic escalation of diversion by Nurse CC.  Nurse CC removed controlled substances on patients without orders for the medications, removed controlled substances on patients that were previously discharged from the ER and not yet been removed from the system, and he failed to document administration of the controlled substances in the charts of the patients that had orders for the medication.  The manager of the ER reported no indications of on-duty impairment throughout his employment with them; other than the morning he was sent home due to sleepiness. 

Once this was reported to the Board, Nurse CC was issued an Order for a Chemical Dependency Evaluation.  To no surprise, the evaluator confirmed a diagnosis of chemical dependency and recommended completion of an Intensive Outpatient Treatment Program.  Nurse CC appeared for an investigative meeting and admitted he diverted controlled substances for his own use.  Entry into the Kentucky Alternative Recovery Effort for Nurses Program (KARE) was discussed as possible resolution to the complaints before the Board as opposed to formal disciplinary action on Nurse CC’s license.  Nurse CC would have to show proof of completion of the evaluator’s recommendations before a formal referral to KARE could be made.

The Board recognizes chemical addiction as a disease.  Nurse CC was obviously suffering from his addictions, primarily to Morphine and Demerol, and would have been a prime candidate for KARE.  He seemed amenable to that possibility. 

Nurse CC failed to maintain further contact with the Board and his case was scheduled for a hearing.  The Board moved for a default order and it was granted pursuant to KRS 13B.080 (6).  This means that Nurse CC failed to respond to the Notice of Hearing and Statement of Charges he was sent via certified mail and he failed to respond or appear at a pre-hearing conference at the Board office. 

Again, it does not stop there.  Nurse CC continued to ignore the Board’s correspondence and ultimately his license was REVOKED for failure to return the license card to the Board.  Not only must he petition for a hearing to request reinstatement of his nursing license, he now must comply with requirements of 201 KAR 20:225 by taking the licensure examination again and achieving a passing score.  Yes, he must take and pass NCLEX again.   In and of itself, taking the NCLEX again could be a nurse’s worst nightmare.

From an Investigator’s standpoint, this case exhibited clear violations of the Kentucky Nursing Laws and could have been resolved in the best interest of the nurse.  However, due to Nurse CC’s noncompliance with the Board, his road to recovery will have many more obstacles and hurdles to overcome.

RESULT:

The Board agreed that Nurse CC’s license should be suspended for one (1) year and he would need to request a hearing to consider reinstatement of his license.  By failing to return his nursing license card to the Board as required his nursing license was revoked.

There can be many lessons learned from this case:

  1. Be aware of your peers and recognize drug use in the workplace.  Look for signs of impairment which include but are not limited to: excessive sick leave, patterns in absenteeism, over willingness to medicate other nurses’ patients, appearing on the floor on their scheduled days off, extended breaks and lunches, personality changes, patient complaints, increased mistakes, errors in judgment, suddenly unable to meet deadlines, inability to perform routine tasks, or sleepiness.

  2. Be aware of the nursing law as it relates to notification of the Board of any criminal conviction, KRS 314.109 reads “…any misdemeanor or felony criminal convictions, except traffic-related misdemeanors other than operating a motor vehicle under the influence of drugs or alcohol, in this or any other jurisdiction.”

  3. Notify KBN of any change in address as the law mandates according to KRS 314.107.  It is possible that Nurse CC merely moved and he failed to change his address with the Board.

  4. Know that the KARE for Nurses Program is a confidential alternative to discipline program to assist nurses with chemical dependency to return to safe nursing practice.

  5. Read the KBN Connection for updates and changes related to the law.  Remember, you worked hard for your license and you need to protect it.  The license you save could be your own.   

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Last Updated 3/25/2014
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