ALJDEC decisions subject to certification as final

21A-201910042-NUR · State Board of Nursing · 2020-12-28

IN THE OFFICE OF ADMINISTRATIVE HEARINGS

IN THE MATTER OF REGISTERED NURSE LICENSE NO. RN145020

ISSUED TO:

KATHERINE DEEANNA GRIEGO,

RESPONDENT

No. 21A-[number redacted]-NUR

ADMINISTRATIVE LAW JUDGE DECISION

HEARING: December 3, 2020 with the record held open until December 18, 2020.

APPEARANCES: The Arizona State Board of Nursing was represented by Assistant Attorney General Elizabeth Campbell. Respondent Katherine Deeana Griego did not appear.

ADMINISTRATIVE LAW JUDGE: Adam D. Stone

_____________________________________________________________________

FINDINGS OF FACT

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, 1663, and 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 1667.

Respondent holds Board-issued registered nurse license number 145020.

Stephanie Chambers, RN, MN, the assigned Board investigator presented testimony as to the three incidents which led to the present action.

First, Ms. Chambers testified that Respondent, while working in the post-operative unit at Banner Desert Medical Center in Mesa, Arizona, on August 27, 2019 failed to accurately document and account for controlled substances she removed from Pyxis (a type of electronic medication dispensing machine) for Patient KW. Specifically, Ms. Chambers testified that Respondent’s charting of administering the medicine did not correspond to the times the medicine was withdrawn from the Pyxis machine. Ms. Chambers testified as to the following occurrences from that date:

Respondent documented that she administered 12.5 mg of Demerol by IV at 11:45 a.m., however, the Pyxis record showed that Respondent did not remove the vial of 25 mg from Pyxis until 12:50 p.m., more than an hour later, and Respondent failed to document that she “wasted” the remaining 12.5 mg until approximately two hours later.

Respondent documented that she administered Demerol by IV at 11:50 a.m., however, the Pyxis record showed that Respondent did not remove the dose from Pyxis until 12:51 p.m., more than an hour later. Respondent failed to document the partial dose waste until 2 hours after she removed it from Pyxis.

Respondent documented that she administered Demerol by IV at 12:00 p.m. however, the Pyxis record showed that Respondent did not remove the dose from Pyxis until 1:11 p.m., more than an hour later.

Respondent documented that she administered Demerol by injection at 1:10 p.m., however, the Pyxis record showed that Respondent did not remove the dose from Pyxis until 2:11 p.m., more than an hour later.

Respondent documented that she administered 50 mg of Demerol by IV at 1:10 p.m., however, however, the Pyxis record showed that Respondent removed only 25 mg from Pyxis at 2:36 p.m., more than an hour and a half later.

Respondent removed Hydromorphone 1 mg from Pyxis at 2:37 p.m., just 1 minute after her previous Demerol removal. Respondent did not administer the medication, and at 3:17 p.m., 40 minutes after removing the dose, she “wasted” the entire amount.

Ms. Chambers testified that the above incidents showed that Respondent removed a total of 150 mg of Demerol from Pyxis during this period, yet she documented that she administered 175 mg, which was 25 mg more than she removed and 25 mg more than was ordered by the physician.

Ms. Chambers testified that these inconsistences were very troublesome as it raised safety concerns for the patient because someone looking at the patient’s chart would not be able to tell how much medication was given, or if any was at all.

Ms. Chambers next testified about another incident on August 28, 2019, while Respondent was working at Banner Desert Medical Center. Upon Ms. Chambers’ review of the records, she determined that Respondent removed one syringe of Hydromorphone from Pyxis under Patient AA’s name, without a physician’s/prescriber’s order. Ms. Chambers testified that from the records, Respondent did not administer the medication and documented that she wasted the entire amount at 6:23 p.m., nearly three hours after removing the medication. Ms. Chambers testified that even if Respondent accidentally received the medication in error, the correct action would be to promptly “waste” the same and not wait approximately three hours.

Ms. Chambers testified that based upon these two incidents, Banner Desert Medical Center reported Respondent’s potential violations to the Board and in addition, notified the Board that Respondent had been terminated on or about September 25, 2019.

Ms. Chambers testified that she mailed an Investigative Questionnaire to Respondent who completed the same on December 11, 2019.

Ms. Chambers testified that Respondent’s narrative indicated that she understood that this was an unsafe practice, and that “untimely charting does not follow Banner policy for safe medication administration.”

Ms. Chambers then testified that on or about January 23, 2020, the Board received a complaint from Chandler Regional Medical Center about Respondent.

Ms. Chambers testified that while Respondent was working at Chandler Regional Medical Center as a travel nurse, she failed to accurately and timely document the controlled substances she removed from OmniCell (another type of electronic medication dispensing machine) for Patient JW. Respondent removed two doses of Stadol 2 mg for IV administration during this shift, however she documented that she administered one dose three and a half hours prior to removing the medications from OmniCell. Respondent documented that she administered the second dose of Stadol three and half hours after removing it from OmniCell. Ms. Chambers further testified that the orders were that the Stadol was to be administered every three hours as needed for pain, yet Respondent removed the Stadol doses less than one hour apart. Ms. Chambers testified that because of these charting issues, it was impossible to determine if Respondent administered the medication and what time and at what dosage.

Further, Ms. Chambers testified that the staffing agency at which Respondent worked, One Staff Medical, requested that Respondent appear for a meeting to discuss the above incident. Upon information and belief, Respondent claimed to have been in an accident and could not make the meeting, but would be available the next morning. The meeting was rescheduled, however, Respondent failed to appear. Because of this, Chandler Regional Medical Center terminated Respondent’s contracts due to the missing narcotics and the documentation discrepancies.

Ms. Chamber’s next testified that on or about August 12, 2020, the Board received a complaint from St. David’s Round Rock Medical Center in Texas. Ms. Chambers testified that Respondent was working as a travel nurse and during the overnight shift on August 10, 2020 to August 11, 2020. Ms. Chambers testified that Respondent at 1:26 a.m., removed a vial of Dilaudid 2 mg from Pyxis for a patient, but remained at the Pyxis station for 25 minutes. Upon information and belief, Respondent walked up and down the hallway several times but never entered a patient’s room. At 3:11 a.m., Respondent went to the Pyxis machine and “wasted” 1 mg of the Dilaudid, and then at 5:08 a.m., Respondent returned to the Pyxis machine and wasted the remaining 1 mg of Dilaudid. It was later determined that upon review of video footage from the hospital that Respondent also failed to properly dispose of the “wasted” medicine.

Ms. Chambers next testified that on August 14, 2020 the facility requested that Respondent take a drug test, however, Respondent never appeared nor responded to any further attempts at communication.

Ms. Chambers then testified that on or about January 24, 2020, the Board mailed an Investigative Questionnaire to Respondent’s address of record requesting that she provide a complete and full written explanation covering the matter reported in the Chandler Regional Medical Center complaint. Respondent did not return the completed Questionnaire and the mail was not returned to the Board as undeliverable. On or about August 18, 2020, the Board mailed an Investigative Questionnaire to Respondent’s address of record requesting that she provide a complete and full written explanation covering the matter reported in in the St. David’s Round Rock Medical Center complaint. Respondent failed return the completed Questionnaire and the mail was not returned to the Board as undeliverable.

Respondent failed to disclose all three of the above incidents to the Board.

Ms. Chambers prepared an Investigative Report which recommended that the Board summarily suspend Respondent’s license, and the Board set a hearing on the Proposed Findings of Public Emergency and Order of Summary Suspension on November 12, 2020.

On or about November 12, 2020, the Board summarily suspended Respondent’s registered nurse license and requested that proceedings be promptly instituted and determined.

On or about November 18, 2020, the Board issued a Complaint and Notice of Hearing, Summary Suspension Expedited Hearing, that alleged violations of A.R.S. § 32-1601(26)(d), (g), (h) and (j) and A.A.C. R4-19-403(1), (7), (8), (9), (12), (16), (25)(a), and (31).

The Notice of Hearing was sent via certified mail to Respondent at her address of record. Further, on or about November 17, 2020, the Office of Administrative Hearings (OAH) sent an Order converting the hearing to a “Google Meet” to Respondent’s address of record.

Respondent did not file a response or exhibits with OAH, nor did she request that the hearing be continued prior to the hearing convening. Although the start of the hearing was delayed 20 minutes to allow Respondent additional time to appear, she failed to appear, personally or through an attorney, and did not contact the OAH to request that the start of the hearing be further delayed prior to the hearing convening. Consequently, Respondent did not present any evidence to defend her Practical Nurse License.

CONCLUSIONS OF LAW

The Notice of Hearing that the Board mailed to Respondent at her address of record was reasonable, and Respondent is deemed to have received notice of the hearing. See A.R.S. § 41-1092.04; A.R.S. § 41-1061(A).

This matter lies within the Board’s jurisdiction under A.R.S. § 32-1606(B)(10).

The Board bears the burden of proof and must establish cause to penalize Respondent’s registered nurse’s license by a preponderance of the evidence. See A.R.S. § 41-1092.07(G)(2); A.A.C. R2-19-119(A) and (B)(1); see also Vazanno v. Superior Court, 74 Ariz. 369, 372, 249 P.2d 837 (1952).

“A preponderance of the evidence is such proof as convinces the trier of fact that the contention is more probably true than not.” Morris K. Udall, Arizona Law of Evidence § 5 (1960). A preponderance of the evidence is “evidence which is of greater weight or more convincing than evidence which is offered in opposition to it; that is, evidence which as a whole shows that the fact sought to be proved is more probable than not.” Black’s Law Dictionary 1120 (8th ed. 2004).

The Board established by a preponderance of the evidence that Respondent engaged in unprofessional conduct as alleged in the Complaint and Notice of Hearing. Ms. Griego’s behavior created a substantial and unnecessary risk of harm to her patients. While no evidence was presented as to if the patients were harmed by Ms. Griego’s falsifying patient records, her actions are nonetheless unacceptable. As such, the Board established cause to impose a disciplinary sanction against Respondent’s license under A.R.S. § 32-1663(D) and A.R.S. § 32-1664(N).

RECOMMENDED ORDER

Based on the foregoing, the Administrative Law Judge recommends that the Board affirm its order summarily suspending Respondent Katherine Deeana Griego’s Registered Nurse License number 145020.

It is further recommended that the Board revoke Respondent Katherine Deeana Griego’s Registered Nurse License number 145020.

-54864001

001

-137160-45720000Done this day, December 28, 2020.

/s/ Adam D. Stone

Administrative Law Judge

Transmitted electronically to:

Joey Ridenour, RN, MN, Executive Director

State Board of Nursing

-54864001

001

-137160-45720000