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18A-1410110-NUR · State Board of Nursing · 2018-10-03

IN THE OFFICE OF ADMINISTRATIVE HEARINGS

IN THE MATTER OF THE REGISTERED No. 18A-1410110-NUR NURSE LICENSE NO. RN117544 ISSUED TO: ADMINISTRATIVE LAW JUDGE DECISION APRIL LYNN COBIA, RESPONDENT. HEARING: November 30, 2017, at 9:00 a.m. and February 26, 2018, at 9:00 a.m.; the record was held open until March 12, 2018, to allow the Administrative Law Judge to have the benefit of the court reporter’s transcript in making her recommendation. APPEARANCES: The Arizona State Board of Nursing (“the Board”) was represented by Sunita Krishna, Esq., Assistant Attorney General; April Lynn Cobia (“Respondent”) appeared on her own behalf. ADMINISTRATIVE LAW JUDGE: Diane Mihalsky _____________________________________________________________________ FINDINGS OF FACT BACKGROUND AND PROCEDURE 1. The Board has the authority to regulate and control the practice of nursing in the State of Arizona, pursuant to A.R.S. §§ 32-1606, 32-1663, and 32-1664. The Board also has the authority to determine whether licensees have committed unprofessional conduct, thereby furnishing cause for discipline under the Nurse Practice Act, A.R.S. §§ 32-1601 through 32-1667. 2. Respondent holds Board-issued registered nurse license RN117544. 3. On or about October 17, 2017, the Board issued a Complaint and Notice of Hearing that set forth certain factual allegations. Based on those allegations, the Board’s Complaint and Notice of Hearing charged Respondent with having committed unprofessional conduct as defined by A.R.S. §§ 32-1601(26)(d), 32-1601(26)(e), 32- 1601(26)(j), and for purposes of 32-1601(26)(d),1 as more specifically defined by A.A.C.

A.R.S. § 32-1601(2) was effective on August 9, 2017. For conduct occurring from July 1, 2016, to August 8, 2017, A.R.S. § 32-1601(24) plied with language identical to the subsequent statutes. For conduct occurring from August 2, 2012, to June 30, 2016, A.R.S. § 32-1601(22) applied with language identical to the subsequent statutes.

Office of Administrative Hearings 1740 West Adams Street, Lower Level Phoenix, Arizona 85007 (602) 542-9826 R4-19-403(1), R4-19-403(2), R4-19-403(8-9), R4-19-403(26), R4-19-403(27), R4-19- 403(28), and R4-19-403(31), and A.R.S. § 32-3208(A) and (D). 4. The Board referred the matter to the Office of Administrative Hearings, an independent agency, for an evidentiary hearing on the allegations in the Board’s complaint. 5. Hearings were held on November 30, 2017 and February 26, 2018. The Board submitted sixteen exhibits and presented the testimony of six witnesses: (1) Katherine Eldredge, RN, the Lead Nurse at Southwest Network, Inc. (“Southwest”), where Respondent was employed from approximately May 2, 2016, to approximately June 16, 2016, (2) Savahna Keliipuleole, RN, the triage nurse at Hospice Family Care under Euro Health Services (“Hospice”), where Respondent worked between June 26, 2017, and July 28, 2017; (3) Kim Delorenzo, RN, the former Director of the Intensive Care Unit at Mountain Vista Medical Center in Mesa (“Mountain Vista”), where Respondent worked between January 11, 2016, and February 9, 2016; (4) Lola Falore, RN, the Director of Nursing/Administrator at Cornerstone Healthcare of Chandler, Arizona (“Cornerstone”), where Respondent worked between May 14, 2014, and October 30, 2014; (5) Keomy Williams, the real estate leasing agent at Garden Grove apartments in Tempe, where Respondent lived sometime before November 9, 2016; and (6) Shawna Bonner, RN, the Board’s nurse consultant who performed its investigation into this matter. Respondent submitted forty-five exhibits and testified on her own behalf. HEARING EVIDENCE The Consent Decrees 6. On or about April 29, 2006 Respondent signed to accept the Board’s Consent Agreement and Order No. 0508143 in which she agreed that she had engaged in various unprofessional conduct while employed as a nurse and caring for patients; including entering inaccurate and incomplete documentation, and giving a diabetic patient an insulin drip at a lower rate than ordered. As a result of the Consent Agreement and Order in Case No. 0508143, Respondent agreed to be placed on probation for twenty- four months. The Consent Agreement provided that the Board could extend the probationary period if it received evidence that Respondent had not complied with the

terms of the order, including the Board’s receipt of an unsatisfactory employer evaluation, verbal or written warning, counseling or disciplinary action, or a new complaint.2 7. On or about August 18, 2009, Respondent signed to accept the Board’s Consent Agreement and Order No. 0802149 in which she agreed that she had engaged in various unprofessional conduct while employed as a nurse and caring for patients, including that Respondent was terminated from a position at Kindred Hospital in Scottsdale, Arizona due to conflict with other staff. The consent agreement in Case No. 0802149 noted that Respondent claimed the termination was due to her reporting two other nurses to the Board for suspected drug diversion and driving while intoxicated. Because Respondent had not worked as a nurse for twenty-four months, the Board determined and Respondent agreed that her probation would be extended twelve months.3 8. On or about October 15, 2013, the Board issued an Order Terminating Consent Agreement and Order No. 0802149, finding that Respondent had completed all of the terms of her probation.4 Ms. Bonner testified that the Board’s policy is to keep records of discipline against licensees on the public website for ten years after closing the case. 9. Respondent challenged the facts of her termination from Kindred Hospital. Respondent testified that, although Kindred Hospital had an open-door policy, its staff called the police to report that Respondent was harassing them.5 Respondent testified that the Board’s employee, Delores Hurtado, who apparently was involved in the Board’s investigations of Case Nos. 0508143 and 0802149, was behind all her problems with the Board.6 10. Respondent testified that the Board posted the consent decrees on the internet, which prevented her from obtaining employment. Respondent testified that more than ten years had passed since 2006, the date of the first consent agreement.

See the Board’s Exhibit 1 at 23 – 33. 3 See id. at 8 – 19. See id. at 1-3. See Respondent’s Exhibit E1-5. See Respondent’s Exhibit D. This is a routine email from Ms. Hurtado in which the Administrative Law Judge found no evidence of animus. Respondent testified that not all consent agreements were posted on the internet.7 Respondent testified that the Board posted information that sanctions had been taken against her LPN and CNA licenses and that she did not have a fingerprint card,8 which was not true. Respondent acknowledged that the licenses were cited in the Consent Agreements in Case Nos. 0808143 and 0802149. 11. Respondent testified that the Board had entered inaccurate information into the National Council of State Boards of Nursing records, which showed up on other websites such as Ask.com. Respondent testified that she had to file a complaint with the ombudsman office to correct the inaccuracies.9 Cornerstone Healthcare (May 14, 2014, to October 30, 2014) 12. Between May 22, 2014, and October 29, 2014, Respondent worked for Cornerstone, providing health care to patients in their homes. Ms. Falore supervised Respondent. Ms. Falore testified that Cornerstone’s patient population includes pediatric and adult patients who were vulnerable. 13. On May 28, 2014, Respondent refused to sign a Verbal Warning on Unacceptable Conduct at Cornerstone, after she failed to inform her supervisor that she had called Adult Protective Services (“APS”) on patient A.P.’s wife. Respondent had been assigned to care for A.P. on May 21, 2014 and had called APS on May 22, 2014 to report A.P.’s wife. Cornerstone’s verbal warning acknowledged that Respondent had a right to call APS if she suspected abuse or neglect, but stated that Cornerstone’s policy required Respondent to report the incident to her immediate supervisor.10 14. Respondent acknowledged that she called APS and failed to inform her supervisor but testified that she had reported Cornerstone for abuse or neglect, not A.P.’s wife. Respondent testified that A.P. had no medications, his lungs were full, and he was on a ventilator. 15. Respondent also testified, inconsistently, that she had informed her supervisor that she called APS to report A.P.’s wife, stating that she had a duty to report abuse or neglect to APS, not Cornerstone. See Respondent’s Exhibit Q1-8. See Respondent’s Exhibit R-1-2, S1-7. See Respondent’s exhibits L1-L7, N1, O1-O4. The Board’s Exhibit 5 at 88. 16. On or about August 1, 2014, Respondent made the following entry into her pediatric patient A.B.’s medical records: 11:55 Katie Riddle from GI doctor’s office called . . . [and] wanted to talk to me. . . . Katie and I discussed Stephanie RN from GI Dr. Kolpuru office and her refusing to collaborate care and correct keppra orders, and the document stating I a [Registered] Nurse take order from [a] speech therapist which is one of the orders that was sent to me on 06/26/2014. I do not take orders from speech therapist, physical therapist, occupational therapist, [LPNs], CNAs, cows, chickens, or roosters, dogs, or cats of any kind. I take orders from MD’s, DO’s, & Nurse Practitioners only.11 Respondent signed the record. Ms. Falore testified that Respondent’s entry into A.B.’s medical record was not appropriate because Respondent was judgmental and had made an entry that was not necessary for A.B.’s care. 17. On or about October 25, 2014 Respondent accompanied patient R.P. to St. Joseph’s Hospital without informing Cornerstone. Cornerstone learned of R.P.’s admittance after St. Joseph’s Hospital informed it on October 29, 2014, when R.P. had been discharged.12 18. The medical record that Respondent entered for R.P. on October 25, 2014, stated in relevant part as follows: Due to heavy drainage from wound #1 pt. was informed she needed to go to ER. The pt. was transported to St. Joes ER via personal vehicle and her family members. I gave report to the triage RN in the ER, the pt. was taken back to the exam bay and Dr. Kirsch was given report, pt. was then taken to pre-op staging area and an IV was started report was given to RN. Pt. was admitted for [inpatient] procedures.

Problem; knowledge deficit regarding wound infection/hygiene practice have changed for better by pt bathing around wound daily and showering before every dressing change/DMII and increased blood sugars due to infection.13 Cornerstone’s October 29, 2014 Incident/Accident Log stated that when Ms. Falore asked her about the incident, Respondent stated that she notified St. Joseph’s Hospital “that she is not competent with wound vacs and agency [cannot] staff the patient at this time”

11 The Board’s Exhibit 12 at 252. See id. at 93. The Board’s Exhibit 11 at 244. and that she notified the case manager to re-route R.P. to another facility. Ms. Falore testified that Respondent’s account was not true because nurses are able to contact her and other supervisors 24 hours a day by email or phone. 19. Because Cornerstone’s policy required Respondent to tell her supervisor that she had accompanied a patient to the hospital and because this was the fifth documented incident of Respondent’s failure to follow policy or inappropriate interactions with patients and their families, on October 29, 2014 Cornerstone terminated Respondent’s employment.14 20. Respondent testified that she told Ms. Falore about taking R.P. to the hospital. 21. Ms. Falore testified that on October 30, 2014, she called Respondent and told her she needed to come in. Respondent stated that if she was going to be terminated, she would not come in and that Respondent never came in to Cornerstone after the incident involving R.P. 22. On October 30, 2014, Ms. Falore filed a complaint against Respondent with the Board. Ms. Falore stated that Respondent was unprofessional, that four patients had reported her bad attitude, rudeness, aggression, and negativity, and that on September 30, 2014, Respondent had reported a patient’s parent to the police, but failed to report the incident to Cornerstone. Ms. Falore also stated that Respondent had reported A.P.’s wife to APS and had taken P.R. to the hospital without informing Cornerstone. Ms. Falore concluded the complaint by stating that Cornerstone had received many internal complaints against Respondent had that were not listed, and that Ms. Falore believed patient safety and convalescence were jeopardized by Respondent’s mental attitude.15 23. Ms. Falore testified that Respondent was always confrontational, talking over supervisors and even talking over doctors when she called them for orders. Respondent did things the way she wanted, not according to doctors’ orders. Ms. Falore testified that Respondent had denied calling APS on A.P.’s wife, but that A.P.’s wife and APS confirmed that Respondent had made a report to APS.

See id. at 107. See the Board’s Exhibit 6 at 115-116. 24. Ms. Falore testified that Respondent was not truthful and had anger issues. She does not believe that Respondent is safe to practice on human beings because she lacks patience, is judgmental, questions doctors’ authority, and disrespects other health care team members. Ms. Falore acknowledged that Respondent had not made any patient medication errors while she was employed by Cornerstone. 25. Respondent testified that Cornerstone terminated her employment because she followed the Nurse Practice Act. Respondent testified that she reported Cornerstone for not following through with patient care and for patient safety concerns and that the Arizona Department of Health Services sanctioned Cornerstone as a result of her complaint. 26. Respondent also testified that she had turned Cornerstone into the Office of the Inspector General for failure to submit proper paperwork for Medicare patients.16 27. Respondent testified that after Cornerstone terminated her employment, she filed for unemployment benefits and received the benefits despite Cornerstone’s challenge.17 Mountain Vista Medical Center (January 11, 2016, to February 9, 2016) 28. Mountain View hired Respondent as an ICU nurse on January 11, 2016, and terminated her employment on February 9, 2016, because none of her assigned preceptors felt comfortable signing off on her competencies. 29. Ms. Delorenzo testified that Mountain View is a 30-bed facility with 76 employees. Mountain View put together a document entitled “April Cobia” orientation when it made the decision to terminate Respondent’s employment. The documented deficiencies included Respondent’s poor time management, inability to document correctly patient assessments, repeated failure to document correctly patients’ symptoms and Foley output, and defensiveness.18 30. Ms. Delorenzo testified that after Respondent expressed concerns about the first preceptor that Mountain View assigned to her because she did not think the nurse liked her, Mountain View assigned her to Faith Phillips, RN. Ms. Phillips’ narrative

16 See Respondent’s Exhibit W1-W3. See Respondent’s Exhibit X1-3. See the Board’s Exhibit 4 at 75-76. expressed concerns about Respondent’s threats of litigation, which required redirection, her observed inability to draw blood, and her criticism of other employees and the Board. After Ms. Delorenzo informed Respondent of issues in her orientation, she became hostile toward Ms. Phillips and “challenged every competency word-by-word as to meaning.”19 After the fourth day, Ms. Phillips refused to act as preceptor to Respondent due to patient safety concerns. 31. Lynette Becker, RN was Respondent’s third preceptor at Mountain View. Ms. Becker’s evaluation stated that she was unable to impress upon Respondent the importance of charting correctly, that Respondent was unable to give a comprehensive report on her patients at shift change, and that she restarted Propofol on a patient for whom it had been discontinued.20 32. Ms. Delorenzo testified that Respondent also had issues with patients and their families. The husband of a 40-year-old female patient had built a bond with staff, but when he came to the nursing station, Respondent scolded him. The husband later complained that Respondent was abusive. 33. On February 9, 2016, Mountain View terminated Respondent’s employment due to patient safety concerns based on her inability to satisfactorily complete her preceptorship.21 Southwest Network (May 12, 2016, to June 16, 2016) 34. Between May 12, 2016, and June 16, 2016, Respondent worked for Southwest, which provides medical services to persons with mental or behavioral health issues, under the supervision of Ms. Eldredge. On June 14, 2016 Ms. Eldredge sent an email to Mitch Garett, Southwest’s Director of Nursing, in relevant part as follows: I was told to email you regarding my concerns about [Respondent]. A couple of red flags during the time she spent with me. The first day she got lost trying to meet me at my first stop in the morning prior to coming into clinic. She came into clinic yelling at the CM’s on my team when they were trying to help her. She was not receptive to anything they said and treated them like they were stupid and [kept] arguing with them that she was right. When I was talking with her about the San Tan clinic she asked me about the RN’s that work there. [Respondent] said she was concerned because 19 See the Board’s Exhibit 4 at 77-79. See the Board’s Exhibit 4 at 80-81. See the Board’s Exhibit 4 at 82. she has had problems with co-[workers] in the past. She seemed very hostile and said that if any of them gave her any problems, they would have a fight on their hands. [Respondent] told me about an incident that happened at her current apartment complex. She told me that she was assaulted by some guy. However when she was telling me what led up to the assault she seemed paranoid that people in her apartment complex were out to get her and her dog. She made a concerning statement about being able to carry a concealed gun and that people in her apartment complex better watch out because she would be carrying her gun when she walked her dog. I just got a strange vibe from her the entire time she was with me.22 Ms. Eldredge testified consistently with her email. Ms. Eldredge testified that even though the problems with Respondent started in May 2016, she waited until Mr. Garrett returned from being out of the office to report her concerns. 35. Ms. Eldredge testified that she received a phone call from Maria, one of the other nurses at Southwest, stating that she was afraid that Respondent would harm her. Amy Elowson, Southwest’s HR manager, sent an email to Amy Henning, Southwest’s CEO, that several staff, including Ms. Eldredge, two case managers, an agency nurse, and the QOL rep at San Tan, had complained that Respondent was combative, argumentative, hostile, and that she frequently mentioned that she had a gun/concealed carry permit, which made the other staff uncomfortable. Staff complained Respondent made their work environment hostile, that she interrupted and became argumentative when they tried to explain procedures, and that they could not calm her down after she became angry, even though they were just trying to help her.23 Ms. Eldredge testified that the whole team was on edge as a result of their interactions with Respondent. 36. On June 16, 2016 Southwest terminated Respondent’s employment, effective immediately and noted she is not eligible for rehire.24 On that date, Respondent signed the inventory return form.25 When Ms. Bonner interviewed Mr. Garrett on August 5, 2017 he stated that he wanted to give Respondent a chance but that after a short time it became evident that it was not going to work out.26

22 The Board’s Exhibit 7 at 137. See the Board’s Exhibit 7 at 138; see also id. at 139-140. See the Board’s Exhibit 7 at 141-145. See the Board’s Exhibit 7 at 144-145. See the Board’s Exhibit 13 at 265. 37. Respondent testified that she had reported Southwest to Mercy Maricopa Integrated Care, the Regional Behavioral Health Authority for Maricopa County, and that the termination was in retaliation for the complaint.27 38. Respondent submitted the police report of her call regarding her neighbor’s dog and photographs of the injuries that she testified were caused by her former neighbor’s dog at Park Grove apartments.28 Hospice Family Care/Euro Health Services (June 26, 2017, to July 28, 2017) 39. Ms. Bonner interviewed Ms. Keliipuleole and Chaplain Don Gutwein of Hospice on August 31, 2017. The Board’s Investigative Report summarized the interview in relevant part as follows: Keliipuleole confirmed that Respondent had made 2 medication errors, specifically had neglected to put all the doses of a medication that was to be given more than once a day out for the mediset at a group home even after remediation. Keliipuleole described Respondent as “paranoid” and that Respondent put tape over the agency-issued tablet’s camera because “Corporate was watching” as well as told Keliipuleole to keep the sound off on the device so “Corporate” couldn’t listen to them. Keliipuleole stated that Respondent drove aggressively and “seemed unstable”. . . . When Keliipuleole complimented Respondent’s nurse bag, Respondent told her that it was a “gun bag” as well.

Keliipuleole denies Respondent threatened anyone with a gun, but did describe an interaction she had heard about between Respondent and Chaplain Don Gutwein when Respondent stated she would shoot a neighbor’s dog and go after the neighbor if the neighbor’s dog attacked Respondent’s dog again. Keliipuleole expressed that she was a little scared about what would happen when Respondent was told that her employment was not going to work out. . . . Keliipuleole stated that Respondent caused a lot of upset with caregivers at the group home, members of the hospice team, patients and families. Keliipuleole stated she wasn’t sure if it was due to Respondent’s poor hearing, but there were a lot of complaints from patients and families about rudeness. Keliipuleole recalled one patient whose husband cried when she informed him that Respondent would be taking over for her, and when Respondent left the company, this man shared that his prayers had been answered. The patient’s daughter went on to say that Respondent would not listen to anything they said, yelled, and talked over them. . . .

See Respondent’s Exhibit PP1-2. See Respondent’s Exhibit Y1-7, Z. I telephonically interviewed Chaplain Don Gutwein immediately after speaking with Savahna Keliipuleole RN. When asked if he had any concerns about Respondent or her practice, Gutwein stated he couldn’t really comment about nursing things, but that Respondent was not a good fit for hospice care. When asked to elaborate, he stated Respondent seemed insecure and lonely and he felt sorry for her. Gutwein stated that Respondent talked a lot and he thought some of her stories were exaggerated. I asked about a story about a dog attack, and Gutwein stated that Respondent told him that a neighbor “sicced” his dog on Respondent’s dog and that if it happened again, Respondent would shoot the dog and go after the neighbor too. Gutwein denied ever seeing the gun, and stated he did not know if she carried it with her on visits, but she did talk about it a lot and how she lived alone and needed protection.

Gutwein recalled one home visit they were on together where Respondent kept referring to the living situation as a “crackhouse” to him. . . . He did not think Respondent said this to the patient, but did to him when they arrived and again when they left. Gutwein stated it was not a good living situation, but didn’t think it was appropriate to make that comment. Gutwein stated Respondent was very opinionated and that did not fit well with the patients or their families. He recalled a time when a hospice patient was talking about their religion and Respondent “jumped down his throat” and was giving her opinion about the beliefs. Gutwein described her as “very anti- Mormon.”29

Ms. Keliipuleole testified consistently with the Investigative Report. She stated that she was not afraid of Respondent until the last day of Respondent’s employment. Ms. Keliipuleole acknowledged that she did not hear the conversation between Mr. Gutwein and Respondent, only Mr. Gutwein’s account of the conversation. Ms. Keliipuleole testified that Respondent’s anti-Mormon comments were inappropriate because many of Hospice’s patients were near the end of their lives, were vulnerable, and frequently took comfort from religion. 40. Respondent denied having any prejudice toward members of the Church of the Latter Day Saints. She testified that she was a Mormon and that one of her preceptors in the Nurse Practitioner program was a Mormon. The Employment Applications 41. On or about November 21, 2013 Respondent submitted a Nurse Employment Application to Victory Medical Solutions. On the application, Respondent The Board’s Exhibit 13 at 281-282. stated that she left her position at Kindred Health because she “reported 2 Rn’s for drug diversion.”30 This statement contradicts the Consent Agreement in Case No. 0802149. 42. OneSource Employer Services placed Respondent at North Phoenix Infectious Disease (“North Phoenix”). On or about November 10, 2015 Respondent’s employment at OneSource Employer Services was terminated for insubordination at North Phoenix.31 A note from Yvette Mayo, RN, the office manager, accompanied the termination. Ms. Mayo’s note described Respondent’s conflict with another nurse at North Phoenix and statements that she does not take orders from a nurse who has less than a Bachelor’s degree, a chiropractor, an osteopathic doctor, or a physician’s assistant (whom Respondent characterized as “piss ants”).32 Ms. Bonner testified that an RN may take orders from a physician’s assistant or osteopathic physician and that her lack of respect for nurses with a different education and other health care professionals was concerning. 43. On August 4, 2017 and August 30, 2017 Ms. Bonner interviewed Ms. Mayo. Ms. Mayo confirmed that Respondent had been terminated from North Phoenix Infectious Disease based on her inability or unwillingness to get along and deal with team members respectfully.33 44. Respondent testified that she had prevailed on her claim for unemployment compensation against OneSource Employer Services.34 45. On December 11, 2015, Respondent applied to be an ICU nurse at Mountain View. On the application Respondent stated that her reason for leaving North Phoenix was “4 hours of a work a week.”35 Respondent e-signed the application. Based on the evidence summarized above, Respondent’s statement was untrue. 46. On the December 11, 2015, application to Mountain View, Respondent stated that her reason for leaving Cornerstone was “school.”36 Based on the evidence summarized above, Respondent’s statement was untrue.

30 The Board’s Exhibit 2 at 39. See the Board’s Exhibit 3 at 45. 32 See the Board’s Exhibit 3 at 46. See the Board’s Exhibit 13 at 262. See Respondent’s Exhibit HH1-2. The Board’s exhibit 4 at 69. See the Board’s Exhibit 4 at 69-70. 47. Between approximately November 19, 2015 and December 18, 2015 Respondent was employed by Celestial Care (“Celestial”). Nursing notes by Respondent’s supervisor, Susan Moran, RN, stated that on December 18, 2015 Respondent refused to take a report from a CNA assigned to care for the patient. Respondent refused to give Imodium to the patient, even though he was in pain and had two explosive bowel movements that day because he could only take the medicine every eight hours. Respondent was not aware of the doctor’s order to administer Imodium more frequently. When Ms. Moran called Respondent’s attention to the order, she became argumentative and stated that the doctor’s order was incorrect.37 Ms. Bonner testified that Respondent’s behavior was concerning because RNs must reply on information about patients provided by CNAs and that Respondent’s attitude showed that she was not putting the patient’s care first. 48. On April 10, 2017 Ms. Bonner interviewed Ms. Moran. Ms. Moran stated that Respondent constantly complained about other staff or doctors, but then it would turn out in a chart review that Respondent had overlooked something, and that she performed some surprise visits to monitor Respondent. Ms. Moran stated that on December 18, 2015 she was told to terminate Respondent’s employment for unprofessional conduct after Respondent failed to follow physician’s orders to medicate a patient. Ms. Bonner also interviewed the Director of Celestial Care, Susan Hefferman, who stated that Respondent “behaved strangely,” and “acted as if she had some sort of disorder that made her hypercritical of everyone else, while not seeing deficits in herself.”38 49. As a result of the December 18, 2015 incident, Celestial Care terminated Respondent’s employment on that same date. Respondent was informed of the termination by email and responded, “I will not be available for any exit interview.” Respondent requested that Celestial Care not delay mailing her last paycheck to her.39 50. On or about May 2, 2016 Respondent submitted an employment application to Southwest. On the application Respondent stated that her reason for leaving Mountain

37 See the Board’s Exhibit 8 at 165-166. The Board’s Exhibit 13 at 263. See the Board’s Exhibit 8 at 171-175. Vista was “schedule not working.” Based on the evidence summarized above, Respondent’s statement was untrue. 51. On the May 2, 2016 application to Southwest, Respondent also stated that the reason for leaving Celestial Care was “hired for full time at other facility.” Based on the evidence summarized above, Respondent’s statement was untrue. 52. On the May 2, 2016 application to Southwest Respondent also stated that the reason for leaving North Phoenix as “full time work.” Based on the evidence summarized above, Respondent’s statement was untrue. 53. On the May 2, 2016 application to Southwest Respondent also stated that the reason for leaving Cornerstone was “Temporary work that was Home Health.”40 Based on the evidence summarized above, Respondent’s statement was untrue. 54. On or about January 17, 2017 Respondent submitted an employment application to Maravilla Care Center (“Maravilla”). Respondent stated on the application that her reason for leaving Southwest was that “patients were not getting their medis [sic].”41 Based on the evidence summarized above, Respondent’s statement was untrue. 55. Respondent also stated on the January 17, 2017 Maravilla application that her reason for leaving Mountain View was “dishonest practice by manager.”42 Based on the evidence summarized above, Respondent’s statement was untrue. 56. Ms. Bonner testified that Respondent’s numerous false statements on the applications that she submitted to Victory Medical Solutions, Mountain View (2), Southwest (4), and Maravilla Care Center (3) were violations of the Nurse Practice Act. Ms. Bonner testified that Respondent’s apparent comfort level with misrepresentation was concerning because a nurse may practice in an autonomous home setting where vulnerable patients are at risk. Ms. Bonner testified that even if a nurse does not agree with an employer’s termination of her employment she must report it on future job applications. The Incident at Garden Grove Apartments (November 9, 2016)

40 The Board’s Exhibit 7 at 130. The Board’s Exhibit 9 at 180. The Board’s Exhibit 9 at 180. 57. On November 9, 2016 an officer from the Tempe Police Department went to the Garden Grove apartments at 900 W. Grove Parkway and interviewed Keomy Williams and Melisa Williams, who worked in the rental office. The officer reported that Respondent had been evicted from the Garden Grove apartments on October 31, 2016, and that she had called the leasing office twice on November 9, 2016. At least one of the calls had been put on speaker phone. According to the five victims/witnesses, at least some of whom are African American, Respondent repeatedly used the “N-word” and offended the witnesses.43 58. When police interviewed Respondent she described “a long history of incidents where she had filed various complaints involving issues with neighbors, feeling threatened by a ‘pedophile’ who was walking his dog, and the lack of help from management.”44 59. As a result of the November 9, 2016 incident, Respondent was cited for disorderly conduct, a class 1 misdemeanor.45 Respondent did not report the charge to the Board within 10 days. 60. Respondent testified that her first lawyer told her that she did not have to report the charge to the Board, but that she reported the charge when her second lawyer told her to do so. 61. On March 19, 2017, Respondent was ordered to complete an adult diversion program as a result of the disorderly conduct charge.46 62. Keomy Williams testified that she is the real estate leasing agent for Garden Grove apartments. Ms. Williams testified that on November 9, 2016, Respondent kept calling her a “f*cking n*gger” and other racist slurs and harassment. Ms. Williams testified that she hung up, but put Respondent on speaker phone when she called back. Ms. Williams testified that Respondent did not behave appropriately and that she felt threatened by Respondent. 63. Ms. Williams testified that when Respondent lived in Park Grove apartments, she had many issues. She would come into office and stare at leasing staff. See the Board’s Exhibit 14. The Board’s Exhibit 14 at 297. See id. at 304. See id. at 305, 307. Respondent called a Hispanic maintenance man a “b*aner.” She once said she did not want an A/C vendor in her apartment because he was black. Respondent said that she was armed with mace. Ms. Williams testified that after she told her boss about Respondent, he put an armed guard outside the office who also walked Ms. Williams to her car. 64. Respondent denied using racist slurs in telephone calls to the Grove Park apartments. Respondent testified that all the staff in the office had their cell phones, but nobody recorded the supposed rant. Respondent submitted her phone records into evidence and testified that she called the apartment complex by accident when she was attempting to call a family member. 65. Respondent testified that she was not evicted from Park Grove apartments for non-payment of rent. She testified that, instead, after the eviction proceedings were initiated, she signed an agreement with Park Grove management to vacate the premises because she was already living in another nicer place.47 66. Ms. Bonner testified that Respondent’s conduct outside the workplace was relevant because the incident at Park Grove apartments demonstrated Respondent was prejudiced toward people of other races. Ms. Bonner testified that nurses must be able to care for patients of other races and orientations. Respondent’s Statements to and Interactions with Board Staff 67. On or about December 19, 2014, Respondent submitted a completed and signed Investigative Questionnaire to Board staff. With the Investigative Questionnaire, Respondent submitted medical records for patient P.A. from Cornerstone, Banner Thunderbird Medical Center, and various doctors.48 68. Ms. Bonner testified that when Respondent submitted the records they were not redacted. Ms. Bonner testified that Respondent should not have had the medical records readily available at her home after Cornerstone had terminated her employment several months earlier. Ms. Bonner testified that a nurse should only use a patient’s medical records to care for the patient and that when she is no longer caring for the patient she should destroy the records. Ms. Bonner testified that Respondent’s retention of the See Respondent’s Exhibits CC1-3, DD1-4, and EE1-2. See The Board’s Exhibit 10 at 204-213. records and provision of the records to the Board violated HIPAA and the Nurse Practice Act. 69. Respondent testified that she had obtained the records from her attorney at the time. Respondent pointed out that Board staff asked her to provide the full names or initials and date of birth of patients that she complained about.49 70. On or about February 12, 2017 Respondent submitted an Arrest/Charge/ Citation Questionnaire to the Board that disclosed the disorderly conduct charge.50 On the questionnaire Respondent stated that North Phoenix Infectious Disease had not terminated her.51 Ms. Bonner testified that Respondent’s answer was false and a violation of the Nurse Practice Act. Respondent’s Mental Health 71. Because the Board was concerned about Respondent’s mental health and ability to safely practice, it had her sign a records release and issued a subpoena duces tecum for records from her treating mental health professional at Crisis Preparation and Recovery. 72. According to her mental health records, on July 13, 2016 as part of intake, Respondent stated that she began going to Terros in 2011, but that a nurse practitioner had her picked up and taken in for involuntary treatment.52 On August 7, 2017 Respondent was diagnosed with general anxiety disorder.53 73. On April 19, 2017, Respondent’s treating provider noted that Client is fixated on Dolores Hurtado with the Arizona State Board of Nursing as being the source of her problems. Client has admitted to this CIT that she does own a gun. Client denies to this CIT, in session, that she has any current plans or ideations of DTO [Danger to Others]. Client states that she will address her complaints by exposing her online with documentation. . . . It is unclear if client’s accusations are founded in fact or a product of delusions, paranoia stemming possibly from hearing impairment and misconceptions.54

See Respondent’s Exhibit NN1-NN7. 50 See the Board’s Exhibit 15 at 310. See the Board’s Exhibit 15 at 312. See the Board’s Exhibit 16 at 337. See id. at 378. The Board’s Exhibit 16 at 400-401. Ms. Bonner testified that this entry was concerning because Respondent was referring to Board staff by her first and last name and that the staff involved with investigating the complaints that led to the Consent Agreements had nothing to do with the current complaints that had been filed with the Board. Ms. Bonner testified that she was not aware of any recent contact between Ms. Hurtado and Respondent. 74. On August 21, 2017, the diagnosis was amended, in relevant part as follows: This CIT believes the diagnosis of Generalized Anxiety Disorder is no longer relevant per presenting symptoms. Client’s pattern of reaction to events and individuals, per self-report and observation by this CIT suggest a diagnosis of Paranoid Personality Disorder. Client is plagued with a pervasive distrust and suspiciousness of others that are often interpreted as malevolent. . . .55 Ms. Bonner testified that the revised diagnosis was relevant because it reinforced reports from previous employers that Respondent bears grudges, sees threats, and reacts with anger. Ms. Bonner testified that patients who require nursing care are not at their best and may behave badly. If the nurse reacts, it could result in abuse or patient harm. 75. Respondent testified that her treating professional at Crisis Preparation and Recovery was not fully licensed but was an intern at the time she made the records.56 76. Ms. Bonner interviewed Respondent on August 15, 2017. Respondent stated that all the talk about guns and threatening came from all of her personal information being on the internet, Bing, ASK.com, and from Ms. Hurtado. Respondent also called Ms. Eldredge a liar and a “jackass.”57 Respondent also claimed that Mountain View’s medical records were falsified.58 Ms. Bonner testified that Respondent’s comments were not appropriate. 77. Respondent submitted a single page of a psychological evaluation performed by one Nancy Eldredge that did not contain a diagnoses.59 Ms. Bonner

55 The Board’s Exhibit 16 at 385. See Respondent’s Exhibit II1-3. See the Board’s Exhibit 13 at 271. See the Board’s Exhibit 13 at 272. See Respondent’s Exhibit JJ. testified that the Board did refer Respondent for a psychological evaluation or approve Dr. Eldredge. Respondent’s Other Defenses 78. Respondent testified that she is enrolled to obtain a Nurse Practitioner degree at Chamberlain College of Nursing and that she has been making good progress toward her degree.60 79. Respondent submitted some of her evaluations for her Nurse Practitioner Program clinical courses, which generally showed satisfactory work.61 CONCLUSIONS OF LAW 1. The Board has jurisdiction to consider disciplinary proceedings against Respondent’s RN license.62 This matter lies within the Board’s jurisdiction under A.R.S. § 32-1606(B)(10). 2. The Board bears the burden of proof to establish by a preponderance of the evidence cause to discipline Respondent’s RN license.63 Respondent bears the burden to establish affirmative defenses and factors in mitigation of the penalty by the same evidentiary standard.64 3. “A preponderance of the evidence is such proof as convinces the trier of fact that the contention is more probably true than not.”65 A preponderance of the evidence is “[t]he greater weight of the evidence, not necessarily established by the greater number of witnesses testifying to a fact but by evidence that has the most convincing force; superior evidentiary weight that, though not sufficient to free the mind wholly from all reasonable doubt, is still sufficient to incline a fair and impartial mind to one side of the issue rather than the other.”66 4. The Board established that Respondent violated Cornerstone’s policy by reporting her patient A.P.’s wife to APS on May 22, 2014, and by accompanying her

See Respondent’s Exhibit B1-11. See Respondent’s Exhibit C1-C7. 62 See A.R.S. § 32-1664. See A.R.S. § 41-1092.07(G)(2); A.A.C. R2-19-119(B)(1); see also Vazanno v. Superior Court, 74 Ariz. 369, 372, 249 P.2d 837 (1952). See A.A.C. R2-19-119(B)(2). MORRIS K. UDALL, ARIZONA LAW OF EVIDENCE § 5 (1960). BLACK’S LAW DICTIONARY at page 1220 (8th ed. 1999).

patient R.P. to the emergency room on October 25, 2014, without informing her supervisor. 5. The Board established that Respondent improperly kept a patient’s medical records after Cornerstone terminated her employment for her own personal use, in violation of HIPAA and the Nurse Practice Act. 6. The Board established that Respondent committed disorderly conduct and threatened Ms. Williams, using racial slurs and racist epithets, and that this kind of behavior in a nurse calls into question her ability to care for patients of different races and judgment. 7. The Board established that Respondent made false statements in writing to the Board’s staff during its investigation. 8. The Board established that Respondent made inappropriate and self- serving entries into patients’ medical records while she was employed at Cornerstone. 9. Respondent did not establish that the Board improperly posted the Consent Agreements on its website or that the public access to the documents prevented her from obtaining employment. In fact, Respondent was employed by at least six different employers after she signed the Consent Agreements. The Consent Agreements were not a factor in employers’ decision to terminate Respondent. 10. The Board established that Respondent made at least ten false statements on employment applications between November 2013 and May 2016. 11. The Board established that Respondent failed to report to the Board within ten days that she had been charged with disorderly conduct on November 9, 2016 based on the incident at Park Grove apartments. 12. Therefore, the Board established that Respondent committed unprofessional conduct as defined by A.R.S. § 32-1601(26)(d), (e), and (j),67 or their

A.R.S. § 32-1601(22) provides in relevant part as follows: "Unprofessional conduct" includes the following, whether occurring in this state or elsewhere: .... (d) Any conduct or practice that is or might be harmful or dangerous to the health of a patient or the public. (e) Being mentally incompetent or physically unsafe to a degree that is or might be harmful or dangerous to the health of a patient or the public. .... predecessor statutes, as further defined by A.A.C. R4-19-403(1), R4-19-403(2), R4-19- 403(8-9), R4-19-403(26), R4-19-403(27), R4-19-403(28), and R4-19-403(31),68 and in violation of A.R.S. § 32-3208(A) and (D).69

(j) Violating this chapter or a rule that is adopted by the board pursuant to this chapter. A.A.C. R4-19-403 provides in relevant part as follows: For purposes of A.R.S. § 32-1601(22)(d), any conduct or practice that is or might be harmful or dangerous to the health of a patient or the public includes one or more of the following: 1. A pattern of failure to maintain minimum standards of acceptable and prevailing nursing practice; 2. Intentionally or negligently causing physical or emotional injury; .... 8. Falsifying or making a materially incorrect, inconsistent, or unintelligible entry in any record: a. Regarding a patient, health care facility, school, institution, or other work place location; or b. Pertaining to obtaining, possessing, or administering any controlled substance as defined in the federal Uniform Controlled Substances Act, 21 U.S.C. 801 et seq., or Arizona’s Uniform Controlled Substances Act, A.R.S. Title 36, Chapter 27; 9. Failing to take appropriate action to safeguard a patient’s welfare or follow policies and procedures of the nurse’s employer designed to safeguard the patient; .... 26. Making a written false or inaccurate statement to the Board or the Board’s designee in the course of an investigation; 27. Making a false or misleading statement on a nursing or health care related employment or credential application concerning previous employment, employment experience, education, or credentials; [; or] 28. If a licensee or applicant is charged with a felony or a misdemeanor involving conduct that may affect patient safety, failing to notify the Board in writing, as required under A.R.S. § 32-3208, within 10 days of being charged. The licensee or applicant shall include the following in the notification: a. Name, address, telephone number, social security number, and license number, if applicable; b. Date of the charge; and c. Nature of the offense .... 31. Practicing in any other manner that gives the Board reasonable cause to believe the health of a patient or the public may be harmed. A.R.S. § 32-3208 provides in relevant part as follows: A. A health professional who has been charged with a misdemeanor involving conduct that may affect patient safety or a felony after receiving or renewing a license or certificate must notify the health professional's regulatory board in writing within ten working days after the charge is filed. .... D. A health professional who does not comply with the notification requirements of this section commits an act of unprofessional conduct. The health professional's regulatory board may impose a civil penalty of not more than one thousand dollars in addition to other disciplinary action it takes. 13. Respondent’s numerous acts of unprofessional conduct furnish cause for the Board to discipline her RN license under A.R.S. §§ 32-1663(D)70 and 32-1664(N).71 14. Respondent has a long history of refusing to take any personal responsibility for her practice or personal interactions with other health care professionals or others with whom she comes into contact. Respondent seemingly refuses to consider the possibility that she has anything to learn from persons to whom she feels superior or that her termination from numerous jobs was based on her actions on the job rather than retaliation for the numerous complaints that she has filed to various agencies about her employers, co-workers, and others. While Respondent may have unaddressed behavioral health issues that affect her practice of nursing, those issues do not excuse her behavior or absolve her from responsibility from consequences stemming therefrom.72 Because Respondent will not or cannot take responsibility for her actions, it does not appear that she can be regulated at this time. RECOMMENDED ORDER In light of Respondent April Lynn Cobia’s numerous acts of unprofessional conduct, it is hereby ordered that her registered nurse license number RN117544 be revoked effective date of the final order in this matter. In the event of certification of the Administrative Law Judge Decision by the Director of the Office of Administrative Hearings, the effective date of the Order will be five days from the date of that certification. Done this day, March 30, 2018. /s/ Diane Mihalsky Administrative Law Judge

A.R.S. § 32-1663(D) provides that “[i]f the board finds, after affording an opportunity to request an administrative hearing pursuant to title 41, chapter 6, article 10, that a person who holds a license or certificate issued pursuant to this chapter has committed an act of unprofessional conduct, it may take disciplinary action.” A.R.S. § 32-1664(N) provides that “[i]f the regulated party is found to have committed an act of unprofessional conduct or to have violated this chapter or a rule adopted pursuant to this chapter, the board may take disciplinary action.” See the Board’s Exhibit 16 at 338. Transmitted electronically to:

Joey Ridenour, RN, MN, Executive Director State Board of Nursing