XAVIER BECERRA 2 3 4 5 6 7 Attorney General of Cal ifornia JOSHUA A. ROOM Supervising Deputy Attorney General CHRISTOPHER M. YOUNG Deputy Attorney General State Bar No. 238532 455 Golden Gate Avenue, Su ite 11000 San Francisco, CA 94102-7004 Telephone: (415)5 10-3554 Facsimile: (4 15) 703-5480 E-mai I: Chris. Young@doj .ca.gov Attorneysfor Complainant 8 BE FORE THE BOARD OF REGISTERED NURSING DEPARTMENT OF CONSUMER AFFAIRS STATE OF CALIFORNIA 9 10 11 12 20) Gt- 90Y 13 In the Matter of the Accusat ion Against: Case No. 14 SHARON A. HUNTER P.O. Box 2447 Mendocino, CA 95460 ACCUSATION 15 16 17 18 Registered Nurse License No. 246265 Public Health Nurse Certificate No. 47371 Nurse Practitioner Certificate No. 6595 Nurse Practitioner Furnishing Certificate No. 6595 19 Respondent. 20 21 Complainant a lleges: 22 23 PARTIES I. Joseph L. Morris, PhD, MSN, RN (Complainant) brings th is Accusation so lely in his 24 officia l capac ity as the Executive Officer of the Board of Registered Nurs ing (Board), 25 Department of Consumer Affairs. 26 27 2. On or about August 3 1, 1974, the Board issued Registered Nurse License Nu mber 246265 to Sharon A. Hunter (Respondent). The Registered Nurse License was in full force and 28 (S HARON A. HUNTER) ACCUSATION effect at all times relevant to the charges brought herein and will expire on April 30, 2020, unless 2 3 renewed. 3. On or about April 5, 1991, the Board issued Public Health Nurse Certificate Number 4 47371 to Respondent. The Public Health Nurse Certificate was in full force and effect at all times 5 relevant to the charges brought herein and will expire on April 30, 2020, unless renewed. 6 4. On or about July 15, 1993, the Board issued Nurse Practitioner Certificate Number 7 6595 to Respondent. The Nurse Practitioner Certificate was in full force and effect at all times 8 relevant to the charges brought herein and will expire on April 30, 2020, unless renewed. 9 5. On or about September 9, 1994, the Board issued Nurse Practitioner Furnishing 10 Certificate Number 6595 to Respondent. The Nurse Practitioner Furnishing Certificate was in 11 full force and effect at all times relevant to the charges brought herein and will expire on April 30, 12 2020, unless renewed. JURISDICTION 13 14 6. This Accusation is brought before the Board under the authority of the following 15 laws. All section references are to the Business and Professions Code (Code) unless otherwise 16 indicated. 17 7. Section 2750 of the Code provides, in pertinent part, that the Board may discipline 18 any licensee, including a licensee holding a temporary or an inactive license, for any reason 19 provided in Article 3 (commencing with section 2750) of the Nursing Practice Act. 20 8. Section 2764 of the Code provides, in pertinent part, that the expiration of a license 21 shall not deprive the Board of jurisdiction to proceed with a disciplinary proceeding against the 22 licensee or to render a decision imposing discipline on the license. Under section 281 l(b) of the 23 Code, the Board may renew an expired license at any time within eight years after the expiration. 24 STATUTORY & REGULATORY PROVISIONS 25 9. Section 2761 of the Code provides, in pertinent part, that the Board may take disciplinary action against a certified or licensed nurse for any of the following: 26 27 28 (a) Unprofessional conduct, which includes, but is not limited to, the following: (I) Incompetence, or gross negligence in carrying out usual certified or licensed nursing functions. 2 (SHARON A. HUNTER) ACCUSATION 10. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Section 2836.1 of the Code provides, in petiinent part, Neither this chapter nor any other provision of law shall be construed to prohibit a nurse practitioner from furnishing or ordering drugs or devices when all of the following apply: (a) The drugs or devices are furnished or ordered by a nurse practitioner in accordance with standardized procedures or protocols developed by the nurse practitioner and the supervising physician and surgeon when the drugs or devices furnished or ordered are consistent with the practitioner's educational preparation or for which clinical competency has been established and maintained. (b) The nurse practitioner is functioning pursuant to standardized procedure, as defined by Section 2725, or protocol. The standardized procedure or protocol shall be developed and approved by the supervising physician and surgeon, the nurse practitioner, and the facility administrator or the designee. (c) (1) The standardized procedure or protocol covering the furnishing of drugs or devices shall specify which nurse practitioners may furnish or order drugs or devices, which drugs or devices may be furnished or ordered, under what circumstances, the extent of physician and surgeon supervision, the method of periodic review of the nurse practitioner's competence, including peer review, and review of the provisions of the standardized procedure. (2) In addition to the requirements in paragraph (1), for Schedule II controlled substance protocols, the provision for furnishing Schedule II controlled substances shall address the diagnosis of the illness, injury, or condition for which the Schedule II controlled substance is to be furnished. (d) The furnishing or ordering of drugs or devices by a nurse practitioner occurs under physician and surgeon supervision. Physician and surgeon supervision shall not be construed to require the physical presence of the physician, but does include (l) collaboration on the development of the standardized procedure, (2) approval of the standardized procedure, and (3) availability by telephonic contact at the time of patient examination by the nurse practitioner. (e) For purposes of this section, no physician and surgeon shall supervise more than four nurse practitioners at one time. (1) 22 23 24 25 26 27 28 (1) Drugs or devices furnished or ordered by a nurse practitioner may include Schedule II through Schedule V controlled substances under the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code) and shall be further limited to those drugs agreed upon by the nurse practitioner and physician and surgeon and specified in the standardized procedure. (2) When Schedule II or III controlled substances, as defined in Sections l 1055 and 11056, respectively, of the Health and Safety Code, are furnished or ordered by a nurse practiti~ner, the, controll~d substances shall be furnished or. ordered in .. accordance with a pat1ent-spec1fic protocol approved by the treatmg or superv1smg physician. A copy of the section of the nurse practitioner's standardized procedure 3 (SHARON A. HUNTER) ACCUSATION 1 relating to controlled substances shall be provided, upon request, to any licensed pharmacist who dispenses drugs or devices, when there is uncertainty about the nurse practitioner famishing the order. 2 3 11. Section 2836.3, subdivision (c), of the Code provides, in pertinent part, 4 5 6 (c) The board may revoke, suspend, or deny issuance of the numbers for incompetence or gross negligence in the performance of fonctions specified in Sections 2836. l and 2836.2. 12. California Code of Regulations, title 16, section 1442, states: 7 8 9 10 11 As used in Section 2761 of the code, 'gross negligence' includes an extreme departure from the standard of care which, under similar circumstances, would have ordinarily been exercised by a competent registered nurse. Such an extreme departure means the repeated failure to provide nursing care as required or failure to provide care or to exercise ordinary precaution in a single situation which the nurse knew, or should have known, could have jeopardized the client's health or life. 13. California Code of Regulations, title 16, section 1443, states: 12 13 14 As used in Section 2761 of the code, 'incompetence' means the lack of possession of or the failure to exercise that degree of learning, skill, care and experience ordinarily possessed and exercised by a competent registered nurse as described in Section 1443.5. 15 14. California Code of Regulations, title 16, section 1443.5 states, in pertinent part: 16 17 18 19 20 21 22 A registered nurse shall be considered to be competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows: (I) Formulates a nursing diagnosis through observation of the client's physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team. (2) Formulates a care plan, in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client's safety, comfort, hygiene, and protection, and for disease prevention and restorative measures. 23 24 25 26 27 28 (5) Evaluates the effectiveness of the care plan through observation of the client's physical condition and behavior, signs and symptoms of illness, and reactions to treatment and through communication with the client and health team members, and modifies the plan as needed. (6) Acts as the client's advocate, as circumstances require, by initiating action to improve health care or to change decisions or activities which are against the interests or wishes of the client, and by giving the client the opportunity to make informed decisions about health care before it is provided. 4 (SHARON A. HUNTER) ACCUSATION DRUGS 2 15. 3 "Dangerous drug" or "dangerous device" means any drug or device unsafe for self­ use in humans or animals, and includes the following: 4 5 6 7 Section 4022 of the Code provides, in pertinent part, that a: (a) Any drug that bears the legend: "Caution: federal law prohibits dispensing without prescription," "Rx only," or words of similar import. (b) Any device that bears the statement: "Caution: federal law restricts this device to sale by or on the order of a," "Rx only," or words of similar import, the blank to be filled in with the designation of the practitioner licensed to use or order use of the device. 8 9 10 (c) Any other drug or device that by federal or state law can be lawfully dispensed only on prescription or furnished pursuant to Section 4006. 16. Alprazolam is a Schedule IV controlled substance as designated by Health and Safety 11 Code section 11057(d)( 1), and is a dangerous drug pursuant to Business & Professions Code 12 section 4022, 13 17, Endocet is a Schedule II controlled substance as designated by Health and Safety 14 Code section 11055(b)(I )(M), and is a dangerous drug pursuant to Business & Professions Code 15 section 4022. 16 18. Fentanyl is a Schedule II controlled substance as designated by Health and Safety 17 Code section 11055(c)(8), and is a dangerous drug pursuant to Business & Professions Code 18 section 4022. 19 19. 1-Iydrocodone is a Schedule II controlled substance as designated by Health and 20 Safety Code section 11055(b)(I)(!), and is a dangerous drug pursuant to Business & Professions 21 Code section 4022. 22 20. Lorazepam is a Schedule IV controlled substance as designated by Health and Safety 23 Code section 11057(d)(16), and is a dangerous drug pursuant to Business & Professions Code 24 section 4022. 25 21. Morphine is a Schedule II controlled substance as designated by Health and Safety 26 Code section 11055(b)(l)(L), and is a dangerous drug pursuant to Business & Professions Code 27 section 4022. 28 5 (SHARON A. HUNTER) ACCUSATION COST RECOVERY 2 22. Section 125.3 of the Code provides, in pertinent part, that the Board may request the 3 administrative law judge to direct a licentiate found to have committed a violation or violations of 4 the licensing act to pay a sum not to exceed the reasonable costs of the investigation and 5 enforcement of the case, with failure of the licentiate to comply subjecting the license to not being 6 renewed or reinstated. If a case settles, recovery of investigation and enforcement costs may be 7 included in a stipulated settlement. FACTUAL BACKGROUND 8 9 10 11 23. At all times referenced herein, Respondent was employed as a Nurse Practitioner at North Coast Family Health Center (NCFHC) in Fort Bragg, California. 24. On or about April 5, 2017, the Board received a complaint from the Medical Board of 12 California concerning Respondent, stating that a patient, NH, had died from acute fentanyl 13 toxicity, and that it appeared that Respondent had overprescribed lorazepam. 14 25. The Board conducted an investigation of the complaint. The Board learned that from 15 on or about March 15, 2010, through January 17, 2013, Respondent was the primary care 16 provider ofNH, who died on January 17, 2013. NH was a 70-year old woman with a history of 17 chronic low back and dental pain, narcotic dependent, benzodiazepine abuse, alcohol abuse, 18 depression, anxiety, spousal abusive situation, hypertension, and hypothyroidism. NH was seen 19 by Respondent primarily on a monthly basis for refill of opioid and benzodiazepine medications 20 pursuant to an Opioid Contract dated March 15, 2010. NH was admitted to a hospital on or aobut 21 July 31, 2012, for altered mental status secondary to a combination of opioid abuse and 22 alcoholism. Respondent's supervising MD then changed NH's prescriptions from Morphine, 23 Xanax, and Endocet to Fentanyl 25mcg every three days, and Lorazepam 1mg. The supervising 24 MD saw NH on August 8, 2012, and the Fentanyl dose was increased to 50mcg along with a 25 Lorazepam refill. On or about August 14, 2012, NH signed a new Opioid contract with another 26 Nurse Practitioner. 27 28 26. Respondent saw NH on August 21, 29, September 12, November 14, and December 13, 2012. On the August 29 visit, NH's Fentanyl dose was increased to 75mcg by Respondent. 6 (SHARON A. HUNTER) ACCUSATION A urine toxicology screen was also ordered on the August 29 visit, which revealed that NH's 2 Fentanyl level was 7.9ng/ml, with the lab reference normal of0.3ng/ml. Therefore NH's lab 3 result indicated over 7 times greater than therapeutic level ofFentanyl in NH's blood. 4 Respondent did not make any notation that she reviewed these lab results with NI-I at the 5 subsequent office visits. Instead, at the September 12 visit, Respondent refilled the increased 6 dosage ofFentanyl for NH, and changed the follow-up period from 2 weeks to 6 weeks. 7 27. 8 DATES DRUG DOSES # PRESCRIPTIONS 9 10/7/10-10/7/11 Morphine 15mg, 30mg and 60mg 10 Respondent prescribed the following dangerous drugs to NI-I: 10 Sulfate 11 10/7/10-10/7/11 Fentanyl 75mcg and l00mcg 4 12 3/2/12-7/24/12 Alprazolam .5mg 10 ( only prescriber of 13 14 this medication) 1/21 /12-8/3/12 15 16 17 18 19 20 Morphine 30mg 9 Sulfate 1/21/12-8/3/12 Endocet 10/325 6 8/21/12-12/13/ 12 Fentanyl 25mcg (1) 50mcg (1) 6 (last RX) 8/21/12-1/10/13 75mcg Lorazepam 1mg 9 (last RX) 21 22 All of these drugs are listed in the NCFI-IC clinic formulary of Scheduled Drugs approved to be 23 prescribed by medical providers. 24 28. The American Pain Society (APS)-American Academy of Pain Medicine (AAPM) 25 published an Opioid Guideline Panel in 2009, establishing a standard of care and guidelines for 26 chronic opioid therapy management in patients experiencing non-cancer related chronic pain. A 27 specific Standardized Procedure for chronic opioid therapy could not be located in the NCFHC 28 Standardized Procedures Manual. 7 (SHARON A. HUNTER) ACCUSATION 29. NH's medical records establish a well-documented history of alcohol abuse by NH, 2 documented by Respondent and other medical providers. Respondent continued to prescribe 3 opioid and controlled substances to NH throughout the three years Respondent treated NH. Even 4 after NH was admitted to the hospital for an overdose on or about July 31, 2012, Respondent 5 continued to prescribe opioid and controlled substances without consultation from a physician, 6 referral to a pain-management specialist, or substance abuse treatment facility for alcohol and 7 prescription drug abuse. In fact, Respondent actually increased NI-l's Fentanyl dosage, without 8 supervising physician consultation, following NI-I's July 2012 hospitalization. Respondent 9 denied identifying drug-seeking behavior by NH, and that NH was "not high on [Respondent's] JO alert list." Respondent did not make an assessment of NI-l's pain in any ofNI-l's medical notes, 11 including identifying NI-l's pain to include severity, description, location, level of functioning and 12 ability to perform activities of daily living. None of the recommended opioid therapy monitoring 13 tools were completed. A limited physical examination was conducted at each visit, without a 14 detailed spine and neurological assessment to the specific area of pain. No follow-up discussion 15 was recorded by Respondent regarding the blood-screen result showing NI-l's Fentanyl level to be 16 over seven times the acceptable limit. Respondent inappropriately monitored NI-l's opioid 17 therapy, and prescribed additional opioids to NH at the September 12, 2012, visit. 30. 18 Respondent provided NH a refill ofLorazepam over the phone on or about January 19 I 0, 2013, a week before NI-l's death. Respondent had noted in NH's record previously that NH 20 was noted to request refills on Lorazepam prior to the 30-day due date. 21 31. Respondent made a recommendation for physical therapy for NH on or about August 22 29, 2012, but Respondent did not follow up with any referral, or provide any documentation on 23 subsequent visits regarding a follow-up with NH regarding this referral. Moreover, Respondent 24 failed to make any referrals for psychiatric and/or social services, despite numerous notations in 25 the medical records regarding a spousal abusive relationship, chronic depression, and alcoholism. 26 I I/ 27 III 28 /// 8 (SHARON A. HUNTER) ACCUSATION FIRST CAUSE FOR DISCIPLINE 2 3 (Unprofessional Conduct-Gross Negligence) 32. Respondent's license is subject to discipline under section 276l(a)(l) of the Code, in 4 that she was grossly negligent as defined by California Code of Regulations, title 16, section 5 1442. As stated above in paragraphs 23-31, and incorporated herein, Respondent failed to 6 adequately monitor NH's opioid pain management plan and/or consult with a supervising 7 physician. Respondent's conduct exhibits a severe and reckless disregard for the life or safety of 8 NH, and Respondent failed to provide an adequate level of care or caution by continuing to 9 prescribe opioid medications without adequate consultation and/or follow up. Even after an 10 overdose incident in July 2012, Respondent increased NH's dosage ofFentanyl without 11 consultation from the supervising physician. Respondent repeatedly failed to provide nursing 12 care as required, and her actions demonstrated an extreme departure from the standard ofcare that 13 she knew or should have known could have jeopardized the life or health of NI-I. 14 SECOND CAUSE FOR DISCIPLINE 15 (Unprofessional Conduct-Incompetence) 16 33. Respondent is subject to disciplinary action under section 2761(a)(l) of the Code, 17 and/or California Code of Regulations, title 16, sections 1443 and 1443.5, for unprofessional 18 conduct amounting to incompetence. As stated above in paragraphs 23-31, Respondent failed to 19 exercise the degree of learning, skill, care, and experience ordinarily possessed and ordinarily 20 exercised by a competent registered nurse, as defined in California Code of Regulations, title 16, 21 section 1443.5. 22 THIRD CAUSE FOR DISCIPLINE 23 (Unprofessional Conduct) 24 34. Respondent is subject to disciplinary action under section 2761, subdivision (a) in 25 that her conduct was unprofessional, as described in paragraphs 23-31, in that she failed to adhere 26 to established standards of practice for nursing in her care of patient NH. Respondent failed to 27 follow the specific procedures that outlined situations which required consultation of a 28 supervising physician and documentation of such consultations, as well as initiating referrals for 9 (SHARON A. HUNTER) ACCUSATION NH for specialty care. Respondent provided years of Opio id Therapy to a complex, chronic pain 2 patient, when NC FH C did not have an established Standardized Procedure for Nurse Practitioners 3 to provide Opioid Therapy. PRAYER 4 5 6 7 8 9 IO II 12 13 14 15 WHEREFORE, Complain ant requests that a hearing be held on the matters herein a lleged, and that fo llow ing the hearing, the Board of Registered Nursing issue a decisio n: I. Revoking or suspend ing Regi stered Nurse License Number 246265, issued to Sharo n A. Hunter; 2. Revok ing or suspending Public Health Nurse Cert ificate Number 4737 1, issued to Sharon A. Hunter; 3. Revoking or suspending Nurse Practitioner Certificate Number 6595, issued to Sharon A. Hunter; 4. Revoking or suspend ing Nurse Practitioner Furnishing Certificate Number 6595, issued to Sharon A. Hunter; 5. Ordering Sharon A. Hunter to pay the Board of Registered N urs ing the reasonable 16 costs of the investigation and enfo rcement of this case, pursuant to Business and Professio ns 17 Code section 125.3;and, 18 6. Taking such other and fu11her action as deemed necessary and proper. 19 20 DATED: June I0 , 201c, . 21 22 23 ~~ (: } JOSEP H ~ D , MSN, RN ~ Executive Officer Board of Registered Nursing Depa11ment of Consumer Affa irs State of Ca liforn ia Complainant 24 25 26 SF2018201264 21346270.docx 27 28 10 (SHARON A. HUNTER) ACCUSATION