Delaware Board of Nursing v. Francis

Citation: 195 A.3d 467Docket: 69, 2018

Court: Supreme Court of Delaware; October 2, 2018; Delaware; State Supreme Court

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The Delaware Supreme Court reversed the Superior Court's decision regarding the disciplinary actions taken by the Delaware Board of Nursing against two nurses for unprofessional conduct. The Board had disciplined the nurses for retrieving medication from a medical waste container for administration to an inmate, asserting that their actions failed to conform to nursing standards and could adversely affect public health. The Superior Court had overturned the Board's ruling, requiring proof that the nurses' actions posed a risk to the inmate or public, which they found unsubstantiated.

The Board, composed of fifteen members (ten with nursing experience and five lay members), is empowered to define "unprofessional conduct." It articulated this definition through a two-part rule: Rule 10.4.1 establishes the general criteria for unprofessional conduct, while Rule 10.4.2 provides specific examples of conduct that violates this definition. The case centered on an incident involving expensive hepatitis C medication, where two other nurses, during a pill count, accidentally spilled pills and disposed of them inappropriately, believing they could not be reused after falling on the floor. The Supreme Court concluded that the Board had applied the correct standard and that the decision was supported by substantial evidence, necessitating the reversal of the lower court's judgment.

Nurses at a prison notified the on-site pharmacist of the need for a refill of medication after disposing of pills. Due to the pills' high cost, the pharmacist contacted her supervisor, who informed the head physician of the patient care company. The physician instructed nurse Christine Francis to retrieve the pills from a locked sharps container. Accompanied by nurse Angela DeBenedictis, Francis unlocked the container, shook out twelve pills, and ignored other medical waste present. The nurses wrapped the retrieved pills and brought them to the pharmacist, who conducted a visual inspection, determining they appeared uncontaminated, despite no professional testimony supporting this method. No checks were made on the cleanliness of the floor or the potential contamination prior to retrieval. The pills were given to an inmate without informing him of their origin, depriving him of the opportunity to consent or refuse. After a nurse reported the incident, disciplinary proceedings were initiated against the nurses and the head physician for unprofessional conduct, citing violations related to safeguarding patient care.

Aiding, abetting, or assisting any violation of laws or regulations governing healthcare providers is outlined alongside the failure to follow patient safety protocols. During the hearing, nurses and the head physician attributed the decision to administer pills to an inmate to pharmacists, asserting that pharmacists are the experts on medication safety. They argued that there was minimal risk of disease transmission, despite the pills being retrieved from a medical waste container. Two experts supported their claims: an infectious disease physician and a seasoned prison healthcare nurse. The physician deemed it reasonable for healthcare providers to rely on the pharmacist's assessment of the pills' safety, stating that the risk was "incalculably small," although this assumption hinged on the presumption that the waste container's contents had been inspected. He emphasized the importance of knowing what the pills might have contacted in the container. The State’s attorney’s question about whether he would take the pills caused a notable delay in his response, which raised concerns. The nursing expert echoed the physician's views on the pharmacists’ reliability and risk assessment, also assuming an inspection of the waste container’s full contents. However, the hearing officer concluded that no examination of the waste container occurred post-spillage, resulting in unknown contaminants. The officer determined that administering the pills posed an unacknowledged risk, referencing the nurses' awareness of the pills' compromised condition. The inmate’s treating physician supported the hearing officer's findings, acknowledging a risk of infection, albeit not significant enough to warrant preventative treatment due to potential greater risks involved.

The hearing officer did not identify a specific individual responsible for determining the fitness of certain pills for use but noted that both nurses received instructions from an on-site pharmacist, who had communicated with the head pharmacist, to return the pills to inventory. The head physician was also involved in this decision, suggesting that the nurses could have faced disobedience if they objected. The officer aimed to determine whether the nurses violated accepted nursing standards and if their actions were justified due to the guidance received. 

It was noted that there was minimal testimony regarding the nursing standards applicable to this case, and the State failed to cite any specific section of the Delaware Nursing Act or relevant regulations for clarity. However, multiple witnesses confirmed that standard protocol necessitated discarding pills that fell on the floor. Testimonies indicated that the Department of Corrections had established a standard for handling spilled medications and that both nurses had been trained to discard such pills due to contamination concerns. 

The hearing officer concluded that the accepted standard of nursing practice required the disposal of medications that fell on the floor, and the nurses' retrieval and administration of those pills breached this standard. The officer also determined that the nurses were obligated to exercise independent judgment and should have objected or intervened, ultimately concluding that their actions violated Rule 10.4.1 regarding unprofessional conduct, as well as Rules 10.4.2.14 and 10.4.2.28 concerning patient safeguarding. The Board adopted the hearing officer's conclusions, placing the nurses on probation for ninety days and mandating training in pharmacology and nursing ethics, without further elaboration on the accepted standards.

The nurses appealed the Board's decision to the Superior Court, arguing that there was no evidence to support the claim that they violated nursing standards. They asserted that to be deemed 'unprofessional' under Rule 10.4.1, their conduct must not conform to established nursing standards, but the State failed to show that nurses must disregard direct instructions from physicians or pharmacists. Both expert witnesses for the nurses testified that it was reasonable for them to rely on pharmacists' judgments, and the State did not present any contrary expert evidence. The nurses also contested the finding that the pills posed a risk to the inmate, asserting that their experts indicated the contamination risk was negligible, and the State provided no evidence to counter this. The Superior Court agreed with the nurses, concluding that the State had to demonstrate harm resulting from the nurses' actions, which it did not.

However, the subsequent analysis disagreed with the Superior Court's interpretation of the rules. It was emphasized that the State's responsibility extends beyond immediate threats to public safety; it must also maintain professional standards and public trust in nursing. The Superior Court's interpretation was challenged for incorrectly reading the two clauses of Rule 10.4.1 as requiring proof of both failure to conform to standards and proof of actual harm. The argument posited that a nurse engaging in behavior that breaches standards may still adversely affect public health, regardless of whether specific harm occurred. The language of the rule suggests that the possibility of harm is sufficient for sanction, indicating that improper conduct creating a risk does not exempt a nurse from accountability if no harm actually results.

The interpretation of the legal rule in question is challenged, specifically regarding the relationship between two clauses in the rule. The first clause establishes the operative rule, while the second justifies it by asserting that a nurse breaching standards poses a potential harm to the public. The use of "thus" indicates that the clauses are interconnected, meaning the purpose clause cannot limit the broader operative rule. Dividing the clauses into independent requirements would eliminate the significance of "thus" and incorrectly suggest that discipline applies only to nurses who both breach standards and cause actual harm.

Furthermore, applying a requirement for proof of actual harm undermines the practical application of the rule and its illustrations. For instance, Rule 10.4.2.5, which addresses violence or abuse, would allow abusive nurses to evade discipline if no risk to patient care could be proven. Similarly, Rule 10.4.2.4, relating to falsifying records, would restrict the Board's authority to act unless a direct link to public health was established. This interpretation leads to absurd outcomes, as it would limit the Board's ability to enforce compliance with its own rules.

Additionally, the Superior Court's view that Rules 10.4.2.14 and 10.4.2.28 require an actual harm element is also criticized. Rule 10.4.2.14 requires nurses to safeguard patients from unethical practices, but the court's interpretation unnecessarily confines this obligation to cases of physical harm. The text of the rule is broader, obligating nurses to act against any incompetent or unethical conduct, regardless of whether harm has occurred. Thus, the requirement for nurses to intervene when witnessing non-compliance with professional standards is deemed a necessary preventive measure rather than a mere formality.

Rule 10.4.2.28 mandates that nurses must take appropriate actions or adhere to established policies and procedures to protect patients. The Superior Court interpreted this regulation as requiring evidence of actual harm for a violation to be sanctionable. However, it is argued that a failure to follow policies designed to safeguard patients constitutes a violation, regardless of actual harm. The Superior Court's view that improper nursing behavior must result in harm to be sanctionable is contested.

Evidence presented indicated that the nurses’ actions, in collaboration with others, placed an inmate patient at risk. The Superior Court found a lack of substantial evidence for the hearing officer’s findings, noting that the only risk evidence came from the nurses’ witnesses, who confirmed no harm occurred. The nurses admitted to being trained to discard pills that fell on the floor due to contamination risks. Their expert physician also emphasized the necessity of inspecting any pills retrieved from a sharps container, suggesting significant risk if such inspections are not conducted. 

While the nurses’ expert testified regarding the risks associated with the pills, the State did not provide expert evidence to counter this. The Superior Court failed to address the core argument from the nurses regarding the absence of expert evidence on accepted nursing standards governing compliance with pharmacist or physician directives. The discussion highlights the complexities of evidentiary standards in nursing regulation and the implications of procedural compliance for patient safety.

The hearing officer and Board determined that the nurses violated established nursing standards by retrieving and administering pills that had fallen on the floor and were discarded in a medical waste container. The initial analysis confirmed that the nurses' actions failed to conform to accepted professional standards, which warranted disciplinary action. The hearing officer also considered whether the nurses' breach could be excused based on reliance on a pharmacist's opinion regarding the safety of the spilled tablets. However, the Board concluded that the nurses' defense—that they were merely following orders—was not valid in this context. Their actions did not stem from a good-faith professional disagreement but involved a fundamental breach of nursing standards, particularly since the nurses knew the retrieval of contaminated pills was incorrect. Furthermore, there was no medical urgency to justify their actions; the impetus was economic. The Board's interpretation of its rules was upheld, and the Superior Court's judgment was reversed, affirming the Board's final order.