ALJDEC decisions subject to certification as final

26A-2025020200-NUR · State Board of Nursing · 2026-01-22

IN THE OFFICE OF ADMINISTRATIVE HEARINGS

IN THE MATTER OF REGISTERED NURSE LICENSE NO. RN260456 ISSUED TO:

CODY CLARK NELSON,

RESPONDENT

No. 26A-[number redacted]-NUR

ADMINISTRATIVE LAW JUDGE DECISION

HEARING: September 5, 2025, October 31, 2025 and January 6, 2026.

APPEARANCES: Assistant Attorney General Roberto Pulver appeared on behalf of the Arizona State Nursing Board. Respondent Cody Clark Nelson appeared on his own behalf.

ADMINISTRATIVE LAW JUDGE: Adam D. Stone

EXHIBITS ADMITTED INTO EVIDENCE: Nursing Board Exhibits 1-21 were admitted into evidence. Respondent’s Exhibits E, F, J-M, O-R were admitted into evidence.

_____________________________________________________________________

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 A.R.S.§§ 32-1606, 32-1663, 32-1664, 41-1092.11(B). The Board also has 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.”) Rules 4-19-101 to -904.

Cody Clark Nelson (“Respondent”) holds Board issued registered nurse

license number RN260456 in the State of Arizona.

Between June 12, 2023 and September 5, 2023, while working as an RN at Banner Gateway Medical Center (Banner) in Mesa, AZ, Respondent demonstrated multiple patient care errors and unprofessional behavior and communication with colleagues on number occasions including:

Attempting on several occasions to give a medication without scanning it;

B. Becoming “flustered” when one patient complained of nausea and vomiting while another patient complained of pain and Respondent did not know what to do;

C. Drawing up IV medications and putting them in his pocket, despite preceptors and management repeatedly instructing him not to do this, as this practice could lead to medication errors and needle sticks;

D. Inability to accurately determine appropriate waste for controlled medications, including IV Fentanyl (a schedule II opioid for pain), and later told his preceptor the reason he was unsure was because the “L” in Fentanyl and the “2” in 2mg on the label of the vial were right next to each other and he read it as “1/2”;

E. Bypassing safety protocols by discarding a vial of unused Fentanyl prior to scanning;

F. Continually becoming defensive, argumentative, and using unprofessional dialogue with preceptors, peers, and Banner management when providing him with instruction or critiquing him during his orientation;

G. Speaking negatively about experiences with preceptors instead of discussing progress and challenges during a discussion with Banner management;

H. Inability to understand lab results and to know when lab results require intervention and provider notification;

I. Inability to accept feedback and dismissive to feedback provided to him on his orientation progress and potential educational opportunities for growth;

J. Carrying multiple medications loose in his pants pockets;

4. On or about September 2, 2023, while working as an RN at Banner in Mesa, AZ Respondent administered Lyrica (a schedule V medication for nerve pain) to a patient whom it was not prescribed for, and admitted to his error in his September 4, 2023 email to Banner management, where he wrote that he “somehow gave her the Lyrica with the Lipitor (a cholesterol medication) and Oxycodone (a schedule II opioid).” In a July 9, 2025 phone conversation with Board staff, Respondent admitted that he “made a negligent mistake at Banner” when he administered Lipitor and Lyrica to the same patient, for whom the Lyrica was not ordered.

A. Respondent told Banner management he removed this patient’s medications at the same time as another patient’s medications, put the medications in his pocket and failed to scan the medications at the time of administration.

B. Respondent told Banner management he was aware he bypassed safety features put in place to avoid medication errors and took accountability for the error.

C. Respondent told Banner management that he must have taken out the medications for both patients and put them in his pocket, and when he went to give her the medications he got confused with which medications were which.

D. When asked by Banner management if he scanned the patient’s medications, Respondent stated he did but since he had another patient’s medications in his pocket he just gave them all to her.

E. By engaging in such conduct, Respondent violated his employer’s Barcode Medication Administration Policy.

Between December 10, 2024 and January 29, 2025, while working as an RN at Arizona Specialty Hospital (ASH) in Phoenix, AZ, Respondent demonstrated multiple patient care errors and unprofessional behavior and communication with preceptors, staff, and patients, including:

A. Falsifying documentation by documenting assessments as completed but not actually performed;

B. Being unable to recall which medications were given to which patients or when;

C. Difficulty understanding and performing narcotic waste procedures correctly;

D. Administering medications without pre- or post-assessment of pain;

E. Missing critical assessments post-operatively;

Leaving medication unattended sitting out on the WOW (workstation on wheels);

G. Leaving medications at the bedside (e.g., Colace) without ensuring patient ingestion;

Continually struggling with time management and prioritization;

Consistently late with medication pass;

Removed an opioid medication [Oxycodone] from the Pyxis (an automated medication dispensing system) for the wrong patient;

Failing to eject air from syringes prior to injecting medication into a

patient;

L. Failing to accept feedback from preceptors, unwilling to listen to them, and becoming frustrated and argumentative with any preceptor who tried to help him or provide guidance to him;

M. Becoming argumentative and defensive with nearly all preceptors and coworkers;

N. Yelling or snapping at co-workers when questioned about care or processes;

O. Engaging in dismissive or passive-aggressive behavior (e.g., “then you do it,” “stop lecturing me”);

Using profane language toward co-workers (e.g., “do it your f***ing self”);

Making inappropriate remarks to patients (e.g., “I used to work on dead people”);

Intimidating coworkers physically (e.g., used physical presence to appear threatening);

Threatening litigation or stated he recorded sessions without consent;

Failing to accept feedback or take accountability; blamed others or circumstances;

Creating a work environment where colleagues felt unsafe or fearful (e.g., preceptor required security escort); and

Consistently denying or minimizing performance feedback and redirected blame.

On or about December 31, 2024, while working as an RN at Arizona Specialty Hospital (ASH) in Phoenix, AZ, Respondent failed to adequately address Patient SF’s low blood sugar reading of 59 at 6:44 a.m. by not documenting this low blood sugar reading, and the treatment provided if any, nor did Respondent document that he notified the oncoming shift nurse.

On or about January 6, 2025, while working as an RN at ASH in Phoenix, AZ, Respondent failed to assess Patient KB’s pedal pulses after spinal fusion surgery, as witnessed by his preceptor, but documented complete physical assessments.

On or about January 17, 2025, while working as an RN at ASH in Phoenix, AZ, Respondent failed to assess Patient CS’s vital signs every 4 hours as ordered by the physician and, held Patient CS’s Metoprolol and Losartan (blood pressure medications) without a physician’s order to do so, which were ordered to be administered at 8:30 p.m.

On or between January 17, 2025 and January 18, 2025, while working as an RN at ASH in Phoenix, AZ, Respondent failed to document a pain assessment on Patient LR every 4 hours as ordered by the provider, and, failed to document a pain assessment prior to administering opioid pain medications to Patients LR and KW.

A. Respondent documented a pain assessment on Patient LR at 4:52 a.m. and 6:39 a.m. on January 18, 2025.

B. Respondent documented administration of opioid pain medications to Patient LR on January 17, 2025 at 9:12 p.m. and on January 18, 2025 at 1:03 a.m. without documenting a pain assessment.

C. Respondent documented a pain assessment on Patient KW at 2:52 a.m. and 6:28 a.m. on January 18, 2025.

D. Respondent documented administration of opioid pain medication to Patient KW on January 17, 2025 at 10:10 p.m. without documenting a pain assessment.

On or about June 24, 2025, while working as an RN via Clipboard Health app for one shift at Maryland Gardens Post-Acute and Assisted Living (Maryland Gardens) in Phoenix, AZ, Respondent failed to complete all of his documentation for his shift. In a July 3, 2025, interview with Board staff, Maryland Gardens Administrator stated that Respondent:

A. “Missed quite a bit of charting”;

B. Administered medications and treatments per his report, but did not sign off most of his MARs (Medication Administration Records) and TARs (Treatment Administration Records); and

C. Failed to complete scheduled evaluations or chart them.

On July 24, 2025, based upon the facts and circumstances set forth above, the Board found that the public health safety and welfare imperatively required Emergency action. Consequently, the Board ordered, pursuant to A.R.S. § 41-1092.11(B), and effective immediately, that Cody Clark Nelson (“Respondent”), the holder of registered nurse license no. RN260456, was Summarily Suspended pending proceedings for revocation and other action by the Board.

On July 29, 2025, the Board issued a Complainant and Notice of Hearing and Summary Suspension Expedited Hearing to Respondent, and set the matter for a hearing on September 5, 2025 before the Office of Administrative Hearings, an independent state agency.

On August 25, 2025, at Respondent’s request, the tribunal held a prehearing conference with the parties to discuss submission and admission of evidence and hearing procedures. The hearing then took place over the course of three days, namely September 5, 2025, October 31, 2025, and January 6, 2026. The tribunal also allowed Respondent to file addition citations to his testimony by January 9, 2026.

The Board presented the testimony of Rachel Kimes, Senior Investigator for the Board; Janet Backers, RN at ASH; and Courtney Clarin, RN, a former employee at ASH. Respondent testified on his own behalf.

Ms. Kimes testified that initially the Board received a complaint filed against Respondent on February 7, 2025. Based upon this complaint, Ms. Kimes commenced an investigation. Ms. Kimes’ investigation consisted of interviewing Mr. Nelson and reviewing his Investigative Questionnaire, as well as obtaining records from Respondent’s previous employers and various patient records. Based upon her investigation, Ms. Kimes drafted two reports which concluded that Respondent potentially violated Arizona Statutes and Rules due to his unprofessional conduct as described above, and that his nursing license should be summarily suspended.

Ms. Backers testified that she was Respondent’s supervisor and wanted Respondent to succeed when even her superiors may have wanted to terminate Respondent sooner. Ms. Backers testified as to her recollection of events during Respondent’s tenure at ASH and had created a timeline of events or notes regarding the same.

Ms. Clarin testified as to what she witnessed during the time she served as Respondent’s preceptor while at ASH as outlined in the above findings of fact. She also testified that she did nothing but try to help Respondent and wanted him to succeed.

Respondent testified passionately that he spent his entire life doing the right things, and that he always followed company policy, and that his life will never be the same because of this case. Respondent also testified as to his history in the profession and first took an interest in the same at age 16. He also testified that there was nothing in the record to demonstrate that he violated any rules or statutes. Respondent further added that he believed that Ms. Backers and Ms. Clarin lacked credibility in their reporting and testimony of the issues. Respondent also testified that he was being retaliated against and harassed by his co-workers at ASH, for sending an email detailing his concerns with his training to Ms. Backers.

CONCLUSIONS OF LAW

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 pursuant to A.R.S. § 32-1601(27)(d), (e), (g), (h), and (j); as well as A.A.C. R4-19-403(1), (2), (7), (8), (9), (12), (31). Further, the preponderance of the evidence demonstrated that Respondent failed to demonstrate honesty and integrity pursuant to A.A.C. R4-19-402(B).

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 Cody Clark Nelson’s Registered Nurse License number 260456.

It is further recommended that the Board revoke Respondent Cody Clark Nelson’s Registered Nurse License number 260456.

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.

-54864001

001

-137160-45720000Done this day, January 22, 2026.

/s/ Adam D. Stone

Administrative Law Judge

Transmitted by either mail, e-mail, or facsimile to:

Joey Ridenour, RN, MN, Executive Director

State Board of Nursing

Cody Clark Nelson

[email redacted]

Roberto Pulver

Office of the Attorney General

Licensing & Enforcement Section

[email redacted]

By: OAH Staff