STATE OF FLORIDA DEPARTMENT OF HEALTH ORDER OF EMERGENCY SUSPENSION OF LICENSE. H. Frank Farmer, Jr., MD, PhD, FACP, State Surgeon General, ORDERS the

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1 Final Order No. DOH-I I %6A FILED DATE 'actk Department of Health STATE OF FLORIDA DEPARTMENT OF HEALTH Deputy Agency Clerk In Re: Emergency Suspension of the License of 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. Crowley holds license number RN Her address of record is 1922 Jacaranda Parkway West, Cape Coral, Florida The following Findings of Fact and Conclusions of Law support the emergency suspension of Ms. Crowley'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. Crowley's license to practice as a registered nurse in accordance with Section (6), Florida Statutes. 2. At all times material to this order, Ms. Crowley was licensed to practice as a registered nurse pursuant to Chapter 464, Florida Statutes. 3. On or about January 6, 2011, Ms. Crowley contacted the Intervention Project for Nurses (IPN) and reported that she had been diverting morphine from her employer, Health Park Medical Center, for about six months. Ms. Crowley explained

2 Austin Laura Crowley, R.N. that she was having trouble sleeping due to stress. On one occasion Ms. Crowley stated she accidentally took some morphine home and used the morphine to help her sleep. Ms. Crowley stated that her use "snowballed" from there. Ms. Crowley stated that the employee assistance program at her workplace directed her to enter into chemical dependency treatment. The IPN case manager advised Ms. Crowley to refrain from nursing practice and notify IPN about her entrance into chemical dependency treatment. 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. Morphine is an opiate class drug prescribed to treat pain. According to Section (2), Florida Statutes, morphine 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 morphine 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. On or about January 13, 2011, Ms. Crowley began intensive outpatient chemical dependency treatment at Southwest Florida Addiction Services. 8. On or about February 15, 2011, Ms. Crowley completed intensive outpatient treatment at Southwest Florida Addiction Services. The treatment team at Southwest Florida Addiction Services diagnosed Ms. Crowley with opioid dependence. 9. On or about February 23, 2011, Ms. Crowley signed a five-year IPN monitoring contract that required her to remain free from all mood-altering, controlled, or addictive substances, including alcohol; participate in aftercare counseling at Southwest Florida Addiction Services; attend a facilitated nurse support group; attend alcoholics anonymous/narcotics anonymous meetings; and submit to drug testing. Ms. Crowley was approved to return to nursing practice provided she remained restricted from access to controlled substances for a period of one year. 10. Incorporated into the IPN monitoring contract was the IPN Participant Manual, which outlined additional requirements of IPN participation. According to the IPN Participant Manual, if a nurse exhibited relapse behaviors, the nurse would be required to refrain from nursing practice, submit to another IPN-facilitated evaluation, and undergo treatment at a higher level of care than received in the past. 11. Ms. Crowley returned to work at Health Park Medical Center. 12. Health Park Medical Center utilized the Pyxis Medstation (Pyxis) medication dispensing system. Pyxis consists of locked medication carts that secure and control access to controlled substances through a computer system. Each cart has a computer terminal on top of the cart that is linked to the pharmacy. Nurses can

4 access Pyxis with either an individual password or through a fingerprint scan. The nurse selects the medication needed and the patient for whom the medication is intended and the specific drawer that contains that medication unlocks and opens. 13. In order to accurately record patient care, and to accurately account for controlled substances, Health Park Medical Center required nurses to document the time each medication was administered to the patient on the patient's medical record. If a dose or partial dose of a controlled substance was removed from Pyxis, but not administered to the patient, the nurse was required to discard the controlled substance in the presence of another licensed nurse witness. The discard of a controlled substance is referred to in Pyxis as a "waste." 14. Upon Ms. Crowley's return to work as a nurse at Health Park Medical Center, Ms. Crowley's access to Pyxis was limited so that when Ms. Crowley logged into Pyxis, she was unable to remove controlled substances from the Pyxis cart. 15. On or about June 23, 2011, Ms. Crowley's supervisor at Health Park Medical Center contacted IPN and reported that Ms. Crowley entered Pyxis under another nurse's password and removed hydromorphone, a controlled substance, from the Pyxis cart. Ms. Crowley was confronted and returned the hydromorphone to the supervisor. The supervisor stated she conducted an investigation and discovered that Ms. Crowley had been asking other nurses to remove controlled substances from Pyxis and hand the controlled substances to Ms. Crowley to administer to the patients. The supervisor discovered multiple incidents where Ms. Crowley did not properly document that the controlled substances were administered. 4

5 16. Hydromorphone is an opioid class drug prescribed to treat pain. According to Section (2), Florida Statutes, hydromorphone 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 hydromorphone may lead to severe psychological or physical dependence. 17. On or about June 23, 2011, the IPN case manager contacted Ms. Crowley who admitted to removing hydromorphone under another nurse's Pyxis access. Ms. Crowley explained that the other nurse did not log out of the Pyxis computer after she removed medications and when Ms. Crowley went to the Pyxis computer the other nurse was still logged into the system. Ms. Crowley then removed hydromorphone from Pyxis, but turned the drug over to her supervisor when she was confronted. The IPN case manager directed Ms. Crowley to refrain from nursing practice and submit to an IPN-facilitated evaluation. 18. On or about July 7, 2011, Ms. Crowley submitted to an IPN-facilitated evaluation conducted by David P. Myers, M.D., a specialist in addiction medicine. At the evaluation, Ms. Crowley explained her initial referral to IPN, stating she was dealing with increased stress, was unable to sleep, and accidentally brought a syringe of morphine home and injected it intramuscularly. Ms. Crowley explained that the morphine helped her sleep and she liked the way morphine made her feel. Ms. Crowley explained that she then began taking, for her own use, the morphine that should have been wasted with a witness. Ms. Crowley stated she progressed to the point of injecting herself with narcotic drugs such as morphine about three times a week. Ms. 5

6 Crowley stated that she did well in IPN until about two weeks prior to the evaluation when Ms. Crowley explained she obtained hydromorphone from Pyxis under another nurse's Pyxis access. Ms. Crowley also admitted to asking other nurses to pull controlled substances for her from Pyxis. After further questioning by Dr. Myers, Ms. Crowley admitted that she used some of the hydromorphone she obtained and injected herself with the hydromorphone intramuscularly about three or four times, last using the drug in about June of Ms. Crowley also admitted to drinking alcohol while under her IPN contract, stating she drank a few beers about two weeks prior to the evaluation. 19. Dr. Myers diagnosed Ms. Crowley with opioid dependence, alcohol abuse rule out dependence, and marijuana dependence in early, full remission. Dr. Myers recommended that Ms. Crowley engage in residential chemical dependency treatment and opined that Ms. Crowley was not able to practice nursing with reasonable skill and safety. 20. On or about July 19, 2011, IPN sent Ms. Crowley a letter that provided her with the contact information of several facilities where Ms. Crowley could obtain the recommended residential chemical dependency treatment. IPN gave Ms. Crowley a deadline of August 2, 2011 to arrange the recommended treatment. 21. On or about July 22, 2011, Ms. Crowley contacted IPN and reported that she could not afford treatment. Ms. Crowley also stated that she was not planning to submit to the IPN-required drug test on that day because she did not want to spend the money. The IPN case manager suggested that Ms. Crowley contact the different 6

7 treatment centers and see what financial terms could be arranged and encouraged Ms. Crowley to remain under IPN monitoring. 22. On or about August 2, 2011, the facilitator from Ms. Crowley's nurse support group contacted the IPN case manager and reported that Ms. Crowley had not attended nurse support group for two weeks. 23. On or about August 3, 2011, the IPN case manager contacted Ms. Crowley to determine her status regarding treatment arrangements. Ms. Crowley reported that she would not be entering treatment due to financial concerns. 24. On or about August 4, 2011, IPN dismissed Ms. Crowley for failing to comply with the conditions of her IPN monitoring contract. 25. 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. 26. Ms. Crowley failed to comply with the terms of her IPN monitoring contract by failing to remain free from all mood-altering, controlled, or addictive substances including alcohol, failing to comply with her restriction from access to controlled substances while working as a nurse, and failing to enter into recommended chemical dependency treatment following a relapse on opioid drugs. 7

8 27. Section (1)(j), Florida Statutes, subjects a licensee to discipline, including suspension, for being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition. 28. Ms. Crowley is unable to practice nursing with reasonable skill and safety to patients by reason of opioid dependence and alcohol abuse. Despite intensive outpatient treatment and IPN monitoring, Ms. Crowley injected herself with hydromorphone, an opioid drug, which she obtained from her place of employment. Ms. Crowley also drank alcohol while under her IPN monitoring contract. According to a physician who specializes in addiction medicine, Ms. Crowley cannot practice nursing with reasonable skill and safety, and needs chemical dependency treatment at a residential treatment program. Ms. Crowley did not enter into the recommended treatment and is no longer monitored by IPN. 29. 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. 30. In the course of their practice, registered nurses have access to powerful medications, including controlled substances, which have a high likelihood for abuse and harm. Due to the potential for abuse of the powerful drugs that nurses have access to, nurses must possess good judgment and good moral character in order to perform their tasks. Ms. Crowley's decision to violate her restriction from access to controlled substances and obtain controlled substances for her own use by entering 8

9 Pyxis under another nurse's name and by asking other nurses to remove controlled substances for her, demonstrates such a complete lack of judgment and moral character, and such a disregard for the laws and regulations governing nurses in this state that the safety of Ms. Crowley's patients cannot be assured as long as she continues to practice nursing. 31. 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. Crowley's diagnosed opioid dependence and alcohol abuse, her return to diverting opioid drugs from work and using those drugs intramuscularly, her use of alcohol while under IPN monitoring, and her failure to enter into residential treatment, demonstrate that Ms. Crowley does not possess the mental fitness and emotional stability necessary to practice nursing safely. According to an evaluation by a specialist in addiction medicine, Ms. Crowley is not able to practice nursing with reasonable skill and safety to patients. 32. Ms. Crowley's lack of good judgment and moral character, her 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. Crowley 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. Crowley's license will ensure the protection of the public from this danger. 9

10 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. Crowley 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. Crowley violated Section (1)(j), Florida Statutes, by being unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition. 4. Ms. Crowley'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. 10

11 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 g day of September, H 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 11

12 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. 12