ORDER OF EMERGENCY SUSPENSION OF LICENSE

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1 Final Order No. DOH-I QA FILED DATE -R AA Department of Health STATE OF FLORIDA DEPARTMENT OF HEALTH In Re: Emergency Suspension of the License of By Deputy Agency Clerk ORDER OF EMERGENCY SUSPENSION OF LICENSE H. Frank Farmer, Jr., MD, PhD, FACP, State Surgeon General, ORDERS the emergency suspension of the license of, to practice as a registered nurse. Ms. Pfeiffer holds license number RN Her address of record is 2337 Galahad Avenue, Spring Hill, Florida The following Findings of Fact and Conclusions of Law support the emergency suspension of Ms. Pfeiffer's license to practice as a registered nurse. 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. Section (8), Florida Statutes, authorizes the State Surgeon General to summarily suspend Ms. Pfeiffer's license to practice as a registered nurse in accordance with Section (6), Florida Statutes. 2. At all times material to this order, Ms. Pfeiffer was licensed to practice as a registered nurse pursuant to Chapter 464, Florida Statutes ( ). 3. On or about February 8, 2010, Ms. Pfeiffer contacted the Intervention Project for Nurses (IPN), and stated that she had been abusing her husband's prescribed oxycodone and was unable to stop. Ms. Pfeiffer reported that she had been

2 abusing the drug for about one year. Ms. Pfeiffer also reported that she was given an intervention at work due to concerns from her co-workers. Ms. Pfeiffer was asked to submit to a drug test, which returned positive for amphetamines. Ms. Pfeiffer stated she was given a diet pill by a friend and is not prescribed amphetamines. Ms. Pfeiffer reported that she had a prescription for Xanax that she took occasionally for anxiety. The IPN case manager advised Ms. Pfeiffer about the requirements of IPN participation including the requirements to refrain from nursing practice and submit to an IPNfacilitated evaluation. 4. IPN is the impaired practitioner program for the Board of Nursing, pursuant to Section , Florida Statutes. IPN is a program that monitors the evaluation, care and treatment of impaired nurses. IPN oversees random drug screens and provides for the exchange of information between treatment providers, evaluators and the Department for the protection of the public. 5. Oxycodone is an opiate class drug prescribed to treat pain. According to Section (2), Florida Statutes, oxycodone is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States. Abuse of oxycodone may lead to severe psychological or physical dependence. 6. Opiate, or opioid, drugs have similar actions as the drug opium and are typically prescribed to treat pain. Opioid drugs are synthetically manufactured, while opiate drugs are naturally occurring, but the terms opioid and opiate are often used interchangeably. Opioid drugs are addictive and subject to abuse. 2

3 7. According to Section (2), Florida Statutes, amphetamine is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States. Abuse of amphetamine may lead to severe psychological or physical dependence. 8. Xanax is the brand name for alprazolam and is prescribed to treat anxiety. According to Section (2), Florida Statutes, alprazolam is a Schedule IV controlled substance that has a low potential for abuse relative to the substances in Schedule III and has a currently accepted medical use in treatment in the United States. Abuse of alprazolam may lead to limited physical or psychological dependence relative to the substances in Schedule III. 9. On or about March 24, 2010, Ms. Pfeiffer submitted to an IPN-facilitated evaluation conducted by Martha E. Brown, M.D., a specialist in addiction psychiatry. At the evaluation, Ms. Pfeiffer reported that she began taking her husband's oxycodone about a year prior to the evaluation. Ms. Pfeiffer reported that she was taking four 30 milligrams (mg) tablets of oxycodone a day and had tapered down to three 15 mg tablets a day. Ms. Pfeiffer reported that she had withdrawal symptoms if she did not take the oxycodone. Ms. Pfeiffer stated she took amphetamines just one time in an attempt to increase her energy level and it was detected in an employer-ordered drug test, which resulted in her losing her job. The drug test done in conjunction with the evaluation retunred positive for oxycodone. Dr. Brown diagnosed Ms. Pfeiffer with opiate dependency and depressive disorder. Ms. Brown opined that Ms. Pfeiffer was not able to practice nursing with reasonable skill and safety. Dr. Brown recommended 3

4 detoxification from the opiate drugs, complete an intensive outpatient chemical dependency treatment program, be evaluated for her depressive symptoms, abstain from all mood-altering substances including alcohol, and that Ms. Pfeiffer be monitored by IPN. 10. On or about April 14, 2010, the IPN case manager contacted Ms. Pfeiffer and provided her with the contact information for several facilities where Ms. Pfeiffer could receive the recommended treatment. 11. On or about May 5, 2010, Ms. Pfeiffer underwent an intake evaluation for admission into intensive outpatient treatment at HealthCare Connection. During that evaluation, the evaluators believed that Ms. Pfeiffer was under the influence of a substance was unsafe to drive home. HealthCare Connection staff contacted a member of Ms. Pfeiffer's family to drive her home. 12. On or about June 3, 2010, one of the physicians from HealthCare Connection contacted IPN and provided the IPN case manager with an update on Ms. Pfeiffer's treatment. The physician explained that Ms. Pfeiffer appeared under the influence during the initial evaluation and he believed that Ms. Pfeiffer might need either inpatient treatment or an inpatient evaluation. However, the physician would only allow her to enter into intensive outpatient treatment if she was not under the influence of substances on her admission to treatment. The physician informed the IPN case manager that he planned to contact Ms. Pfeiffer to discuss her treatment options. 13. On or about June 14, 2010, Ms. Pfeiffer entered into intensive outpatient substance abuse treatment at HealthCare Connection. 4

5 14. On or about June 22, 2010, Ms. Pfeiffer submitted to a drug test as required by HealthCare Connection's treatment program. That drug test returned positive for oxycodone. 15. On or about June 24, 2010, HealthCare Connection notified IPN that Ms. Pfeiffer's drug test was positive for oxycodone. 16. On or about June 29, 2010, HealthCare Connection notified IPN that Ms. Pfeiffer had not returned to treatment since her positive drug test and that they had been unable to make contact with her. 17. On or about July 1, 2010, IPN sent a letter to Ms. Pfeiffer advising her to return to chemical dependency treatment or risk dismissal from IPN. IPN gave Ms. Pfeiffer a deadline of July 13, 2010, to restart treatment. 18. On or about July 8, 2010, Ms. Pfeiffer sent an to one of the treating physicians at HealthCare Connection explaining that she had relapsed. In the Ms. Pfeiffer expressed regret and indicated that she planned to return to treatment on or about July 12, Ms. Pfeiffer did not return to treatment on or about July 12, On or about July 22, 2010, after receiving no correspondence from Ms. Pfeiffer regarding her treatment, IPN contacted HealthCare Connection to determine whether or not Ms. Pfeiffer returned to treatment. The representative from HealthCare Connection advised that they had received no contact from Ms. Pfeiffer and that she had not returned to treatment. 5

6 21. On or about July 26, 2010, IPN made the decision to terminate Ms. Pfeiffer's monitoring contract with IPN due to Ms. Pfeiffer's refusal to return to chemical dependency treatment. 22. On or about July 28, 2010, Ms. Pfeiffer contacted IPN and asked that she not be terminated from the program. Ms. Pfeiffer stated she planned to be admitted to Town and Country Hospital for detoxification from the oxycodone that she continued to take. The IPN case manager allowed Ms. Pfeiffer to remain in IPN. 23. On or about July 28, 2010, Ms. Pfeiffer was admitted to Town and Country Hospital for detoxification from opioid drugs, specifically oxycodone. At admission, Ms. Pfeiffer stated that she was taking six oxycodone 30 mg tablets a day. 24. On or about July 31, 2010, Ms. Pfeiffer was discharged from Town and Country Hospital after being detoxified from oxycodone. The treatment plan was for Ms. Pfeiffer to enter into intensive outpatient chemical dependency treatment. 25. From on or about July 31, 2010, until on or about October 28, 2010, Ms. Pfeiffer informed IPN about various plans to enter into intensive outpatient treatment at several different facilities including one in the State of New York. However, Ms. Pfeiffer never enrolled in intensive outpatient treatment during that time. 26. On or about November 2, 2010, Ms. Pfeiffer began intensive outpatient chemical dependency treatment at Springbrook Hospital, in Brooksville, Florida. 27. On or about December 17, 2010, Ms. Pfeiffer completed intensive outpatient chemical dependency treatment at Springbrook Hospital. 6

7 28. From on or about January 18, 2011, until on or about January 20, 2011, Ms. Pfeiffer was hospitalized for mental health issues. 29. On or about January 28, 2011, the IPN case manager spoke to Ms. Pfeiffer and directed her to send IPN a copy of the discharge summary from her recent hospitalization. Ms. Pfeiffer advised IPN that she was prescribed Klonopin. IPN informed Ms. Pfeiffer that if she needed to remain on Klonopin long term, she would need an evaluator to clear her to return to nursing practice while taking Klonopin. Ms. Pfeiffer was not approved to return to nursing practice at that time. 30. Klonopin is the brand name for clonazepam and is prescribed to treat anxiety. According to Section (2), Florida Statutes, clonazepam is a Schedule IV controlled substance that has a low potential for abuse relative to the substances in Schedule III and has a currently accepted medical use in treatment in the United States. Abuse of clonazepam may lead to limited physical or psychological dependence relative to the substances in Schedule III. 31. On or about February 1, 2011, Ms. Pfeiffer signed a five-year IPN monitoring contract that required her to remain free from all mood-altering, controlled, or addictive substances, including alcohol; attend a facilitated nurse support group; attend alcoholics anonymous/narcotics anonymous meetings; see a psychiatrist for drug testing; and to submit to random drug testing. Ms. Pfeiffer was not approved to return to nursing practice at that time. 32. Incorporated into the IPN monitoring contract was the IPN Participant Manual, which outlined additional requirements of IPN participation. According to the 7

8 IPN Participant Manual, if a nurse exhibits relapse behaviors, the nurse would be required to refrain from nursing practice, submit to another IPN-facilitated evaluation, and attend treatment at a higher level of care than received in the past. 33. On or about February 4, 2011, Ms. Pfeiffer contacted IPN to advise that she was not taking the Klonopin very often, and explained that she would be starting intensive outpatient treatment soon. The IPN case manager asked Ms. Pfeiffer to provide the discharge summary from her recent hospitalization. 34. On or about February 9, 2011, IPN received Ms. Pfeiffer's discharge summary indicating that Ms. Pfeiffer had been hospitalized for anxiety and depression. The discharge summary indicated that Ms. Pfeiffer needed to follow up with intensive outpatient treatment. IPN contacted Ms. Pfeiffer who reported that she started intensive outpatient treatment at Springbrook Hospital and that she had been seeing a psychiatrist. Ms. Pfeiffer reported that her psychiatrist wanted her to remain on Klonopin at that time and would taper off the Klonopin when he believed Ms. Pfeiffer was ready. Ms. Pfeiffer reported that her psychiatrist did not believe she was ready to return to work. IPN directed Ms. Pfeiffer to provide IPN with documentation of her care plan from her psychiatrist. 35. On or about February 22, 2011, Ms. Pfeiffer submitted to an IPN-required urine drug test. The specimen Ms. Pfeiffer provided was dilute. 36. Dilute urine specimens occur when an individual drinks large amounts of fluids. Drugs are more difficult to detect in urine specimens that are dilute. Drinking 8

9 large amounts of fluids is a method used to avoid detection of drugs in urine specimens. 37. On or about February 28, 2011, IPN attempted to contact Ms. Pfeiffer in order to direct her to provide another urine specimen for a drug test. Ms. Pfeiffer's phone number was not working so IPN contacted one of Ms. Pfeiffer's family members and requested that the family member give Ms. Pfeiffer a message to contact IPN. 38. On or about March 8, 2011, the facilitator from Ms. Pfeiffer's nurse support group reported to the IPN case manager that Ms. Pfeiffer had not been attending facilitated nurse support group. 39. On or about March 11, 2011, Ms. Pfeiffer completed intensive outpatient treatment at Springbrook Hospital. 40. On or about March 11, 2011, Ms. Pfeiffer left IPN a voic message with a new telephone number. 41. On or about March 11, 2011, the IPN Urine Drug Screen Specialist attempted to contact Ms. Pfeiffer to direct her to submit to a drug test. The Urine Drug Screen Specialist was unable to leave a voic message for Ms. Pfeiffer because her mailbox was full. 42. On or about March 15, 2011, IPN sent Ms. Pfeiffer a letter indicating that she was at risk for being dismissed from IPN. The letter directed Ms. Pfeiffer to engage in all aspects of her contract including attendance at facilitated nurse support group, provide IPN with documentation from her psychiatrist regarding her care and specifically addressing her use of Klonopin, and to provide IPN with a telephone number 9

10 where she could be reached or where a message could be left that would be responded to on the same day. 43. IPN continued to have difficulty reaching Ms. Pfeiffer until on or about March 22, 2011, when the IPN case manager spoke to Ms. Pfeiffer. Ms. Pfeiffer explained the reasons for the difficulty reaching her and provided another contact number. Ms. Pfeiffer stated she was still taking Klonopin, but was being tapered off the drug. Ms. Pfeiffer explained that she did not attend the nurse support group due to car trouble, but would be attending the next group meeting. Ms. Pfeiffer reported that she would obtain documentation from her psychiatrist, and that she would submit to a drug test on that day. 44. On or about May 4, 2011, Ms. Pfeiffer contacted IPN and asked when she would be approved to return to work. The IPN case manager advised Ms. Pfeiffer that IPN was still waiting for details about Ms. Pfeiffer's taper off of Klonopin. 45. On or about May 12, 2011, Ms. Pfeiffer contacted IPN and reported that she had not taken Klonopin for two months. The IPN case manager advised Ms. Pfeiffer that IPN had not received documentation regarding the Klonopin from Ms. Pfeiffer's psychiatrist. 46. On or about May 17, 2011, IPN received documentation from Ms. Pfeiffer's psychiatrist indicating that Ms. Pfeiffer was off Klonopin and stating that Ms. Pfeiffer was not prescribed any controlled substances. 10

11 47. On or about May 23, 2011, the IPN case manager contacted Ms. Pfeiffer and advised that if Ms. Pfeiffer's most recent drug test was negative, she would be approved to return to nursing practice. 48. On or about May 26, 2011, IPN received Ms. Pfeiffer's drug test results indicating that the drug test results were negative. IPN contacted Ms. Pfeiffer and advised her that she was approved to return to nursing practice. 49. Ms. Pfeiffer did not report to IPN that she secured employment in nursing. 50. On or about July 13, 2011, Ms. Pfeiffer submitted to an IPN-required urine drug test. 51. On or about July 25, 2011, IPN received the results from Ms. Pfeiffer's drug test taken on or about July 13, 2011, indicating a positive result for oxycodone. The IPN left a voic message at Ms. Pfeiffer's home directing her to contact IPN. 52. On or about July 25, 2011, IPN sent Ms. Pfeiffer a letter informing her that her drug test was positive for oxycodone. The letter directed Ms. Pfeiffer to refrain from nursing practice and submit to an IPN-facilitated evaluation. The letter provided the contact information for several physicians who could conduct the evaluation. Ms. Pfeiffer was given a deadline of August 8, 2011, to arrange the evaluation. 53. On or about July 26, 2011, the IPN case manager spoke to Ms. Pfeiffer about the positive drug test. Initially, Ms. Pfeiffer denied using oxycodone, but after further questioning she admitted that she took one oxycodone tablet that she received from a friend about three days before the drug test. The IPN case manager directed 11

12 Ms. Pfeiffer to refrain from nursing practice and submit to another IPN-facilitated evaluation. 54. On or about August 4, 2011, a representative from Ms. Pfeiffer's psychiatrist's office contacted IPN and reported that Ms. Pfeiffer last saw her psychiatrist on or about June 23, 2011, and that there had been no further contact with Ms. Pfeiffer since that time. The representative stated that Ms. Pfeiffer had not followed through with seeing the substance abuse counselor. 55. On or about August 5, 2011, the IPN case manager left Ms. Pfeiffer a voic message at or about 8:50 a.m. advising Ms. Pfeiffer that IPN needed to hear from her by on or about August 8, 2011, or she would be dismissed by IPN. 56. By on or about August 8, 2011, IPN did not receive any notice from Ms. Pfeiffer that she had arranged an IPN-facilitated evaluation. 57. On or about August 12, 2011, IPN dismissed Ms. Pfeiffer for failing to comply with the conditions of her monitoring contract. 58. Section (1)(hh), Florida Statutes, subjects a licensee to discipline, including suspension, for being terminated from a treatment program for impaired practitioners, which is overseen by an impaired practitioner consultant as described in Section , Florida Statutes, for failure to comply, without good cause, with the terms of the monitoring or treatment contract entered into by the licensee, or for not successfully completing any drug or alcohol treatment program. 59. Ms. Pfeiffer failed to comply with the terms of her IPN monitoring contract by failing to remain free from all mood-altering, controlled, or addictive substances 12

13 including alcohol, and failing to obtain an IPN-facilitated evaluation following a relapse on oxycodone. 60. Section (1)(h), Florida Statutes, subjects a licensee to discipline, including suspension, for unprofessional conduct as defined by Board of Nursing Rule. Rule 64B (12), Florida Administrative Code, defines unprofessional conduct to include testing positive for any drugs under Chapter 893, Florida Statutes, on any drug screen when the nurse does not have a prescription and legitimate medical reason for using such drug. 61. On or about July 13, 2011, Ms. Pfeiffer tested positive for oxycodone in an IPN-required urine drug test. 62. Section (6), Florida Statutes, authorizes the Department to summarily suspend a registered nurse's license if the Department finds that the nurse presents an immediate serious danger to the public health, safety, or welfare. 63. Because registered nurses are required to assess the condition of their patients and make complex decisions regarding patient care, mental fitness and emotional stability are essential traits that a registered nurse must possess in order to competently practice nursing. Ms. Pfeiffer's diagnosed opioid dependence, her initial difficulty getting off of the opioid drug oxycodone, and her return to oxycodone use despite treatment at two different facilities and IPN support and monitoring demonstrate that Ms. Pfeiffer does not possess the mental fitness and emotional stability necessary to practice nursing safely because of her continued drug use. 13

14 64. Ms. Pfeiffer's disregard for the laws and regulations governing the practice of nursing, and her lack of mental fitness and emotional stability represent a significant likelihood that Ms. Pfeiffer will cause harm to the health, safety, or welfare of patients. This probability constitutes an immediate serious danger to the health, safety, or welfare of the citizens of the State of Florida. Nothing short of the immediate suspension of Ms. Pfeiffer's license will ensure the protection of the public from this danger. CONCLUSIONS OF LAW Based on the foregoing Findings of Fact, the State Surgeon General concludes as follows: 1. The State Surgeon General has jurisdiction pursuant to Sections and (8), Florida Statutes, and Chapter 464, Florida Statutes. 2. Ms. Pfeiffer violated Section (1)(hh), Florida Statutes, by being terminated from a treatment program for impaired practitioners, which is overseen by an impaired practitioner consultant as described in Section , Florida Statutes, for failure to comply, without good cause, with the terms of the monitoring or treatment contract entered into by the licensee, or for not successfully completing any drug treatment or alcohol treatment program. 3. Ms. Pfeiffer violated Section (1)(h), Florida Statutes, by engaging in unprofessional conduct as defined by Rule 64B (12), Florida Administrative Code, to include testing positive for any drugs under Chapter 893, Florida Statutes, on 14

15 any drug screen when the nurse does not have a prescription and legitimate medical reason for using such drug. 4. Ms. Pfeiffer's continued practice as a registered nurse constitutes an immediate serious danger to the health, safety, or welfare of the public and this summary procedure is fair under the circumstances to adequately protect the public. WHEREFORE, in accordance with Section (6), Florida Statutes, it is ORDERED THAT: 1. The license of, license number RN , is immediately suspended. 2. A proceeding seeking formal suspension or discipline of the license of, to practice as a registered nurse will be promptly instituted and acted upon in compliance with Sections and (6), Florida Statutes. DONE and ORDERED this a day of September, k Farmer, Jr., M i 1 PhD, FACP State Surgeon General PREPARED BY: Kathy Gatzlaff F/B/N Consultant Attorney DOH, Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida (850) Telephone (850) Telefax 15

16 NOTICE OF RIGHT TO JUDICIAL REVIEW Pursuant to Sections (6), and , Florida Statutes, this Order is judicially reviewable. Review proceedings are governed by the Florida Rules of Appellate Procedure. Proceedings are commenced by filing a Petition for Review, in accordance with Florida Rule of Appellate Procedure 9.100, with the District Court of Appeal, accompanied by a filing fee prescribed by law, and a copy of the Petition with the Agency Clerk of the Department within 30 days of the date this Order is filed. 16

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