ALJDEC decisions subject to certification as final
24A-2024010287-NUR · State Board of Nursing · 2024-07-29
IN THE OFFICE OF ADMINISTRATIVE HEARINGS
IN THE MATTER OF THE REGISTERED NURSE LICENSE NO. RN281950 ISSUED TO:
ASHLEY RENEE STEVENS,
AKA: Ashley Renee Schwinn, Ashley Renee Lane,
RESPONDENT.
No. 24A-[number redacted]-NUR
ADMINISTRATIVE LAW JUDGE DECISION
HEARING: Convened and concluded on June 21, 2024.
APPEARANCES: Respondent failed to appear. Assistant Attorney General Debborah Abbey and Michelina Stazzone appeared for the Arizona Board of Nursing.
ADMINISTRATIVE LAW JUDGE: Samuel Fox
EXHIBITS ADMITTED INTO EVIDENCE: Arizona Board of Nursing’s Exhibits 1 through 16.
_____________________________________________________________________
FINDINGS OF FACT
The Arizona State Board of Nursing (the “Board”) had the authority to regulate and control the practice of nursing in the State of Arizona, pursuant to Arizona Revised Statutes (“A.R.S.”) §§ 32-1606, 32-1663, 32-1664, 41-1092.11(B). The Board also had the authority to impose disciplinary sanctions against the holders of nursing licenses for violations of the Nurse Practice Act, A.R.S. §§ 32-1601 to 1667 and Arizona Administrative Code (“A.A.C.”) R4-19-101 to R4-19-904.
Ashley Renee Stevens (“Respondent”) held Board issued practical/registered nurse license number RN281950 in the State of Arizona.
On January 12, 2024, the Board received a Complaint from Mayo Clinic Hospital in Phoenix, Arizona, describing the following incident:
An investigation was conducted starting on December 20, 2023, to determine if Ms. Stevens had been diverting medication during her care of patients. After an investigation, it was determined that diversion was occurring, and her employment was terminated on January 9, 2024.
Michelina Stazzone, APRN Nurse Consultant, investigated this matter. For this matter, Ms. Stazzone reviewed employment records, hospital policies, patient records, and controlled substances prescription monitoring program (“CSPMP”) reports.
Ms. Stazzone testified in support of the facts provided by the Board. Without any contradicting evidence in the record, the Tribunal adopts the following facts as provided in the Board’s Complaint and Notice of Hearing and supported by testimony and records:
1. On or between September 30, 2023 and October 7, 2023, while working as a Registered Nurse (RN) at Mayo clinic in Phoenix, AZ, Respondent removed Hydromorphone (opioid) from the Pyxis (automated medication dispenser) for Patient RA and did not document administration accurately.
On 9/30/23, removed Hydromorphone 2mg at 11:11 pm, documented at 6:34 am, as administered at 10:36 pm.
On 10/1/23, removed Hydromorphone 2mg at 3:29 am, documented at 6:34 am, as administered at 2:40 am.
On 10/7/23, removed Hydromorphone 2 mg at 3:26 am, documented at 6:09 am, as administered at 2:06 am.
Mayo’s Guideline for Controlled Substances notes the chain of custody and individual accountability must be maintained to ensure the integrity of all controlled substances located in the area to reduce the potential for drug diversion, theft, and/or misuse of controlled substances. Respondent violated the guideline when she did not accurately document the administration time of the Hydromorphone for Patient RZ.
The standard of practice is to accurately document the administration of medications. Respondent violated the standard when she documented administration of three doses of Hydromorphone to Patient RA hours after she had removed the narcotic and entered an administration time that was prior to the removal time.
2. On or between November 3, 2023 and November 6, 2023, while working as an RN at Mayo clinic in Phoenix, AZ, Respondent removed Oxycodone 10 mg (opioid) from the Pyxis for Patient CH, but did not accurately document administration, and gave one dose earlier than ordered. The provider’s order on October 13, 2023, was for Oxycodone IR 10 mg every 4 hours as needed for pain, and the order was changed during the dayshift on November 5, 2023, to Oxycodone 10 mg every 6 hours as needed for pain.
On 11/5/23, removed 2 tablets of Oxycodone 5 mg at 12:51 am, documented at 3:56 am as administered at 12:04 am.
On 11/5/23, removed 2 tablets of Oxycodone 5 mg at 3:31 am, documented at 3:55 am as “not given”, and documented at 5:16 am that the “medication was disposed of in sharps container and unable to be safely/hygienically retrieved”.
On 11/5/23, removed 2 tablets of Oxycodone 5 mg at 4:46 am, documented administered at 5:16 am.
On 11/5/23, removed 2 tablets of Oxycodone at 8:11 pm, documented at 9:09 pm as administered at 7:40 pm.
On 11/5/23, removed 2 tablets of Oxycodone at 11:09 pm, documented administration at 11:35 pm, which was sooner than the new order for every 6 hours.
Mayo’s Guideline for Controlled Substances notes that controlled substances are administered immediately after removing from storage or if the controlled substance cannot be administered within 30 minutes from removal from Pyxis, the medication should be returned to Pyxis automated medication management system, and the chain of custody and individual accountability must be maintained to ensure the integrity of all controlled substances located in the area to reduce the potential for drug diversion, theft, and/or misuse of controlled substances. Respondent violated the guideline when she did not accurately document the administration time of the Oxycodone 10 mg for Patient CH.
The standard of nursing practice is to accurately document medication administration at the time it is administered. Respondent violated the standard when she documented the administration times of three doses of Oxycodone 10 mg for Patient CH as prior to the time she removed the medication from the Pyxis.
The standard of nursing practice is to have a witnessed waste to any controlled substance. Respondent violated the standard when she documented she disposed of Oxycodone 10 mg in the sharps container without a witness to the waste.
The scope of nursing practice is to administer medications as ordered by a provider. Respondent violated the scope of practice, when she administered a dose of Oxycodone 10 mg to Patient CH that was ordered every six hours, only three hours after the previous dose.
3. On or about November 20, 2023, while working as an RN at Mayo clinic in Phoenix, AZ, Respondent removed 2 tablets of Alprazolam 0.25 mg (benzodiazepine) for Patient HC from the Pyxis immediately after removal of the previous dose without documentation of return or waste.
On 11/20/23, removed 2 tablets of Alprazolam 0.25 mg at 9:10 pm, and another 2 tablets at 9:12 pm, documented 0.5 mg was administered at 9:14 pm, with no documentation of administration, return or witnessed waste of the remaining 0.5 mg.
Mayo’s Guideline for Controlled Substances notes controlled substances are administered immediately after removing from storage or when dispensed by pharmacy, and if the controlled substance cannot be administered within 30 minutes from removal from Pyxis or receipt form pharmacy, the medication should be returned to Pyxis automated medication management system. Respondent violated the guideline when she removed a second dose of Alprazolam 0.5 mg for Patient HC immediately after the first dose without documentation of return, waste or administration.
The scope of nursing practice is to administer medications as ordered by a provider. Respondent violated the scope of practice, when she removed a dose of Alprazolam 0.5 mg for Patient HC two minutes after she had removed the previous dose and did not document administration, return or witnessed waste of the remaining 0.5 mg.
4. On or between December 9, 2023 and December 12, 2023, while working as an RN at Mayo clinic in Phoenix, AZ, Respondent removed Zolpidem (sedative for insomnia) and Hydromorphone for Patient DP just after removing a prior dose without documentation of return or waste.
On 12/9/23, removed Zolpidem 5 mg at 8:38 pm and another 5 mg at 8:43 pm, documented administration of 5 mg at 8:56 pm, with no documentation of administration, return or witnessed waste of the remaining 5 mg.
On 12/10/23, removed Hydromorphone 2 mg at 3:21 am and another 2 mg at 3:22 am, documented administration of 2 mg at 3:24 am, with no documentation of administration, return or witnessed waste of the remaining 2 mg.
On 12/10/23, removed Hydromorphone 2 mg at 6:10 am two times, documented administration of 2 mg at 6:13 am, with no documentation of administration, return or witnessed waste of the remaining 2 mg.
On 12/10/23, removed Hydromorphone 2 mg at 7:55 pm and another 2 mg at 7:59 pm, documented administration of 2 mg at 8:00 pm, with no documentation of administration, return or witnessed waste of the remaining 2 mg.
On 12/10/23, removed Zolpidem 5 mg at 8:00 pm two times, documented administration of 5 mg at 8:07 pm, with no documentation of administration, return or witnessed waste of the remaining 5 mg.
On 12/10/23, removed Hydromorphone 2 mg at 11:09 pm two times, documented administration of 2 mg at 11:10 pm, with no documentation of administration, return or witnessed waste of the remaining 2 mg.
Mayo’s Guideline for Controlled Substances notes controlled substances are administered immediately after removing from storage or when dispensed by pharmacy, and if the controlled substance cannot be administered within 30 minutes from removal from Pyxis or receipt form pharmacy, the medication should be returned to Pyxis automated medication management system. Respondent violated the guideline when she removed a second dose of Hydromorphone 2mg for Patient DP immediately after the previous dose without documentation administration, return or witnessed waste of the second dose.
The scope of nursing practice is to administer medications as ordered by a provider. Respondent violated the scope of practice, when she removed a dose of Zolpidem 5 mg for Patient DP minutes after she had removed the previous dose and did not document administration, return or witnessed waste of the second dose.
The scope of nursing practice is to administer medications as ordered by a provider. Respondent violated the scope of practice, when she removed a dose of Hydromorphone 2 mg for Patient DP four times just minutes after she had removed the previous dose and did not document administration, return or witnessed waste of the second dose.
5. On or between December 10, 2023 and December 11, 2023, while working as an RN at Mayo Clinic in Phoenix, AZ, Respondent removed Oxycodone 5 mg for Patient MP on three occasions immediately following the removal of the first dose without documentation of administration, return, or witnessed waste of the second dose removed. On December 6, 2023, the provider’s order was for Oxycodone 10 mg every 4 hours as needed, which was discontinued on 12/8/23 and the new order on December 10, 2023 was for Oxycodone 5 mg tab every 4 hours as needed.
On 12/10/23, removed Oxycodone 5 mg at 8:31 pm, removed a second 5 mg dose at 8:36 pm and returned it to stock, removed a third 5 mg dose at 8:36 pm, and documented administration of 5 mg at 8:50 pm, with no documentation of administration, return or witnessed waste of the remaining 5 mg.
On 12/11/23, removed Oxycodone 5 mg at 12:47 am two times, documented administration of 5 mg at 12:49 am, with no documentation of administration, return or witnessed waste of the remaining 5 mg.
On 12/11/23, removed 2 tablets of Oxycodone 5 mg, and documented 10 mg was administered at 2:13 am, when the order for a 10 mg dose was discontinued on 12/8/23.
On 12/11/23, removed 5 mg of Oxycodone at 4:42 two times, documented administration of 5 mg at 4:43 am, with no documentation of administration, return, or witnessed waste of the remaining 5 mg.
Mayo’s Guideline for Controlled Substances notes the chain of custody and individual accountability must be maintained to ensure the integrity of all controlled substances located in the area to reduce the potential for drug diversion, theft, and/or misuse of controlled substances, and controlled substances are administered immediately after removing from storage or when dispensed by pharmacy, and if the controlled substance cannot be administered within 30 minutes from removal from Pyxis or receipt form pharmacy, the medication should be returned to Pyxis automated medication management system. Respondent violated the guideline when she removed a second dose of Oxycodone 5 mg for Patient MP immediately after the previous dose without documentation of administration, return, or witnessed waste.
The scope of nursing practice is to administer medications as ordered by a provider. Respondent violated the scope of practice, when she removed a dose of Oxycodone 5 mg for Patient MP, three times immediately after she had removed the previous dose and did not document administration, return, or witnessed waste.
The scope of nursing practice is to administer medications as ordered by a provider. Respondent violated the scope of practice, when she removed a dose of Oxycodone 10 mg for Patient MP after the order had been discontinued three days prior.
6. On or between September 30, 2023 and December 12, 2023, while working as an RN at Mayo clinic in Phoenix, AZ, Respondent failed to document a pain scale score when she administered narcotics to Patients RA, CH, DP, and MP.
Mayo Pain Management Policy, requires that a nurse document pain management which includes patient’s rating of pain before and after pain management interventions. Respondent violated this policy when she failed to document pain scores for Patients RA, CH, DP, and MP.
The Board attempted to contact Respondent on multiple occasions by email, mail, and phone.
On or about February 21, 2024, the Board mailed a request to Respondent for a full and complete written explanation of the allegations submitted by Mayo Clinic. Respondent failed to furnish a written explanation or respond to the Board.
On or about April 23, 2024, the Board emailed Respondent requesting the written response previously requested. Respondent failed to furnish a written explanation or respond to the Board.
On April 28, 2024, Ms. Stazzone reached Respondent by phone. Respondent had been out of Arizona due to bereavement, but indicated she would be returning to Arizona May 14, 2024. Ms. Stazzone advised Respondent about the process, including the need to file a written response and to schedule a drug test. Ms. Stazzone was unable to contact Respondent again after that call.
On May 16, 2024, the Board found that the public health safety and welfare imperatively required emergency action. Consequently, the Board issued Findings of Public Emergency and Order of Summary Suspension to Respondent.
On May 23, 2024, the Board issued the Complaint and Notice of Hearing, Summary Suspension Expedited Hearing, setting a hearing for June 21, 2024 at 9:00 AM.
The Office of Administrative Hearings conducted the hearing on June 21, 2024, but Respondent failed to appear at the hearing. Accordingly, Respondent did not enter any evidence into the record.
At the conclusion of the hearing, the Board requested an Order of Revocation due to Respondent’s inability or unwillingness to be regulated. The Board also requested that patient documents be marked confidential.
CONCLUSIONS OF LAW
This matter lies within the Board’s jurisdiction pursuant to A.R.S. § 32-1606(B)(10).
Respondent is deemed to have received the Complaint and Notice of Hearing by methods reasonably calculated to effect notice. The Board mailed copies of the Complaint and Notice of Hearing to her address and email address of record.
The Board bears the burden of proof and must establish cause to penalize Respondent’s practical nurse license by a preponderance of the evidence. A preponderance of the evidence is “evidence which is of greater weight or [is] more convincing than evidence which is offered in opposition to it,” showing that a fact is more probably true than not.
In Arizona, when construing statutes, we look first to a statute’s language as the best and most reliable index of its meaning. If the statute’s language is clear and unambiguous, we give effect to that language and apply it without using other means of statutory construction, unless applying the literal language would lead to an absurd result. Words should be given “their natural, obvious, and ordinary meaning,” unless defined by the legislature.
Pursuant to A.R.S. §§ 32-1663 and 32-1664, unprofessional conduct is grounds for disciplinary action.
The preponderance of the evidence established that Respondent’s conduct constituted “unprofessional conduct” as defined in A.R.S. § 32-1601(27):
“Any conduct or practice that is or might be harmful or dangerous to the health of a patient or the public.” A.R.S. § 32-1601(27)(d).
“Wilfully or repeatedly violating a provision of this chapter or a rule adopted pursuant to this chapter.” A.R.S. § 32-1601(27)(g).
“Committing an act that deceives, defrauds or harms the public.” A.R.S. § 32-1601(27)(h).
“Violating this chapter or a rule that is adopted by the board pursuant to this chapter.” A.R.S. § 32-1601(27)(j).
The preponderance of the evidence established that Respondent’s conduct was “unprofessional conduct” that “is or might be harmful or dangerous to the health of a patient or the public” as defined in A.A.C. R4-19-403:
“A pattern of failure to maintain minimum standards of acceptable and prevailing nursing practice.” A.A.C. R4-19-403(1).
“Failing to maintain for a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to the patient.” A.A.C. R4-19-403(7).
“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.” A.A.C. R4-19-403(9).
“Failing to: . . . a. Furnish in writing a full and complete explanation of a matter reported pursuant to A.R.S. § 32-1664, or . . . b. Respond to a subpoena issued by the Board.” A.A.C. R4-19-403(25).
“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.A.C. R4-19-403(31).
The Board established violations of each provision identified in paragraphs 6 and 7 above, by the preponderance of the evidence.
In light of the evidence of record and the risk of harm to which patients and the public were and could be exposed as a result of Respondent’s actions and violations of the Nurse Practice Act, the Board established cause to impose a disciplinary sanction against Respondent’s license.
RECOMMENDED ORDER
IT IS RECOMMENDED that the Board affirm its order summarily suspending Respondent Ashley Renee Stevens’s practical/registered nurse license number RN281950.
IT IS FURTHER RECOMMENDED that the Board revoke Respondent Ashley Renee Stevens’s practical/registered nurse license number RN281950.
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.
-137160-45720000Done this day, July 29, 2024.
/s/ Samuel Fox
Administrative Law Judge
Transmitted by either mail, e-mail, or facsimile to:
Joey Ridenour, RN, MN
State Board of Nursing
ATTN: Trina Smith
[email redacted]
[email redacted]
Ashley Renee Stevens
[email redacted]
Deborah Abbey
Office of the Attorney General
[email redacted]
By: OAH Staff