ALJDEC - Licensing
24A-2023100534-NUR · State Board of Nursing · 2025-07-21
IN THE OFFICE OF ADMINISTRATIVE HEARINGS
IN THE MATTER OF THE REGISTERED NURSE LICENSE NO. RN14335 ISSUED TO:
LISA RUTH MOON,
RESPONDENT.
No. 24A-[number redacted]-NUR
ADMINISTRATIVE LAW JUDGE DECISION
HEARING: Evidentiary hearing sessions on December 4, 2024 and February 20, 2025, followed by written legal briefs and review of the exhibits and Official Record.
APPEARANCES: Attorney Paul J. Sheston represented Lisa Ruth Moon. Assistant Attorney General Elizabeth Campbell represented the Arizona State Board of Nursing at the hearing sessions; Assistant Attorney General Roberto Pulver represented the Arizona State Board of Nursing during the post-hearing legal argument process.
ADMINISTRATIVE LAW JUDGE: Kay Abramsohn
EXHIBITS ADMITTED INTO EVIDENCE: Board Exhibits 1 through 21; Respondent Exhibit A.
_____________________________________________________________________
FINDINGS OF FACT
The Arizona State Board of Nursing (Board) has the authority to regulate and control the practice of nursing in the State of Arizona, pursuant to Arizona Revised Statutes (Ariz. Rev. Stat.) §§ 32-1606, 32-1663, and 32-1664. The Board also has the authority to impose disciplinary sanctions against the holders of nursing licenses for violations of the Nurse Practice Act, ARIZ. REV. STAT. §§ 32-1601 through 32-1669 and Arizona Administrative Code (Ariz. Admin. Code) R4-19-101 through R4-19-815.
The Board may undertake investigations with regard to holders of nursing licenses. In connections therewith, pursuant to Ariz. Rev. Stat. § 32-1664, the Board may obtain any documentation that indicates a regulated party may have violated the Arizona nursing laws and rules. If the Board determines that a licensee has committed unprofessional conduct, the Board may take disciplinary action pursuant to ARIZ. REV. STAT. § 32-1663(A).
Lisa Ruth Moon (Respondent) holds Board-issued Registered Nurse (RN) License No. RN14335 in the State of Arizona; the license was issued on December 21, 2006.
COMPLAINTS AND INVESTIGATION
On October 23, 2023, the Board received information from Neika Sloan, Acting Director of Nursing at Maryland Gardens Post-Acute (MGPA), a long term care facility, regarding Respondent’s actions on October 22, 2023. Respondent had worked a shift at MGPA, attempting to use the Shiftkey technology for her work that day. MGPA reported the following:
On 10/22/2023, Lisa Moon arrived at 7:20am for her 6:00am scheduled shift. She reported that she had gotten lost.
Upon counting narcotics, she was observed bouncing from foot to foot and turning herself in circles. She sat down to work in the electronic record and her legs were bouncing and moving very rapidly the entire time she was sitting.
She then placed a mask on her face, was playing with her nose, blowing her nose, and then removed the mask very abruptly. Then she placed the mask back on her face, start playing with her nose, and then remove it abruptly once again. Lisa then got up from the work station and began pacing, turning in circles, and then sitting back down.
At 10:47am, Lisa was observed popping medications for med pass without the proper tools to provide safe medication administration. The laptop that contains the e-mar records/orders was laying closed on the desk while she was at the medication cart removing meds. Lisa was also observed nodding off and almost falling into the med cart during this time as well.
She asked the staff which facility she was at multiple times. She kept taking multiple bathroom breaks. She keep playing with her nose, fidgeting, and pacing throughout the shift.
Lisa did not document that any medications were given to any residents during the duration of her shift except for the following:
[M.F.]-Morphine Sulfate 15mg po q 12 hrs @ 0900 and Norco 5/325mg 1 po PRN @ 1130;
[F.G.]-Tramadol 50mg 1 po q 6hrs PRN @ 1500;
[S.P.]-Tramadol 50mg 1 po BID @ 0800.
She did not complete any treatments, behavior charting, change of condition charting, or vital sign monitoring and pain assessments during the duration of the shift.
With regard to the MGPA complaint, Inv. Stazzone began her investigation and requested documentation. Inv. Stazzone interviewed Neika Sloan, Jenny Lass (Director of Nursing, MGPA), Tameika Moody (LPN, MGPA), and Camie Gonzales (LPN, MGPA).
On November 30, 2023, the Board informed Respondent that the Board was conducting an investigation.
On December 29, 2023, Inv. Stazzone emailed Respondent with a request for a 12-panel hair drug test.
Inv. Stazzone did not receive information back from Respondent regarding the MGPA complaint until February 2, 2024. On February 21, 2024, Inv. Stazzone notified Respondent that, although she had provided a narrative response, Respondent needed to complete the investigative Questionnaire.
Inv. Stazzone did not hear back from Respondent with regard to the drug testing until February 2024. However, Respondent did not present a completed drug test at that time.
While investigating the MGPA complaint, Investigator Michelina Stazzone received information regarding Respondent’s actions or alleged issues raised by Honor Health Deer Valley and Stellar Healthcare. The two issues were as follows:
a. On 5/8/22, you were terminated from HonorHealth Deer Valley for theft of food from the Food Cart while it was closed.
b. On 2/16/23, you were terminated for failure to submit a for-cause drug test while working for Stellar Healthcare.
On February 22, 2024, Inv. Stazzone notified Respondent that she had received information regarding those stated allegations, and requested Respondent’s full explanation by February 26, 2024. Inv. Stazzone also indicated that Respondent’s failure to supply a timely response could be considered to be unprofessional conduct under Ariz. Rev. Stat. §§ 32-1664(A) and 32-1601(27)(d).
Inv. Stazzone began her efforts to schedule an interview with Respondent. On February 23, 2024, Respondent advised Inv. Stazzone that she was having some phone issues and Respondent provided a temporary number.
On February 28, 2024, Inv. Stazzone advised Respondent that the pending investigation/case was scheduled for the March 21/22, 2024 Board Meeting as a proposed summary suspension.
On February 28, 2024, Respondent advised Inv. Stazzone that she needed to reschedule the March 1, 2024 interview, due to transportation issues, and she had not yet met with legal counsel, and she had not yet responded as she was waiting for some supporting documentation to provide regarding the HonorHealth and Stellar Healthcare allegations.
On March 5, 2024, Inv. Stazzone conducted an interview with Respondent regarding the three complaints. Following the March 5, 2024 interview, on March 6, Respondent e-mailed that she would provide information on March 6, 2024; however, Respondent did not provide information regarding Complaint 2 or 3 on March 6, 2024.
Respondent did not send further information to Inv. Stazzone until March 11, 2024; therein, she indicated she would send a “more polished” version by March 19, 2024.
On or about March 13, 2024, Respondent notified Inv. Stazzone that she wanted to supply additional information. In response, Inv. Stazzone advised Respondent that the Board had a 48 hour cut-off prior to a Board meeting to receive information so that the Board would have the chance to review it.
In the “Investigative Questionnaire” Exhibit 16, the hearing record contains several statements and other related supporting documents from Respondent regarding Complaint #1, #2 and #3. Respondent’s written statements are unsigned, undated, and are not date-stamp received by the Board or Inv. Stazzone as of any particular date. However, the documents were received within the 10-day window to be able to go the Board for the Board meeting.
Inv. Stazzone received Recovery Trek drug test results on April 10, 2024. An initial testing had not contained a sufficient sample for testing. The second testing documented negative results for any substance other than for Respondent’s prescribed medication.
On March 21, 2024, following its consideration of Inv. Stazzone’s Investigative Report and information provided at the Board meeting, the Board summarily suspended Respondent’s RN license and requested prompt institution of an administrative hearing.
The Board subsequently referred the matter to the Office of Administrative Hearings (Tribunal), an independent agency, for an evidentiary hearing.
On March 29, 2024, the Board issued a Complaint and Notice of Hearing, setting the matter for an expedited formal administrative hearing on May 10, 2024. The Board’s Complaint and Notice of Hearing is hereby incorporated into the official hearing record. Multiple continuances ensued on behalf of both parties during the time the parties were participating in settlement discussions.
At hearing, Inv. Stazzone provided testimony consistent with the findings and facts in her Investigative Report and the Updated Report. The collected information therein supports Inv. Stazzone’s findings and facts.
Regarding Complaint #1 - MGPA. In addition to the initial complaint recitation regarding concerns with behaviors, Inv. Stazzone determined that there were issues with the MAR records.
a. Respondent had assigned as removed one tablet of Hydrocodone/Acetaminophen 5/325 mg, a Schedule II controlled substance (i.e., Opioid with Tylenol) for Patient M.F. but Respondent did not document the administration, waste, or return of the medication in MAR records.
b. Respondent documented that she had administered Lyrica 50 mg (i.e., Pregabalin 50 mg) at 2:00 pm for Patient M.F., but Respondent never removed the medication from the controlled medication cart.
c. Respondent assigned out two Tramadol 50 mg tablets (i.e., an opioid) for Patient S.P., but documented the administration of only one tablet and did not document the administration, waste, or return of the remaining tablet.
Regarding Complaint #2 – Honor Health Deer Valley (HHDV). Investigator Stazzone reviewed two allegations regarding Respondent’s actions or inactions at HHDV and determined the following:
a. Respondent had not timely competed training on the EPIC system and had been working multiple shifts without having access to EPIC or to the HHDV electronic medication dispensing system (PYXIS) or to the time clocking system.
b. While on her shift(s) Respondent neglected to perform essentials tasks assigned to her with regard to multiple patients, including taking vital signs, removing an IV, washing hands before administering IV medications, unclamping IV tubing for an infusion; further, Respondent had not completed requisite orders for a patient with chest pain without prompting.
c. Respondent demonstrated behaviors such as nervousness and hyperactivity, giving the impression to HHDV staff that she was impaired; Respondent appeared to be unable to concentrate. HHDV staff expressed concerns regarding Respondent’s readiness during her orientations and further concerns regarding patient safety, delay in patient care, and patient abandonment.
d. Respondent was sent home On May 8, 2022, and subsequently terminated, for taking food from the Food Cart while it was closed for business, and never paying for the items she took; HHDV considered the taking of food from the Food Cart as being theft in violation of HH Employee Standards of Conduct Policy No. 11716430.
Complaint #3 – Stellar Healthcare (Stellar). Investigator Stazzone reviewed two allegations regarding Respondent’s actions or inactions at Stellar and determined the following:
Respondent’s behavior on February 10, 2023, was reported by coworkers as agitated, jittery, and restless, giving the impression to Stellar staff that she was impaired. Respondent was stated to have bounced from foot to foot, moved around the kitchen, and pounded the table with her hands. Staff indicated that Respondent asked a lot of the same questions over and over and did not appear to be able to focus.
When Kim Smith, Owner of Stellar, arrived at the Stellar location on February 10, 2023, it appeared to her that Respondent was impaired. Ms. Smith drove Respondent home and told Respondent to take a drug test.
A narcotic count after Respondent’s shift showed a missing dose of Phenobarbital, a Class C IV controlled substance; it was suspected that Respondent had diverted the medication.
Respondent was told to submit a for-cause drug test.
On February 16, 2023, when she returned to Stellar for a shift, Respondent was terminated for failure to have submitted a for-cause drug test for the suspected diversion.
Respondent’s written statements, provided a few days prior to the March 21, 2024 Board meeting, gave details regarding each of the three Complaints.
In her written statement regarding Complaint #1 at MGPA, Respondent denied having been impaired or having diverted any medication. Respondent indicated that the Shift Key employment app had not been working the night before the shift and she had been unable to double check the details of the assignment; therefore, she mistakenly thought the shift started at 7:00 a.m. Respondent noted that when she arrived at 7:00 a.m. at the MGPA front office, she was directed to the post-acute area which was in the next building; Respondent believed she arrived at approximately 7:10 a.m. to the nursing desk. Respondent indicated that she had put on masks because she was fighting a cold and had a runny nose. Respondent indicated that she was using the desktop EMAR/Orders because the laptop computer that had rested on the medication cart had died and was being recharged. Regarding the failure to have documented medications, Respondent indicated that she was not trained how to properly document using the MGPA system and she stated that there was no charge nurse, manager nurse, manager, or any other administrative staff member present at the time.
At hearing, Respondent testified that she had not taken her ADHD medication on October 22, 2023, and that such a situation results in an increase in her hyperactivity.
In the videos taken at MGPA by LPN Moody, Respondent can be seen to be masking and unmasking and fidgeting; further, it appears that she is touching or massaging her leg a few times and then stretching her back several times. One of the videos does demonstrate what appears to be Respondent jerking in a way that can be described as catching yourself from falling asleep.
In her written statement regarding Complaint #2 and the HHDV coffee cart, Respondent indicated that she had had every intention to pay at the coffee cart. Respondent provided the following explanations: it was around 11:30-ish and she notified the preceptor that she needed to grab something to eat; when she arrived at the coffee cart, there was a sign that said, be right back and she waited, thinking the staff there would be returning very soon; after waiting, for what seemed to be about 10 minutes, she approached a female sitting at the receptionist’s desk next to the coffee cart and told her she was going to take a picture of things she was taking and asked that person to let the coffee cart staff she would be right back to pay; she stated the person suggested that Respondent write a note, but she didn’t have any paper to do so; she sat down and started eating, thinking that the staff would be back by the time I had eaten some of the snacks, and that she would then pay; when no one had returned she decided to go back to the ER and tell the preceptor of the situation; she had not imagined the coffee cart staff would be gone for more than 30 minutes; she returned to the ER and told the charge nurse and preceptor that no one had been at the coffee cart she needed to go back and pay. Respondent indicated that other nursing and charting activity ensued until the House Supervisor and the ER charge nurse pulled her aside and notified her that she was being sent home early pending an investigation of “inappropriate behavior” that had been brought to the House Supervisor’s attention. Respondent inquired whether she was being sent for testing, drug screening, and the House Supervisor told her no, No, it was not about “impaired” behavior. Respondent indicated that she went to the coffee cart on her way out of the hospital but it was “closed” and, being on a Sunday, she had no idea who to contact. Respondent indicated she then wrote a letter explaining what had happened, leaving her name, badge number, and the items she needed to pay for. Respondent indicated that, subsequently, she received a call from the ER Senior Director Davey Ellison and he had said to her “Lisa I am sorry but it is just not going to work out, I am sorry.”
In her written statement regarding the HHDV concerns on nursing and charting activity, Respondent gave no details regarding the tasks to which she had been assigned in the ER that day. Respondent indicated that when she returned to the ER, the preceptor informed her that she started the triage and assessment on a 20-something year-old female patient with stroke symptoms. Thereafter, a stroke alert was called and she and the preceptor both went to CT with the patient. Respondent indicated that they then transported the patient back to her assigned room and reconnected her to the monitor. Respondent stated that, after that, the preceptor sat with her offered her assistance to catch up on charting and review things.
In her written statement regarding Complaint #3 at Stellar, Respondent simply denied ever having been under the influence and denied ever having been instructed, in February 2023, to get a drug test. Respondent supplied multiple text messages from June of 2023 regarding training at a second Stellar location.
At hearing, Respondent testified consistent with her written statements regarding the three complaints and her explanations thereof. Respondent credibly testified that she had never failed a drug test at any of her employment or other screens. In this regard, Respondent documented her most recent drug testing, on November 5, 2024, that was negative for any substances other than her ADHD medication.
The Board’s position is that the evidence of record demonstrates Respondent engaged in unprofessional conduct, unprofessional nursing practices, unprofessional decision-making, and showed signs of impairment while working at HHDV [April 18, 2022 to May 8, 2022], at Stellar [January 9, 2023 to February 109, 2023] and at MGPA [October 22, 2023] during her employment or registry status at those facilities. The Board argues that the evidence of record documents issues with Respondent’s repeated failures to competently comply with nursing orders, repeated failures to timely and competently complete assessments, and repeated failures to accurately account for and administer medications on those multiple complained-of shifts and, thus clearly demonstrated that Respondent is a danger to patients and to the public. The Board requested that the Tribunal affirm the Board’s Order of Summary Suspension and recommend revocation of Respondent’s RN License No. 143335.
Respondent’s position is that the Board unjustly and inappropriately took action to suspend Respondent’s license in the absence of consideration of all the evidence, in that the Board was lacking the results of the Board-requested drug screen, which was negative for any illegal substances. Further, that the evidence of record lacked credibility, had little to no foundation and was speculative or largely opinion-based. Respondent argued that the Board had not demonstrated that Respondent had been given appropriate training on new-to-her facility systems such that she would have been able to properly utilize the system or that the alleged failures in completing training on facility systems was solely due to Respondent’s actions or inactions. Respondent argued that the Board failed to interview or bring forward other possible witnesses, such as those persons named or referenced within the gathered documents. Respondent argued that the Board had not demonstrated that any patient at any of the facilities scrutinized herein suffered any harm due to any of Respondent’s alleged actions or inactions. Respondent argued that the Board purposely strained to find potential evidence after receiving only the one MGPA complaint, in order to damage Respondent’s reputation and create the justification for a “planned” emergency summary suspension. Respondent argued that the Board had not met its burden to demonstrate the alleged failures, and that the hearing evidence did not warrant affirmation of the summary suspension or a recommendation for revocation of Respondent’s RN license.
The Board’s Complaint and Notice of Hearing alleges that cause exists to discipline Respondent’s RN license under ARIZ. REV. STAT. § 32-1601(27)(d), (e), (g), (h), and (j) and ARIZ. ADMIN. CODE R4-19-403(2), (7), (8), (9), (12), (15), (16), (18), and (31).
APPLICABLE LAW
ARIZ. REV. STAT. § 32-1601(27) defines “unprofessional conduct” to include, in pertinent part, as follows: ...
(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. ...
(g) Wilfully or repeatedly violating a provision of this chapter or a rule adopted pursuant to this chapter.
(h) Committing an act that deceives, defrauds or harms the public. ...
(j) Violating this chapter or a rule that is adopted by the board pursuant to this chapter.
ARIZ. ADMIN. CODE R4-19-403 describes various conducts or practices that are or might be harmful to the public and, as charged in this matter, in pertinent part, ...
2. Intentionally or negligently causing physical or emotional injury. ...
7. Failing to maintain a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided.
8. Falsifying or making a materially incorrect, inconsistent or unintelligible entry in any record: ...
(b) [p]ertaining 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. ...
12. Assuming patient care responsibilities that the nurse lacks the education to perform, for which the nurse has failed to maintain nursing competence, or that are outside the scope of practice of the nurse. ...
15. Removing, without authorization, any money, property, or personal possessions, or requesting payment for services not performed from a patient, employer, co-worker, or member of the public.
16. Removing, without authorization, a narcotic drug, controlled substance, supply, equipment or medical record from any health care facility, school institution, or other work place location. ...
18. Obtaining, possessing, administering, or using any narcotic, controlled substance, or illegal drug in violation of any federal or state criminal law, or in violation of the policy of any health care facility, school, institution, or other work location at which the nurse practices. ...
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.
VIOLATIONS
A standard of nursing practice is to provide for patient safety and practice in a manner that does not harm the patient or the public. While working as an RN at HHDV between April 25 2022, and May 11, 2022, Respondent violated this standard when she did not complete her documentation training, which denied her access to the medical record and the medication dispensing system, and when she failed to follow provider orders and failed to complete tasks or failed to complete them in a timely manner.
A standard of practice is not to remove any property from an employer or the facility without authorization. On or about May 8, 2022, while working as an RN at HHDV, Respondent violated this standard, and the HonorHealth Employee Standards of Conduct Policy No. 11716430HHDV, when she removed food without permission or payment from an HHDV food cart.
A standard of practice is to follow orders and accurately document assessments, medication administration, and care provided as ordered. While working as an RN at MGPA on October 22, 2023, Respondent violated this standard when she failed to complete patient treatments, and document ordered shift assessment for Patient S.P., Patient M.F., and Patient F.G. Further, Respondent failed to document shift assessments of mental status, mood, medication tolerance, and safety for Patients M.F., F.G., and S.P., as ordered.
A standard of practice is to accurately document the administration, waste, or return of controlled substances signed out for a patient. While working as an RN at MGPA on October 22, 2023, Respondent violated this standard when:
a. Respondent assigned as removed Hydrocodone/Acetaminophen 5/325 mg (schedule II controlled substance, Opioid with Tylenol), one tablet for Patient MF but did not document administration, waste, or return.
b. Respondent documented she administered, Lyrica 50 mg (aka Pregabalin 50 mg, for nerve pain and seizures) at 2:00 pm for Patient MF, but never removed it from the controlled medication cart.
c. Respondent assigned out two Tramadol 50 mg tablets (controlled substance, opioid for pain) for Patient SP when only one was ordered, but documented administration of only one tablet with no documentation of administration, waste, or return of the second tablet.
A standard of nursing practice is to account for all medications and properly document administration, waste or return. On or about February 10, 2023, while working as an RN for Stellar, Respondent violated the standard when she did not account for a missing narcotic; a narcotic count on February 10, 2023 showed a missing dose Phenobarbital, a Class C IV controlled substance.
A standard of practice is to follow employer policy and submit a for-cause drug test if requested. After working for Stellar on February 10, 2023 and being instructed to obtain a drug test, Respondent violated the standard when she attempted to return to work on February 16, 2023 without having submitted to and providing the results of a for-cause drug test as had been requested.
CONCLUSIONS OF LAW
This matter lies within the Board’s jurisdiction. The Board bears the burden of proof and must establish cause to discipline Respondent’s RN license by a preponderance of the evidence. See ARIZ. REV. STAT. § 41-1092.07(G)(2); ARIZ. ADMIN. CODE R2-19-119(A) and (B)(1); see also Vazzano 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 in this matter that, as found within, Respondent acted in violation of Arizona laws and Arizona Board-regulated standards and practices as defined in ARIZ. REV. STAT. § 32-1601(27)(d), (g), and (j) and ARIZ. ADMIN. CODE R4-19-403(7), (8), (9), (12), (15), (16), and (31).
The Board failed to establish by a preponderance of the evidence in this matter that Respondent acted in violation of ARIZ. REV. STAT. § 32-1601(27)(e) or (h) or ARIZ. ADMIN. CODE R4-19-403(2) or (18).
Given the determined violations of law and rules applicable to Respondent, the Administrative Law Judge concludes that the Board established cause to impose disciplinary sanctions of suspension or revocation against Respondent’s license under the foregoing laws and rules.
RECOMMENDED ORDER
Based on the foregoing, the Administrative Law Judge recommends that the Board affirm its March 21, 2024 Summary Suspension Order suspending Respondent Lisa Ruth Moon’s RN License No. 143335.
The Administrative Law Judge further recommends that the Board revoke Respondent Lisa Ruth Moon’s RN License No. 143335.
Pursuant to ARIZ. REV. STAT. § 41-1092.08(I), the licensee may accept the Administrative Law Judge Decision by advising the Office of Administrative Hearings in writing not more than ten (10) days after receiving the decision. If the licensee accepts the Administrative Law Judge Decision, the decision shall be certified as the final decision by the Office of Administrative Hearings.
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 forty (40) days from the date of that certification.
Done this day, July 21, 2025.
/s/ Kay Abramsohn
Administrative Law Judge
Transmitted electronically to:
Joey Ridenour, RN, MN, Executive Director
State Board of Nursing
Paul J. Sheston
Sheston Law Group PLLC
[email redacted]
[email redacted]
Roberto Pulver
Office of the Attorney General
Licensing & Enforcement Section
[email redacted]
[email redacted]
By: OAH Staff