Final Order No. DOH-18-0544.6M -MQA STATE OF FLORIDA DEPARTMENT OF HEALTH By: Fl TE -MAR 10 'V 2018 De rtment of H try Deputy Agency Clerk te In Re: ORDER OF EMERGENCY RESTRICTION OF LICENSE Celeste Philip, M.D., M.P.H., State Surgeon General, ORDERS the emergency restriction of the license of, (Ms. Stokes) to practice nursing in the State of Florida. Ms. Stokes holds license number PN 5187826. Her address of record is Post Office Box 465, San Mateo, Florida 32187. She may also be located at 111 Live Oak Street, San Mateo, Florida 32187. The following Findings of Fact and Conclusions of Law support the emergency restriction of Ms. Stokes's license to practice nursing in the State of Florida. FINDINGS OF FACT 1. The Department of Health (Department) is the state agency charged with regulating the practice of nursing pursuant to Chapters 20, 456, and 464, Florida Statutes (2017). Section 456.073(8), Florida Statutes (2017), authorizes the Department to summarily restrict Ms. Stokes's license to practice nursing.
2. At all times material to this Order, Ms. Stokes's was licensed to practice as a practical nurse in the State of Florida, pursuant to Chapter 464, Florida Statutes. 3. In May 2017, Ms. Stokes was employed as a licensed practical nurse (L.P.N.) at Lakewood Nursing Center (LNC), located in Crescent City, Florida. 4. On or about May 24, 2017, during her shift at LNC, Ms. Stokes exhibited multiple signs of impairment, including being lethargic, appearing to move in slow motion, being very disoriented, having glassy, abnormal looking eyes, continually resting her head on things, and having disheveled hair and food on her face. 5. LNC staff asked that Ms. Stokes submit to a urine drug screen. 6. Prior to entering the restroom to provide a urine sample, Ms. Stokes asked at least two co-workers to provide her with their urine. 7. Ms. Stokes also asked an LNC resident to provide a urine sample for her. 8. LNC staff accompanied Ms. Stokes to the restroom to complete her drug screen, where she repeatedly made excuses for not being able to provide a urine sample. Page 2 of 14
9. After sitting on the toilet seat, Ms. Stokes laid her head on the wall adjacent to the toilet and began to sway back and forth. 10. Ms. Stokes began to tap on her stomach, and said that she was doing so to make herself urinate. 11. Ms. Stokes removed all her clothing from the waist down, and said that she needed to get naked in order to provide a urine sample. 12. Ms. Stokes bent over with her hands on her ankles, shaking her rear end, and said that she was attempting to shake her urine out. 13. Ms. Stokes then sat on the toilet seat, and said she needed to make a bowel movement. 14. Once she was seated on the toilet, Ms. Stokes advised she was urinating, but that she was unable to catch her urine for a sample. 15. A staff member was forced to collect Ms. Stokes's urine for her. 16. Ms. Stokes attempted to dress herself, but placed her pants on backwards, and staff had to assist her. 17. Ms. Stokes's urine tested positive for amphetamines', 1 According to Section 893.03(2), Florida Statutes (2016-2017), amphetamine is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States. Amphetamine is a stimulant, and abuse of amphetamines may lead to severe psychological or physical dependence. Page 3 of 14
benzodiazepines2, opiates3, and Oxycodone4. 18. Ms. Stokes stated that her drug screen was positive due to medications she takes for Lupus5. 19. Staff advised Ms. Stokes that she needed to bring her prescriptions to LNC by May 25, 2017. 20. Ms. Stokes left LNC, and never returned or provided a prescription for any of the substances found in her urine sample. 21. On or about November 20, 2017, Scott A. Teitelbaum, M.D., F.A.A.P., D.F.A.S.A.M. (Dr. Teitelbaum), a physician specializing in addiction medicine, conducted an IPN-facilitated evaluation of Ms. Stokes. 22. Ms. Stokes told Dr. Teitelbaum that she has taken opioids sporadically since the year 2000. 23. Ms. Stokes told Dr. Teitelbaum that she has been prescribed 2 Benzodiazepines are a class of drugs that cause sedation and can be habit forming. Benzodiazepines are typically prescribed to treat anxiety or insomnia. 3 Opiate, or opioid, drugs have similar actions as the drug opium and are typically prescribed to treat pain. Opioid drugs are synthetically manufactured, while opiate drugs are naturally occurring, but the terms opioid and opiate are often used interchangeably. Opiate drugs are addictive and subject to abuse. Opiates are technically the naturally occurring drugs derived from opium, such as codeine, morphine, heroin, but the term is used interchangeably with opioid. 4 According to Section 893.03(2), Florida Statutes (2016-2017), oxycodone is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States. Oxycodone is commonly prescribed to treat pain. Abuse of oxycodone may lead to severe psychological or physical dependence. Lupus is a chronic inflammatory disease that occurs when the body's immune system attacks its own tissues and organs. Inflammation caused by lupus can affect many different body systems, including joints, skin, kidneys, blood cells, brain, heart and lungs. Page 4 of 14
and ingested Percocet,6 Norco/ Dilaudid,8 and tramado1.9 She reported that she has taken these medicines for pain associated with Lupus and arthritic pain in her hands, knees, and feet. 24. Ms. Stokes told Dr. Teitelbaum that at one point her physician began prescribing her hydrocodonel instead of oxycodone, due to her increasing doses of oxycodone. 25. Ms. Stokes told Dr. Teitelbaum that the last time she ingested pain medication was sometime in October. 26. Dr. Teitelbaum noted that, although Ms. Stokes stated that she takes opioid medications due to the swelling and pain in her hands, her hands displayed no swelling on the day of the evaluation. 6 Percocet is the brand name for a drug that contains oxycodone and is prescribed to treat pain. According to Section 893.03(2), Florida Statutes (2017), oxycodone is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States. Abuse of oxycodone may lead to severe psychological or physical dependence. ' Norco contains hydrocodone and acetaminophen, or Tylenol and is prescribed to treat pain. According to Section 893.03(3), Florida Statutes (2017), hydrocodone, in the dosages found in Norco, is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States. Abuse of hydrocodone may lead to severe psychological or physical dependence. 8 Dilaudid is the brand name for hydromorphone and is prescribed to treat pain. According to Section 893.03(2), Florida Statutes (2017), hydromorphone is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States. Abuse of hydromorphone may lead to severe psychological or physical dependence 9 Tramadol, commonly known by the brand name Ultram, is an opioid-class narcotic medication prescribed to treat pain. According to Title 21, Section 1308.14, Code of Federal Regulations, tramadol is a Schedule IV controlled substance. Tramadol, like all opioid-class drugs, can affect mental alertness, is subject to abuse, and can be habit forming. 10 Hydrocodone is commonly prescribed to treat pain. According to Section 893.03(2), Florida Statutes (2017), hydrocodone is a Schedule II controlled substance that has a high potential for abuse and has a currently accepted but severely restricted medical use in treatment in the United States. Abuse of hydrocodone may lead to severe psychological or physical dependence. Page 5 of 14
27. Ms. Stokes reported that she first consumed alcohol in her late teens/early twenties. She further reported that, as a rule, she does not drink alcohol. 28. Despite reporting that she does not drink alcohol, Ms. Stokes told to Dr. Teitelbaum that her last drink of alcohol was on November 11, 2017. She also reported that in the previous month she never consumed more than one drink when she did consume slcohol, and denied ever drinking more than four drinks at a time. 29. Ms. Stokes told Dr. Teitelbaum that she has been prescribed several sedative hypnotics, including Ativann and Valium,12 for anxiety. 30. Ms. Stokes told Dr. Teitelbaum that she has been prescribed Adipex,13 but reported she had not taken it in at least six months. 11 Ativan is the brand name for lorazepam, a benzodiazepine prescribed to treat anxiety. Lorazepam can decrease mental alertness and affect judgment. According to Section 893.03(4), Florida Statutes (2017), lorazepam is a Schedule IV controlled substance that has a low potential for abuse relative to the substances in Schedule III and has a currently accepted medical use in treatment in the United States. Abuse of lorazepam may lead to limited physical or psychological dependence relative to the substances in Schedule III. 12 Valium is the brand name for diazepam and is prescribed to treat anxiety. According to Section 893.03(4), Florida Statutes (2017), diazepam is a Schedule IV controlled substance that has a low potential for abuse relative to the substances in Schedule III and has a currently accepted medical use in treatment in the United States. Abuse of diazepam may lead to limited physical or psychological dependence relative to the substances in Schedule III. 13 Adipex is the brand name for Phentermine, which is a stimulant commonly prescribed to assist with weight loss. According to Section 893.03(4), Florida Statutes (2017), phentermine is a Schedule IV controlled substance that has a low potential for abuse relative to the substances in Schedule III and has a currently accepted medical use in treatment in the United States. Abuse of phentermine may lead to limited physical or psychological dependence relative to the substances in Schedule III. Page 6 of 14
31. Ms. Stokes also reported being prescribed Celexa.14 When questioned why she was prescribed Celexa, she could provide no reason, except that her physician told her it would help with her medical problems. 32. Based on the materials he reviewed and his evaluation of Ms. Stokes, Dr. Teitelbaum found that Ms. Stokes exhibits a persistent desire or unsuccessful efforts to cut down or control her opioid use, has recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home, and that she has developed a tolerance to opioids. 33. Dr. Teitelbaum opined that Ms. Stokes does not need any short-acting euphorigenic opioids to treat her chronic pain issues. 34. If she does require opioids, Dr. Teitelbaum opined that they should be prescribed by a physician who is experienced in substance use disorders and has expertise in chronic pain management. He also opined that Ms. Stokes should not be allowed to work as a nurse while she is taking these medications. 35. Dr. Teitelbaum opined that Ms. Stokes has no reason to take Celexa. This is due to the potential interaction between benzodiazepines and opiates which can cause significant impairment, such as that which 14 Celexa is an antidepressant belonging to a group of drugs called selective serotonin reuptake inhibitors (SSRIs). Citalopram is used to treat depression Page 7 of 14
was described during Ms. Stokes's incident at work. In Re: 36. On or about November 20, 2017, Ms. Stokes submitted to toxicology tests which were positive for alcohol. 37. Dr. Teitelbaum opined that Ms. Stokes's toxicology results indicate that she was not truthful about her alcohol usage, and that her veracity is questionable. He opined that her inconsistent reports of her alcohol usage are likely due to fear and shame. 38. Dr. Teitelbaum opined that Ms. Stokes's potential for relapse or return to her problematic usage is very high. 39. Dr. Teitelbaum diagnosed Ms. Stokes with mild opiate use disorder and that she is in need of continued evaluation for her opiate use disorder; sedative use disorder versus unspecified sedative use disorder; and alcohol use disorder. 40. Dr. Teitelbaum opined that Ms. Stokes is not able to practice nursing with reasonable skill and safety to patients. 41. Dr. Teitelbaum opined that Ms. Stokes likely suffers from a more severe substance use problem than she reports. 42. Dr. Teitelbaum recommended that Ms. Stokes be monitored by Page 8 of 14
the Intervention Project for Nurses (IPN),15 and maintain documented sobriety for at least six months, before considering whether she can safely return to the practice of nursing. He opined that any material noncompliance from a positive alcohol or drug test should be met with an immediate reevaluation with strong consideration to send Ms. Stokes directly into treatment. 43. Dr. Teitelbaum recommended that Ms. Stokes's return to the practice of nursing should be contingent upon complete compliance with IPN. 44. As of the date of this Order, Ms. Stokes has not complied with Dr. Teitelbaum's recommendations. 45. In the course of their practice, practical nurses must possess good judgment, be able to recognize abnormal signs or symptoms of patients, and provide emergency care when needed. Ms. Stokes's diagnoses of mild opiate use disorder, her need for continued evaluation for her opiate use disorder versus unspecified opiate use disorder, her sedative use disorder versus unspecified sedative use disorder, and her 15 IPN is the impaired practitioner program for the Board of Nursing, pursuant to Section 456.076, Florida Statutes (2017). IPN monitors the evaluation, care, and treatment of impaired nurses. IPN oversees random drug screens and provides for the exchange of information between treatment providers, evaluators, and the Department for the protection of the public Page 9 of 14
alcohol use disorder, her positive toxicology testing for alcohol indicating a lack of veracity regarding her alcohol usage, and her obvious impairment while working as an LPN, all compromise her ability to effectively monitor, treat, or care for her patients. Based on this, Ms. Stokes's continued unrestricted practice as a practical nurse presents an immediate serious danger to the health, welfare, and safety of the public. Because Ms. Stokes has not complied with the recommendations of Dr. Teitelbaum, the danger to the public is likely to continue. 46. An independent medical expert has determined that Ms. Stokes is unable to practice nursing with reasonable skill and safety to patients due to mild opiate use disorder and need for continued evaluation for her opiate use disorder versus unspecified opiate use disorder, her sedative use disorder versus unspecified sedative use disorder, and her alcohol use disorder. Based on that opinion, as well as Ms. Stokes's untruthful reporting of her alcohol consumption, despite the significant professional ramifications of that usage, her obvious impairment while working, and her failure to comply with Dr. Teitelbaum's recommendations, there are no less-restrictive means than the terms outlined in this Order that will adequately protect the public. Page 10 of 14
CONCLUSIONS OF LAW Based on the foregoing Findings of Fact, the State Surgeon General concludes as follows: 1. The State Surgeon General has jurisdiction over this matter pursuant to Sections 20.43 and 456.073(8), Florida Statutes (2017), and Chapter 464, Florida Statutes (2017). 2. Section 464.018(1)(j), Florida Statutes (2017), subjects a licensee to discipline, including restriction, for "[b]eing unable to practice nursing with reasonable skill and safety to patients by reason of illness or use of alcohol, drugs, narcotics, or chemicals or any other type of material or as a result of any mental or physical condition." 3. Ms. Stokes violated Section 464.018(1)0), Florida Statutes (2017), by being unable to practice nursing with reasonable skill and safety due one or more of the following: a. mild opiate use disorder; b. need for continued evaluation for opiate use disorder versus unspecified opiate use disorder; c. need for continued evaluation for sedative use disorder Page 11 of 14
versus unspecified sedative use disorder; and d. need for continuing evaluation for alcohol use disorder. 4. Section 120.60(6), Florida Statutes (2017), authorizes the Department to restrict a practical nurse's license if the Department finds that the practical nurse presents an immediate, serious danger to the public health, safety, or welfare. 5. Ms. Stokes's continued unrestricted practice constitutes an immediate serious danger to the health, safety, and welfare of the public, and this summary procedure is fair under the circumstances to adequately protect the public. WHEREFORE, in accordance with Section 120.60(6), Florida Statutes (2017), it is ORDERED THAT: 1. The license of, license number PN 5187826, is hereby immediately restricted to prohibit her from practicing nursing until such time as IPN or an IPN-approved evaluator notifies the Department that Ms. Stokes is safe to resume practicing nursing. 2. A proceeding seeking formal discipline of the license of Satura Tamicka Stokes to practice nursing will be promptly instituted and acted Page 12 of 14
upon in compliance with Sections 120.569 and 120.60(6), Florida Statutes (2017). DONE and ORDERED this da of 2018. Celeste Philip, M.D., M.P.H. Surgeon General and Secretary PREPARED BY: Lindsey H. Frost, Esq. Florida Bar No. 109766 Assistant General Counsel Prosecution Services Unit 4052 Bald Cypress Way, Bin C-65 Tallahassee, Florida 32399-3265 (P) 850-558-9841 (F) 850-245-4662 (E) lindsey.frost@flhealth.gov Page 13 of 14
NOTICE OF RIGHT TO JUDICIAL REVIEW Pursuant to Sections 120.60(6), and 120.68, Florida Statutes, this Order is judicially reviewable. Review proceedings are governed by the Florida Rules of Appellate Procedure. Proceedings are commenced by filing a Petition for Review, in accordance with Florida Rule of Appellate Procedure 9.100, with the District Court of Appeal, accompanied by a filing fee prescribed by law, and a copy of the Petition with the Agency Clerk of the Department within 30 days of the date this Order is filed. Page 14 of 14