STATE OF FLORIDA DEPARTMENT OF HEALTH Final Order No. DOH-18-0217-00 1QA FILED DATE - 5E13 0 1 2018 Department of Health By. eputy Agency Clerk In Re: Emergency Restriction of the License of ORDER OF EMERGENCY RESTRICTION OF LICENSE Celeste Philip, M.D., M.P.H., State Surgeon General, ORDERS the emergency restriction of the license of, (Ms. Whitson) to practice as a registered nurse in the State of Florida. Ms. Whitson holds license number RN 9455673. Ms. Whitson's address of record is 7840 Lilac Lane, Apartment 107.1 The following Findings of Fact and Conclusions of Law support the emergency restriction of Ms. Whitson's license to practice as a nurse in the State of Florida. FINDINGS OF FACT 1. The Department of Health (Department) is the state agency charged with regulating the practice of nursing pursuant to Chapters 20, 456, and 464, Florida Statutes (2017). Section 456.073(8), Florida Statutes (2017), authorizes the State Surgeon General to summarily restrict Ms. Whitson's license to practice as a nurse in the State of Florida, in accordance with Section 120.60(6), Florida Statutes (2017). 1 Ms. Whitson has indicated that her current address is 9841 Crestmont Circle, Pensacola, Florida.
2. At all times material to this Order, Ms. Whitson was licensed as a registered nurse in the State of Florida, pursuant to Chapter 464, Florida Statutes, and was employed by Lakeview Center Baptist Health Care (Lakeview Center), located in Pensacola, Florida. 3. On December 6, 2017, Patient J.A., a 33-year-old male presented to the Baptist Hospital Emergency Room, located in Pensacola, Florida, with complaints of increased depression and suicidal ideation. 4. Patient J.A. was placed under a Baker Act2 and was involuntarily admitted to Lakeview Center for acute stabilization and observation. occasions. 5. Patient J.A. admitted to attempting suicide on two previous 6. Lakeview Center staff were required to observe Patient J.A. every 15 minutes. 7. On December 10, 2017, Ms. Whitson reported to work and was responsible for Patient J.A. 2017. 8. Ms. Whitson observed Patient J.A. at 6:45 p.m. on December 10, 2 Pursuant to Chapter 394, Florida Statutes, the Baker Act permits the involuntary commitment and examination of an individual who has been found to possibly have a mental illness and is a harm to self, harm to others, or is self-neglectful. 2
9. Ms. Whitson did not return to check on Patient J.A. until 12:40 a.m. on December 11, 2017. 10. At 12:40 a.m., Patient J.A. was found deceased, hanging from the bathroom door. Patient J.A. had tied bedsheets provided by Lakeview Center to the handle of the bathroom door and his neck. 11. At the time of Patient J.A.'s death, Ms. Whitson told her supervisors that she had checked on Patient J.A. every 15 minutes, as required. Ms. Whitson stated that she had last seen Patient J.A. at 12:00 a.m. and that he was sleeping in his bed. Ms. Whitson admitted to missing the 12:15 a.m. and 12:30 a.m. rounds because she was busy. 12. Ms. Whitson further stated that she requested E.G., a tech, to complete her charts for her. The charts reveal that Ms. Whitson purportedly observed Patient J.A. every 15 minutes as required. Ms. Whitson stated that she watched E.G. fill in the charts to ensure their accuracy. 13. However, video surveillance from that night revealed that during her shift, Ms. Whitson only observed Patient J.A. twice. The last time Ms. Whitson observed Patient J.A. prior to his death was at approximately 10:32 p.m. 14. Based on the video surveillance, Ms. Whitson not only failed to observe Patient J.A. every 15 minutes as required, but also instructed another 3
employee to create false records on her behalf. In Re: Emergency Restriction of the License of 15. An expert in the practice of nursing reviewed this matter and opined that Ms. Whitson fell below the standard of care in her treatment of Patient J.A. Ms. Whitson failed to observe a patient suffering from delusions, depression, and suicidal ideations as often as required. 16. Indeed, between 6:45 p.m. and 12:45 a.m., Ms. Whitson should have observed Patient J.A. 25 times. However, Ms. Whitson only observed him twice. 17. Registered nurses are entrusted with the care of their patients and have the responsibility of ensuring that their patients are not harmed. Ms. Whitson practiced nursing in the Acute Stabilization Unit of a hospital, a setting with patients suffering acute psychiatric symptoms, including suicidal ideation and intent. Nurses in this setting are required possess good judgement and to provide attention and care to their patients. Ms. Whitson's failure to observe Patient J.A. every 15 minutes fell below the required standard of care and contributed to Patient J.A.'s untimely death. Furthermore, Ms. Whitson's failure to honestly report her conduct to her supervisor and her falsification of records indicates that she lacks the judgment and moral character necessary to practice as a nurse in the state of Florida. Any patient admitted to a psychiatric unit and 4
under Ms. Whitson's care, is likely to be in the same or similar setting to Patient J.A. The severity of Ms. Whitson's negligence compounded by her attempt to cover it up through falsified records indicates that her conduct is likely to continue. Therefore, Ms. Whitson's continued unrestricted practice as a nurse presents an immediate, serious danger to the health, welfare, and safety of the public. 18. Based on Ms. Whitson's egregious failure to meet the standard of care in the treatment of Patient J.A., her falsification of records, and her failure to honestly recount the events related to Patient J.A.'s death, there are no lessrestrictive means other than the terms outlined in this Order that will adequately protect the public. CONCLUSIONS OF LAW Based on the foregoing Findings of Fact, the State Surgeon General concludes as follows: 1. The State Surgeon General has jurisdiction over this matter pursuant to Sections 20.43 and 456.073(8), Florida Statutes (2017), and Chapter 464, Florida Statutes (2017), as set forth above. 2. Section 464.018(1)(f), Florida Statutes (2017), authorizes discipline, including restriction, against a nurse for making or filing a false report or record,
which the licensee knows to be false, intentionally or negligently failing to file a report or record required by state or federal law, willfully impeding or obstructing such filing or inducing another person to do so. Such reports or records shall include only those which are signed in the nurse's capacity as a licensed nurse. 3. Ms. Whitson violated Section 464.018(1)(f), Florida Statutes, by instructing a tech to falsify Patient 3.A.'s records on her behalf. 4. Section 464.018(1)(h), Florida Statutes (2017), authorizes discipline, including restriction, against a nurse for engaging in unprofessional conduct, as defined by board rule. 5. Rule 64B9-8.005(6), Florida Administrative Code, defines unprofessional conduct to include falsifying or altering patient records or nursing progress records, employment applications, or time records. 6. Ms. Whitson engaged in unprofessional conduct by instructing a tech to falsify Patient 3.A.'s records on her behalf. 7. Section 464.018(1)(n), Florida Statutes (2017), authorizes discipline, including restriction, against a nurse for failing to meet minimal standards of acceptable and prevailing nursing practice, including engaging in acts for which the licensee is not qualified by training or experience. 6
8. Ms. Whitson failed to meet the minimal standard of acceptable and prevailing nursing practice by: a. Failing to observe Patient J.A. every 15 minutes as required; b. Delegating the task of charting her observation of Patient J.A. to E.G.; c. Instructing E.G. to falsify Patient J.A.'s progress notes; d. Lying to Lakeview Center staff about her treatment of Patient J.A. following Patient J.A.'s death. 9. Section 456.072(1)(m), Florida Statutes (2017), authorizes discipline, including restriction, against a nurse for making deceptive, untrue, or fraudulent representations in or related to the practice of a profession or employing a trick or scheme in or related to the practice of a profession. 10. Ms. Whitson made deceptive, untrue, or fraudulent representations in or related to the practice of nursing by falsely stating that she observed Patient J.A. every 15 minutes during her shift beginning on December 10, 2017. 11. Section 120.60(6), Florida Statutes (2017), authorizes the State Surgeon General to summarily restrict a nurse's license upon a finding that the nurse presents an immediate, serious danger to the public health, safety, or welfare. 7
12. Ms. Whitson's continued unrestricted practice as a nurse constitutes an immediate, serious danger to the health, safety, or welfare of the citizens of the State of Florida, and this summary procedure is fair under the circumstances to adequately protect the public. WHEREFORE, in accordance with Section 120.60(6), Florida Statutes (2017), it is ORDERED THAT: 1. The license of, to practice as a registered nurse, license number RN 9455673, is immediately restricted to prohibit Amanda Whitson, R.N. from practicing nursing in any setting in which she is responsible for the care of suicidal patients and acute patient care and observation, including in any psychiatric unit, intensive care unit, or similar setting. 2. A proceeding seeking formal discipline of the license of Amanda Whitson, R.N., to practice as a nurse in the State of Florida will be promptly instituted and acted upon in compliance with Sections 120.569 and 120.60(6), Florida Statutes (2017). [Signature appears on following page] 8
DONE and ORDERED this 2018. Celeste thilip, M.D., M.P.H. Surgeon General and Secretary PREPARED BY: Kristen M. Summers Assistant General Counsel DOH Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, FL 32399-3265 Florida Bar Number 112206 (T) (850) 558-9909 (F) (850) 245-4662 (E) Kristen.Summers@flhealth.gov 9
NOTICE OF RIGHT TO JUDICIAL REVIEW Pursuant to Sections 120.60(6), and 120.68, Florida Statutes, the Department's findings of immediate danger, necessity, and procedural fairness shall be judicially reviewable. Review proceedings are governed by the Florida Rules of Appellate Procedure. Such proceedings are commenced by filing a Petition for Review, in accordance with Florida Rule of Appellate Procedure 9.100, and accompanied by a filing fee prescribed by law with the District Court of Appeal, and providing a copy of that Petition to the Department of Health within thirty (30) days of the date this Order is filed. 10