CHASE RIVElAND
. Secretary

..../

RECEIVE.~

STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS

JAN 0 9 1996

McNEIL ISLAND CORRECTIONS CENTER

of Corrections
D~.!:~~ent
"~I of Human ResoUIT'

P.

o. Box 900

•

Steilacoom. Washington 98388-0900

January 3, 1996

Donna L. Evans

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PERSONAL SERVICECONFIDENTIAL

Ms. Evans:

This is official notification of your immediate suspension, at 12:01 a.m. on January 8,
1996 through 12:00 midnight on January 22, 1996, followed by your dismissal effective
at 12:01 a.m. on January 23, 1996, from your position as a Licensed Practical Nurse 3
with the Department of Corrections (DOC), McNeil Island Corrections Center (MICC).
This disciplinary action is taken pursuant to the authority of the Civil Service Laws of
Washington State, Chapter 41.06, RCW, and the Merit System Rules, Title 356 WAC
(MSR), Section 356-34-010 Disciplinary actions - Causes fer demotion-SuspensionReduc,ion in salary-Dismissal. (1) (a) Neglect of duty, (h) Gross misconduct and (i)
W!ilful violation of published employing agency or Depal1ment of Personnel rules and
regulations, RCW 356-34-040 Dismissal - Notification and RCW 356-34-050 Suspension
- Followed by dismissal.,
Specifically, you neglected your duty, committed act(s) of gross miscond4c;1 and willfully
violated published employing agency rules when you, by your own admission dUring the
administrative review of this incident, accessed and dispensed-' medication
inappropriately, and without proper documentation (i.e., Primary.;..l;ncounter Report, PER),
from the MICC mini-pharmacy tackle box when you removed:+O Furosemide 40 mg
tablets sometime between June 28, 1995, and July 14, 1995, without having. been
directed or ordered to do so by a PA or Physician. This incident is described in detail
in the Employee Conduct Report (ECR) completed on December 5, 1995 (Attachment
1).
The mini-pharmacy is a restricted area, providing accessibility to narcotics and
prescription/legend drugs on an emergency basis for appropriately licensed health
services staff from 6 p.m. to 6 a.m. (during off duty hours for pharmacy staff). Pharmacy
staff began tracking medications, that were not documented with an associated PER,
beginning in May, 1995. Specifically, Pharmacy Assistant Jan White was tasked with
daily checking of the tackle box, that was located in the mini pharmacy, documenting
wl:1en the tamper-evident seal was broken. When the seal was broken, she ch~cked the

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Number of Pages (including this page):

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Additional Information:

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Conna" L. Evans
December 14, 1995
Page 2 of 8
The mini-pharmacy is a restricted area, providing access~bility to narcotics and
prescriptionJlegend drugs on an emergency basis for appropriately licensed health
services staff from 6 p.m. to 6 a.m. (during off duty hours for pharmacy staff). Pharmacy
staff began tracking medications, that were not documented with an associated PER.
beginning in May, 1995. Specifically, Pharmacy Assistant Jan White was tasked with
daily checking of the tackJe box. that was located in the mini pharmacy. documenting
when the tamper-evident seal was broken. When the seat was broken, she cheeked the
enclosed vials for replenishment of medications as needed. She also noted and reported
to her supervisor, any discrepancies in the number of tablets that were undocumented
(Le., no PER was completed). On June 27, 1995. Ms. White found the tamper-evident
seal broken and found that seven Furosemide tablets were missing (between June 5,

1995 and June 27, 1995). No PER's were written during this time for the drug. On June
28, 1995. Ms. White restocked the tackle box in Vial No.2 with 25 tablets of Furosemide
40rng. On July 14. 1995. Ms. White found the tamper-evident seal on the tackle box
broken. She counted the tablets and found only 15 of the 25 that had been placed in
the vial. No PER's were written for the missing 10 tablets.

Vial No.2. when the final discrepancy was discoveredJ on July 14. 1995. was properly
stored and delivered to James Cooper of the MICC Intelligence and Investigations office.
When checked, it yielded clear fingerprints that were identified as your own.

There is no documentation establishing the medication that you removed was dispensed
appropriately to the MICC inmate population. nor have you provided any supporting
documentation of legitimate reasons you would have taken the tablets.

In fact. you

admitted to me that you failed to follow procedure by preparing the PERS for signature
when you gathered medications upon the direction of a PA or Physician.
A Pharmacy In-Service Memorandum. dated March 3, 1994, (Attachment 2), which you

0824

Donna L. Evans
December 14. 1995
Page 3 of 8
admit having knowledge of. states, in pertinent part:
"A PER must be written for any item issued from the after-hours Pharmacy
(or ER) and signed by a PAlMD.
Leave a PER for anything that was removed from the tackle box and the
bottle that was used in the refill box under the pill line cart along with the
broken seal. II.

WAC 246-838-030 Standards of conduct for discipline, which outlines the level of
standards of professional conduct for licensed practical nurses, (Attachment 3) states.
in pertinent part:

liThe licensed practical nurse assumes a measure of responsibility, trust
and the corresponding obligation to adhere to the standards of condud.
which include. but are not limited to the following:

(1)

.,. shall be responsible and accountable for his or her own nursing

jUdgements, actions . . .

(5) The licensed practical nurse shall not abide. abet or assist any other
person in violating or circumventing the laws or rules pertaining to the
conduct and pradice of licensed practical nursing.
(10) The licensed practical nurse shall report unsafe acts and practices,
unsafe practice conditions. and iIIegal.acts to the appropriate supervisory
personnel ...

0825 .

Canna L. Evans
December 14, 1995
Page 4 of 8
(12) The licensed practical nurse shall make accurate, intelligible entries

into records required by law, employment, or customary practice ...

(18) The licensed practical nurse shall respect the property of the . . .
employer and shall not take ... drugs for his or her own use or benefit.

(19) The licensed practical nurse shall not obtain, possess, distribute Or

administer legend drugs . . . to any person, including self, except as
directed by a person authorized by law to prescribe drugs.

RCW 18.130.180 Unprofessional Conduct (Attachment 4) states, in pertinent part:

liThe following conduct. acts, or conditions constitute unprofessional
conduct for any license holder ... under the jurisdiction of this chapter.
Which states in pertinent part. but is not limited to the following:

(1) The commission of any act involving moral turpitude, dishonesty. or
corruption relating to the practice of the person's profession, whether the
act constitutes a crime or not.

(7) Violation of any state or federal statute or administrative rule regulating
the profession in question including any ... rule defining or establishing
standards of ... professional conduct or practice.

(23) Current misuse of:

(c) Legend drugs."

0826

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· .'-

OonnaL. Evaris
December 14, 1995
Page 5 of 8

RCW 18.79.270 Licensed Practical Nurse - Activities allowed (Attachment 5) states, in
pertinent part:
"A licensed practical nurse under his or her license may perform nursing
care, ... and in the course thereof may, under the direction of a licensed

physician ... physician assistant, ... administer'drugs, medications, ...
when selected to do so by one of the licensed practitioners designated

in

this section, . ' . if the order given is reduced to writing within a reasonable
time and made a part of the patient's record. 1I
On September 10, 1993. you signed for your receipt (Attachment 6) of the DOC
Employee Handbook, which states, in pertinent p.alt on pages two through four
(Attachment 7):
"CODE OF ETHICS
High moral and ethical standards among correctional employees are
essential for the success of the departmenfs programs. The Department
of Corrections subscribes to a code of unfailing honesty, respect for dignity
and individuality of human beings. and a commitment to professional and
compassionate service."
DOC Policy 801.001 Ethics (Attachment 8) states, in pertinent part
"POUCY

Restrictions:

082"

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Donna L Evans
December 14, 1995
Page 6 of 8

Additional restriction placed upon employees include, but are not limited to
the following:

2. Employees shall not use state resources for personal benefit or to
benefit another excapt as may be required during the execution of their
official. duties.

Responsibilities

Violations of the State Ethics Law and/or this policy may lead to corrective
or disciplinary action up to and including dismissal."

You have

a dUty to follow the licensing standards and uphold the professional conduct

entrusted to you as a licensed practical nurse. You also have a duty to follow procedure
that is designed to support you in accomplishment of your professional service to the

DOC inmate population, using resources properly and not for your personal use.
Your actions in this matter were irresponsible, unprofessional, unethical and
counterproductive to achieving the Department's mission to provide fair and equitable
treatment to inmates while they are under our supervision. You neglected your duty to
follow the professional standards of your licensure which includes honest and
responsible execution of your duties and the expectations of your employer. By your
actions you did not property complete associated paperwork when you accessed drugs
in the mini-pharmacy tackle box and lied about accessing the medications.
behavior was

a willful

Your

violation of pUblished agency rules and regulations as identified.

a neglect of your duty as outlined in the licensing guidelines cited and rises to the level

of gross misconduct.

0828

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Donna L. Evans
December 14,1995
Page 7 of 8

As a result of the administrative review held on November 17. 1995, I determined. and
verbally notified you and your representatives at that time. that misconduct had occurred.
We convened in a Loudermill hearing on November 20. 1995. to discuss your possible
termination. You were allowed an opportunity to fully discuss and refute the charges
and/or to present reasons why your termination was not appropriate. Throughout that
meeting you .demonstrated that you do not accept your responsibilities in this matter.
stating that everyone was lax and thars just the way it was done. By your actions and
your repeated failure to recognize your lack of responsibility in this matter, you have lost
my trust in your ability to honestly and professionally perform your duties. I find your
attitude and defense of your actions and admitted failure to follow procedure intolerable
and unprofessional.

This is not the standard of professional performance that I expect

of staff, especially staff with access to controlled sut?stances and who are responsible
for tne medical health and welfare of the inmate papulation.

In addition. you provided no defense or plausible explanation for your fingerprints to be
on Vial No.2. when the 10 missing Furosemide tablets were discovered. I can only
conclude that you have lied about your contention that you did not access the vial, and
you stole the tablets and used them inappropriately.

Therefore. I find that your

immediate suspension. followed by termination is fully warranted.

Attachments one through eight are attached hereto and by this reference, made a part
of as though fltlly set forth herein.
Under the provisions of WAC 358-20-010 and 358-20-040, you have the right to appeal
this action OR to file a grievance per Article 10 of the Collective Bargaining Agreement

between the Department of Corrections and the Washington State Corrections Employee
Association. If you file an appeal, it must be filed in writing at the Office of the Personnel
Appeals Board, 2828 Capitol Boulevard, Olympia. Washins':':-' 98501. within thirty (30)
days after the effective date stated in the first paragraph of this letter.

0829

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Danna L. Evans
December 14, 1995
Page 8 of 8

The Merit System Rules. WAC's. Department of Carrectian~ policies and the Collective
Bargaining Agreement are available for your review upon request.

Belinda D. Stewart. Superintendent
McNeil Island Corrections Center

Attachment(s)

cc:

Tom Rolfs, Director. Division of Prisons
Jennie Adkins. Director. Division of Human Resources
Donna Grazzini. 'NWC Area Personnel Manager
Linda Dalton. Sr. Assistant Attorney General
Katherine Deuel. MiCe Personnel Officer
Employee Personnel File

0830

Supervisory Report
Donna Evans (AKA Turner, Lake) ECA issued September 22, 1995
Missing Drugs from Mini-Pharmacy tackle box
Page 3

On July 14, 1995, Ms. White found the tamper-evident seal an the tackle box broken.
In the presence of Health Care Manager Robert Cloke, Ms. White counted the
Furosemide 40mg tablets in the tackle box, again wearing vinyl gloves and conducting
a double count. The count was 15 tablets, indicating that 10 tablets had been
removed betWeen June 28, 1995, and July 14, 1995. Again, no PERs were written
for this drug during this time period.
With HCM Cldke observing, Ms. White placed the empty vial that contained the
Furosemide 40mg into a brawn paper bag, to be turned aver to 1&1. Correctional
Investigator Jim Cooper picked up the bag containing this empty vial on approximately
July 18, 1995. Between the time the vial was placed in the paper bag and the time
Mr. Cooper took possession of the bag, it was secured in the main Pharmacy. For
purposes of this report, this vial will be referred to as "vial 2."
.
On July 24, 26, 27, and 28, 1995, Ms. White found the tamper-evident seal on the
tackle box broken. On each date, using vinyl gloves, Ms. White counted the
Furosemide 40mg tablets and found 25 tablets present an each of those dates,
indicating no tablets had been removed since July 14, 1995.
The Pharmacy only stacks Furosemide in a 40mg tablet or a 20mg injection. If
inmates are prescribed a 20mg dose in tablet form, a 40mg tablet is halved. The
40mg tablets are scared for that purpose.
Pharmacy staff researched all PERs written during that time period to determine if
Donna Evans had legitimately accessed the Mini-Pharmacy and issued any type of
pharmaceutical from the tackle box during the time period of May 25-July 14, 1995.
They found only one PER written by Ms. Evans on July 14, 1995, where she r~moved
a Motrin 600mg for an inmate under the order of PA Bartram (Attachment D). As
Motrin 600mg is not a legend drug, it is not secured in the tackle box itself, but is
secured in the Mini-Pharmacy.
In addition to the Furosemide 40mg tablets missing from the tackle box, two different·
inmates had diuretics missing from their prescriptions at pill line. One inmate
was missing 2 Furosemide 40mg tablets between July 13 - 28,
1995. The exact date cannot be determined, as the discrepancy was noted when the
prescription was turned into the Pharmacy for refill before the issued amount should
had all 30 tablets of HCTZ
have been consumed. Another inmat
25mg missing from pill line on August 3, 1995, from a prescription that was filled by
the Pharmacy on August 1, 1995. This was discovered by RN Sharon Stevens when
she compared the prescriptions present in the pill line room to the log. Ms. White

tl831
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Supervisory Report
Donna Evans (AKA Turner, Lake) ECR issued September 22, 1995
Missing Drugs from Mini-Pharmacy tackle box
Page 4

checked the log and found that the inmate had not signed for receipt of his
prescription (required for all pill line medications), nor had it been returned to the
Pharmacy (Attachment E).
Both of these inmates were received on the incoming chain from WCC on June 29,
1995, and had been prescribed daily doses of Furosemide (Lasix) at WCC. As part of
the medical process on incoming chains, that prescription information was
documented on a PER by Donna Evans (Lake), as she processed the inr:oming chain
on that date (Attachment F). The prescriptions were written by WCC medical staff.
On October 4, 1995, I interviewed Chief Nurse Pat Callaghan regarding who had
access to the pill line room on August 1 - 3, 1995. Ms. Callaghan stated that RN
Stevens had been assigned to the pill line during that time, but that other nursing staff
often assist, including those assigned to the Annex pill line. Ms. Evans was assigned
to the Annex pill line on those days. Health Services currently only documents the
nurse in charge of the main institution pill line, so there is no record of which other
staff may have assisted during those days.
Ms. Callaghan stated that she had observed, and other nursing staff had reported to
her, that Ms. Evans was often tthanging around" the Mini-Pharmacy. Ms. Evans'
regular work schedule is 8am to 4pm, Monday through Friday. The main Pharmacy
is open during all those times.
On September 28, 1995, I interviewed Jim Cooper, as 1&1 had an ongoing
investigation into medications missing from the Mini-Pharmacy. Mr. Cooper relayed
that on June 30, 1995, he placed a pill vial (viall) from the Mini-Pharmacy into
evidence. He contacted the Washington State Patrol Crime Lab to see if they. would
process the vial for fingerprints, which they agreed to do. Mr. Cooper then requested
hospital staff fingerprint cards from the Personnel Office, but subsequently learned
that the WSP identification section should have fingerprint cards for state employees.
Oil July 18, 1995, Mr. Cooper took viall to the Crime Lab for processing, along with
a list of personnel having access to the Mini-Pharmacy (Attachment G). Later that day
he was notified by lab personnel that, due to turnover in their staff, fingerprint cards
had not been consistently maintained on file. Mr. Cooper then re-requested fingerprint
cards from employee personnel files. On August 16, 1995, Mr. Cooper delivered vial
2 to the Crime Lab for processing.
On or about August 7, 1995, Mr. Cooper received word from lab personnel that the
fingerprint cards from the employees' personnel files were not sufficient for latent print

0832

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Supervisory Report
Donna Evans (AKA Turner, Lake) ECR issued September 22, 1995
Missing Drugs from Mini-Pharmacy· tackle box
Page 5

identification purposes, and that "major case prints" would be needed. Mr. Cooper
discussed this with the Superintendent, who decided to have all Health Services staff
fingerprinted, which was done.
Mr. Cooper stated that the Crime Lab indicated the fingerprints an vial 1 were not
sufficient to make a positive identification, but that vial 2 contained identifiable prints.
On September 11, 1995, Mr. Cooper informed the Superintendent that he had
received the latent print written report from the Crime Lab, and that twa latent
fingerprint lifts an vial 2 were identified as the right palm of Danna Evans· (AKA
Turner, Lake). A re-lift of one of the latent lifts contained one identifiable latent
impression which was negative in comparison to the fingerprint cards submitted. The
complete lab report is included as Attachment H.
On October 30, 1995, I interviewed Donna Evans regarding the ECR allegations. Also
present was her attorney, John C. Cain. Ms. Evans confirmed that her 'Nork hours are
8 a.m. to 4 p.m., Monday through Friday, and that she has worked at MICC since
1992.
I asked Ms. Evans to describe to me what a "PER" was and haw it was used- Ms..
Evans described that the form was a Primary Encounter Report that was used by
doctors and nurses to document patient care for inmates. The form is to be used for
any type of encounter, including lab draws and infractions issued. She stated that
was the "ultimate goal" but that PERs are not always completed, e.g., replacement
of hearing aid batteries. Ms. Evans stated that it doesn't always happen [PER
completed] with the tackle box. Ms. Evans further related that if there was an
immediate need in the emergency room, a Physician's Assistant would order the nurse
to obtain something from the mini-pharmacy, but that she would depend an. the PA
to complete the PER. Ms. Evans stated that training on the use of the PER was part
of the on-the-job training she received at MICC.
Ms. Evans stated that it was common to access the mini-pharmacy, but not the tackle
box, when the main pharmacy was open when Health Services was in the old hospital
building, as pill line was set up and ran from the mini-pharmacy. With the move to the
new building, pill line is separate from the mini-pharmacy.
Ms. Evans stated that in both the old and new buildings, the main pharmacy was
closed 1 or 2 times per week at 1 p.m. Ms. Paulson refutes this statement, saying
the pharmacy may have closed early while they were in the old location, but such
closures were "few and far between" and with the move to the new location there are
two pharmacy shifts.

0833

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UI:t'AH'rMI:HT 0 .. CUHHR:I,;IIUN:=I

THIS FORM TO BE USED IN COMPLIANCE WITH

EMr OYEE CONDUCT REPORT
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POLICY DlRECTI'JE NO, 857.005
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INSTRUCTIONS AND TIME UMITS:
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1. The person making the report shall provide a clear description 01 the incident under "Desc~iption of Incident" yv; A \\.
and. with any witness(es) or person(s) having knowledge. shall sign in the space provided and submit to the r.·':
supervisor of the involved employee within fourteen (14) calendar days after the dlllte of discovery 01 an.¥Jj\.
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employee's alleged misconduct.
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2. The form shall be submitted to the employee involved who shall complete the "Employee's Statement" and
retum the report to his/her supervisor within seven (7) calendar days·fol!owing the date of receipt.

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3. The appropriate supervisor shall review the facts 01 the incident. complete the "Supervisor's Report" and
submit the report to the Office Head within seven (7) calendar days following the date 01 receipt.
4. The Office Head or designated representative shall review and within thirty (30) calendar days following "the
date 01 receipt determine whether misconduct has occurred. This shall be reported under"Administrative
Comments" and shared with the employee. When the supervisor and Office Head are the same person. the
supervisor's supervisor shall complete the Administrative Comments.
;!IoIPUlYEEIHVQ.VED

, ORGolHlZAnONAL UNIT

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Donna Evans
''J5mOHnru:

RN

Hospital Serrices
CATE OF lHCIUEHT

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OF 'NCIOENT

DAM

September 11, 1995

IilPM

DESCRIPTION OF INCIDENT:

The allegations outlined below came to my attention on September 11. 1995.
It is alleged that you removed 20 fu=semide 40 mg tablets from the sealed taCkle
box in the mini-pharmacy between the months of Oecember 1994 and May 25, 1995.
I-: is 3.ddit'ionally ~.U "!qed that you :'e..~::;.,::!~ twc furse!!'ide taLl~~; b~t.;.:e!::l May

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and June 5, 1995; and between June 5, 1995 and June 27, 1995 you removed seven more
fursemide tablets.

It is further alleged that between June 27, 1995 and July 14,

that you removed ten fursewide 40 mq tablets f=nm thP.
mini -pharmacy.

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It is alleged that the fursemide 40 mg tablets were removed for your cersonal use
and that Pri.n1ary Encounter Reports were not comcleted.

There has been no offender

prescriptions of ,fursemide 40 mg tablets since December of 1994.

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Attachment

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DATE DEUVEREO TC

APLOYEE"S STATEMENT:

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.

JPERVISOR'S REPORT:

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0,\TE RECEIVED BY SUPERVISOR

BY:

Signature & Titl
of Supervisor.

Date:

)MINISTRAnve·COMMENTS: DATE RECEIVED gy OFFICE HEAD

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BY:
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Ae met on November 17, 1995, in the administrative review of this emoloyee conduct report (ECR)
~lso

oresent were

yo~r

union reoresentative, Kurt Hansen, your attorney, John Cain. and MICC

Jersonnel officers Katherine Deuel and Arturo Haro.
5ubstantiated on the first three allegations.

I have determined misconduct could not be

However, misconduct did occur when you removed

10 fursemide tablets from the MICe mini-pharmacy tackle box sometime between June 27. 1995 and
July 14, 1995. and that you failed to complete a PER documentjng that removal.

Signalure 0
Office Head:
OISTRl8unoN:
OAlGlHAl-EIolPI.OVEFS I'Ei!SCHHEL FilE
ONE COPV-EMl't.OVEE

Date:

12 -: 5 - 95
P...

.

0835

Supervisory Report
.
Donna Evans (AKA Turner, Lake) ECR issued September 22, 1995
Missing Drugs from Mini-Pharmacy tackle box
Page 2

Investigation
On October 3, 1995, I interviewed Pharmacist Supervisor Linda Paulson and Pharmacy
Assistant A Jan White in the MICC Mini-Pharmacy. During the week of May 8-12,
1995, an empty bottle of Furosemide 40mg tablets was returned from the tackle box
to the Pharmacy for refill. Furosemide (trade name Lasixl is a potent type of diuretic,
usually prescribed for high blood pressure. The empty bottle appeared unusual to
Pharmacy staff, as they could not recall an inmate being prescribed that drug. Their
research via the pharmacy computer database revealed that no inmate had been
issued this particular drug since December 17,1994 (Attachment C), and no PERs had
been prepared for issues of this drug from the tackle box. At this point, Pharmacy
staff began counting all three types of diuretics (Furosemide, HCTZ, and
Spironolactone) each time the tamper-evident seal on the tackle box was broken.
Each count was conducted in the presence of other staff.
On May 25, 1995, Ms. White placed 25 Furosemide 40mg tablets into a new, sterile,
labelp.d container. Ms. White wore vinyl gloves during this process, used a wipedclean, sterile vial double-counted the pills, and replaced the container in the tackle
box. The t'NO other diuretics maintained in the tackle box were also double-counted
(HCTZ 25mg = 45 tablets and Spironolactone 25mg = 29 tablets).
On June 5, 1995, Pharmacy staff checked the tackle box and found the tamperevident seal broken. The diuretics were double-counted by Ms. White, and 23 tablets
of Furosemide 40mg were present, indicating that 2 tablets had been removed
between May 25, 1995, and June 5, 1995. There were!JQ PERs written during this
time period for that medication, and no Mice inmates had been prescribed that
medication since December 17, 199~ 'Nhen one tablet was issued from the ta~kle box
in an emergency situation. None of the other two diuretics were missing.
On June 27, 1995, Pharmacy staff again found the tamper-evident seal broken on the
tackle box. Wearing vinyl gloves, Ms. White double-counted the diuretics and found
the Furosemide 40mg vial contained only 16 tablets, indicating that 7 tablets had been
removed between June 5, 1995, and June 27, 1995. Again, no PERs were written
during this time period for this drug and no inmates had been prescribed that drug.
The original Furosemide 40mg vial was placed in a plastic "zip-lock bag and turned
over to the MICC Intelligence and Investigations office (1&1) and placed into evidence
on June 30, 1995. For purposes of this report, this vial will be referred to as "vial 1."
It

On June 28, 1995, Ms. White, again wearing vinyl gloves and using a wiped-clean,
sterile, labeled bottle, restocked the tackle box with 25 tablets of Furosemide 40mg.

083S

I .$0/27

Supervisory Report
Donna Evans (AKA Turner, Lake) ECR issued September 22, 1995
Missing Drugs from Mini-Pharmacy tackle box

Background
This background information was obtained by interviewing Pharmacist Linda Paulson
and Pharmacy Assistant Jan White.
The Mini-Pharmacy is a small, secure room located separate from, but adjacent to the
main Pharmacy, on the third floor of the Education Services Building. The MiniPharmacy contains various types of over-the-counter medications, controlled drugs
(schedule 2 through 5 narcotics), various syringes and needles in a padlocked
container, medicine which requires refrigeration, and a "tackle box" containing various
prescription medications, commonly known as "legend" drugs, as each prescription
bottle is marked with "Warning: State or Federal law prohibits transfer of this drug to
any person other than the person for whom it was prescribed." (Attachment A)
The main function of the Mini-Pharmacy is to provide Health Care staff access to
various drugs when the main Pharmacy is closed, Le., evenings and weekends. The
main Pharmacy operates on a 12/5 schedule (approximately 6:30am to 6:00pm,
Monday through Friday). By Pharmacy Board regulations, a pharmacy itself cannot
be accessed by persons who are not licensed Pharmacists (or assistants). Thus. the
Mini-Pharmacy contains those medicines which may be prescribed and/or administered
by licensed medical practitioners during hours that the Pharmacy is closed.
Consequently, all licensed medical staff (Dr. Buck, Physician's Assistants, RNs, LPNs
and Pharmacy staff) have a key to the Mini-Pharmacy. A total of 31 staff are known
to have access to the Mini-Pharmacy, covering three shihs, seven days per week.
The tackle box maintained in the Mini-Pharmacy closely resembles a fishing-type tackle
box approximately 30" by 12" by 18". The box is secured by a tamper-evid~nt seal.
Only Pharmacy staff have access to the supply of those seals. At the beginning of
each work shift, Pharmacy staff inspect the tackle box to determine if it had been
accessed during the off-hours. If the Mini-Pharmacy is accessed" during off-hours,
specific written procedures are in place which require the person who acc7ss~s the
area to complete a Primary Encounter Report (PER) to document what medlcatlon(s)
was issued to which inmate(s). The Pharmacy uses the PER as part of their source
documents to maintain a database of all pharmaceuticals issued to each inmate. The
procedures are documented in a March 1, 1994, "P~armacy In-service Memo,.... which
was part of training provided by Ms. Paulson to all licensed healt~ care practltlo~ers,
including Ms. Evans (Attachment B). When the main Pharmacy IS open, there I~ no
reason to access the tackle box. This memo also states that personal use of
medications from M\Ce is prohibited.

Supervisory Report
Donna Evans (AKA Turner, Lake) ECR issued September 22, 1995
Missing Drugs from Mini-Pharmacy tackle box

Page 6

I asked Ms. Evans if she could recall accessing the tackle box during her regular work
shih during December 1994 and July 1995. She stated she knew she had. She
described that it was common to access the mini-pharmacy and/or tackle box if pill
line medication came up short. She further stated that PERs were supposed to be
filled out for items removed, but they typically were not. I described this scenario to
Ms. Paulson who stated it was not procedure to make up for short pill line by using
either the mjni~pharmacy or the tackle box. Ms. Paulson stated that could happen in
the rare ins~ance where medication was immediately needed. but it would olily be one
dose. It is not common practice.
Ms. Evans stated that "everybody" could go through the mini-pharmacy, as all
licensed health care staff have a ke'l to that room. There is no sign-in sheet to
indicate who accessed the room. Ms. Evans stated that she had "heard" there was
now a sign-in sheet for pill line.
At this point, Mr. Cain began asking some questions of Ms. Evans to facilitate her
sharing additional information. He asked if there' were inmates who had been
prescribed 20mg doses of furosemide. Ms. Evans stated there had been three inmates
since last December {1994J that had been on a 20mg dose, and that 40mq tablets
were split. She stated one inmate whose name she remembered was something like
_
and that she remembers him from the incoming chain. There was a.n
inmate _ w h o arrived on ~he June 29, 1995 chain from wec, howe~er hiS
prescription was for 40mg furosemide. not 20mg. Ms. Evans processed that Inmate
in (Anachment Fl. My research with pharmacy staff indicated that there were three
inmates since December 1994 who had been prescribed furosemide:

111

(21

,.

083'9

Supervisory Report
Donna Evans (AKA Turner, Lake) ECA issued September 22, 1995
Missing Drugs from Mini-Pharmacy tackle box

Page 7

(3)

Inmat
came to MiCe from wce (June 29, 1995)
with a prescription of fursemide 40mg ILasix trade name). Medication
issues to this inmate are documented in the pharmacy database
(Attachment K). I n m a t e _ transferred to Lincoln Park Work
Release on August 16, 1995.

-

':........
When asked to describe the tackle box seal, Ms. Evans stated that anybody can seal
it and that in die old hospital, the breakable plastic seal tabs were storeEj.irra~drawer.
She stated she did not know where the seals were stored in the new building. She
further stated that the tackle box is not always resealed and it has gone for "days"
without being resealed. I questioned Ms. Paulson regarding these statements and Ms.
Paulson reaHirmed her earlier statements that in both locations the seals were locked
in the pharmacy and only pharmacy staff resealed the tackle box. Ms. Paulson also
stated that the longest period of time the tackle box woutd go unsealed was if it were
to be accessed after the pharmacy closed on a Friday, and until pharmacy staff arrived
the following Monday.
Ms. Evans also stated that furosemide tablets were kept in the Emergency Room crash
cart. I questioned He:;llth Car~ Mana;;e!" Robert Cloke regardir.g this sterement. Mr.
Cloke personally inspected the cart and quesrioned a Physician's Assistant and a
Nurse. Furosemide is available on the crash cart in 20mg iniectable form only.
Tablets are not. and have not been available on the crash cart.
Ms. E'lans further stated that the Pharmac'l counts have not always been accurate
when issues were made to the tackle box, and that counts have also been short on
pill line, issuable medications (over the-counter typel. and narcotics. No specifics
were provided.
4

Mr. Cain asked Ms. Evans to describe what furosemide ILasix) was and how it was
used. Ms. Evans stated that it was used ror heart patients to control fluid retention:
as it takes excess fluid out of the system. She stated the drug was not available over
the-counter, but that a close over-the counter product would be Aqua·Ban, which is
a water pill. I questioned Ms. Paulson to determine the pharmacological validity of
that comparison. Ms. Paulson researched the Aqua-Ban formula and reported that it
contains 100mg caffeine and 325mg ammonium chloride as its active ingredients. A
direct comparison between the products cannot be made, as they are two completely
different compounds.
4

4

M{ _Cain then asked 'IT Ms. Evans had experienced recent weight loss and why/how.
Ms. Evans stared that due to "family problems" she had recently lost 60 pounds since

,

OS3~

/ giJdZ"i

Supervisory Report
Donna Evans (AKA Turner, Lake) ECR issued September 22, 1995
Missing Drugs from Mini-Pharmacy tackle box
Page 8

November 1994. She stated that she accomplished and maintained that weight loss
through a combination of changed diet habits and an exercise regimen. She stated
that she modified her diet to include more chicken and rice and participates in daily
exercise such as going to the gym, speed walking, racquetball, swimming,
weighttifting, etc. Ms. Evans stated that she did not exercise prior to her weight loss.
Ms. Evans stated t h a t _ i n her ankles was aggravated by her prior weight.
Mr. Cain then·stated that they may have additional names to provide me who. would
be helpful in completion of this investigation. After a brief, private discussion with
Ms. Evans, Mr. Cain stated they did not wish to give me any names until they had a
chance to get permission from those people. I made sure Mr. Cain had correct phone
numbers for me and for my fax machine. As of this date, no further contact has
occurred with either Mr. Cain or Ms. Evans regarding these names.

0810

Supervisory Report - Supplemental Information
Donna Evans (AKA Turner, Lake) ECR issued September 22, 1995
Missing Drugs from Mir:'!i-Pharmacy tackle box

On Monday, November 13, 1995, upon arriving at work there was a fax from Ms.
Evans' attorney (sent November 10, 1995, a state holiday) indicating that his office.
had not provided me with names of other individuals who may have pertinent
information regarding this issue. He provided the names of Bill Dalton, Sherry Van
Horn, Yoshi Parker, and Sharon Kiesel.
.Yoshi Parker
Mr. Parker no longer works for the Department of Corrections.
Bill Dalton
On November 15, 1995, I interviewed Bill Dalton, RN, .by telephone, after explaining
to him that his name was referred to me by Ms. Evans' attorney. Mr. Dalton stated
that he did not witness anything, as he works a different shift (midnight to 8am,
Wednesday thru Sunday) that Ms. Evans.
Mr. Dalton characterized the pharmacy operation as "sloppily run." He stated that the
pharmacy is prone to miscounting, and that the tackle box had been left unsecured
in the old hcspitai buiiding for a one-week period. He further stated that when
working with pill line that prescriptions would run out over the weekend, and that
bags of issuable medications were "obviously short." During a 4-week period he
stated he wrote five memos concerning pill line shortages. I asked if he knew for
certain that the shortages were due to pharmacy errors. He stated that was an
assumption on his part.
Regarding access to the tackle box in the new pharmacy location, he stated it could
be left unsecured over a weekend if the seal was broken Friday night. I asked about
documentation prepared for accessing the tackle box and he stated there was no
guarantee that documentation would be prepared.
Mr. Dalton estimated that it has been four to five years since he worked the same
shift as Ms. Evans.
When asked if he had any other information to provide, he stated that "I can't see her
[Donna Evans] being that dumb." He further stated that she is a military dep.endent
and could get that drug free or at a very reduced cost.
Mr. Dalton also stated that Judy Perry, a nurse in lower E unit, told him that they are
now required to count pills coming from the pharmacy due to numerous miscounts.

0841
AttachMent

/

II) J/29

_"

Supervisory Report - Supplemental Information
. Donna Evans (AKA Turner, Lake) ECR issued September 22, 1995 :
Missing Drugs from Mini-Pharmacy tackle box
.:"f"~ .:-:;'fj
Page 2
--

t·:

oJ

,/

i

....( Sherry Van Horn
I contacted Ms. Van Horn on November 15, 1995, and indicated that her name had
been referred to me by Ms. Evans' attorney. Ms. Van Horn declined to discuss the
matter.
.
Sharon Kiesel
I spoke with Ms. Kiesel on November 16, 1995. Ms. Kiesel stated that she had no
direct knowledge of the new hospital/pharmacy procedures. Ms. Kiesel did work as
a pharmacy assistant at MICC in the old hospital.
Ms. Kiesel stated that the tackle box was not sealed until after she started working
at MICC. She further indicated that during the time she worked in the pharmacy that
PERs were inconsistently done.
Ms. Kiesel indicated that she and Ms. Evans were good friends and that Pat Callaghan
would do anything to get Ms. Evans out, as Ms. Evans helped Ms. Kiesel during some
per50nr:~1 iSS\.,;9S.

Ms. Kiesel stated that Ms. Evans had recently lost a significant amount of weight and
had done so through diet and exercise.
Ms. Kiesel stated that she thinks they [hospita~orsl were "watching" Ms.
Evans. She also stated that Ms. Evans is very _
over this situation.

- .~

Ms. Kiesel indicated that there have been many instances of missing medications
before, without this type of investigation occurring.
Other Information
I also contacted the Washington State Poison Control Center for an independent
comparison of furosemide and Aqua-Ban. (See page 7 of supervisory report. Ms.
Evans stated the latter was a close over-the-counter version of the former.) I asked
for a rough comparison of how many Aqua-Ban tablets would give an equivalent
diuretic effect of a 40mg furosemide.
The Poison Control Center staff researched both drug formulas and related to me that
no comparison could be made, as the drugs have completely different compounds and
work differently. Staff indicated that my question was like asking "how may
pineapples would it take to make a watermelon."

0842
Att~chment

/ /It'/Zr.

•

•• _ - -

-

•

••

•

'O".

., . . .

__ ,

._.

...--.-........_--..-. -..........

McH8L ISLAND CORRECTION CEHTER PHARMACY
Poe. BOX8S900

~~.,-

STBLACOOM, WA98388

512-6647

0843
Attachment

liZ,rJIZ9.·

...

...

,

Pha%mac:y Inservice Hemo

March ]"
page 2
I.

PRESCRIPTI.ON ORDERS (po..' S)
.~.

. .

,

....'

"~

..

: ..~ .... ":-

~

REQUIRED ELEMENTS ON

PER

~.

Pacient name and ID number.

2.

Birthc.at.e.

3.

~le=gies.

-

....
~

1.994

~46-87S-020 list.s minimum re~i=ec informacion on a
pa::ient: r::ec.ication record ... "Any pat.ier-~ alle==ies,
idias~c=as:es, 0= c~=onic condi:ion whic~ ~y =ela:e
c~~g ~:ili=a:ion.
I: the=e is no pat.ie~: allergy
da:a ... ir-c.':"cate nor-e or 1tN"':CA" (no k......ewn a:"!.erg-.f)
'\

" 4.

Complet.e

di=ec~ions.

~ri.C

246-"875-020 "The complete direc:ions ::er use a:': t.h.e
c..="'~S".
The ~e~ lias di=oc~=d" is ':J:-~~i=:'~Q.c. pl..:.=s~a=-_~ t.~
;tCW 13 -64245 a:'lc. 69.41. 050. II
;tC~'; ~a.:4 .2!s6 "To evs:::y bcx, bet::e, jar. t.'.!be cr ct.::e=
co=~ai~e= ef a presc=iption which is dispensec t~e=e
s~all be fixed a label beari~g ... name of t.~e presc=i~e=,
h~s ~~=ec~ions...

I'

• Prescriptions whic~ do not. list patient allergies
_Cl. ... _..... ·'se
...
..._ 1
_ • ..,
w~'
~
..... -...
a ""c.·/c- c,....- '! at-e ....11.• ...~c-~ons i=c'" m~d': ,..--.:,....""
be fille~ Sv the oharmacv. OTC items are nc~ ~(e~~~
(ac=~r=ir.c
the-State Board of ?~a~acv) becacse-~e
~~s~ precess eve~:hing h~re as a presc=lption.
.,

_

..,_ _ _

I,.;.

__

.....

..

_

_

..

:0

~.

C~rre~t

7he

medications.

p~a~a=y

computer is not tiec in to OBTS.
send the prescr~p:~cn ~d we
the PER.

~~ ~ow w~e=e to
i~fo~at.ion from

We need
ge~

t.~':"s

This is especially important i: the dosage is variable
and pm. Example: 1-2 tablets Q 4-6H pm x 1 days.
"These directions are acceptable, but a specific quancit.y
to issue must be written.

a.

Signature of prescriber.

0844

Pha:ma.cy :Inservic:e Memo
KArch 1, 1994

Page 3

* Scan each PER for these elements before turning it into the
Pharmacy. This will save time and efforts to back-track.
B.

There have been problems with changes being made on the
yellow PER but not documented in ehe profile.
Examples:
Lisinopril changed to Vasotec or Erythromycin changed to
Tetracycline.
1 . . The prescriber who makes the
on documentation.

2.
3.

4.

,..'-a

The

c~anges

c~ange

must follow

t~r~ug~

must be initialed or signed.

vWAC 246-87S-040 ... "Any order mcc~fiec in t~e sys~;~ ~~s:
car=y in the audit trail the ~~~~e ident~=i;r of t~e
oerson who modified the order ... tha~ the chancas be
accurately documented in the record syste~, w~~~ou: "
destroyi."'lg the original rec~rd or its auc.~: trail. II

The pha~acy will photocopy .a~y ~E~'s wi:~ c~a~ges a~=
put t~e copies L"'l the appropriate f=esc=~ber's box.
This is to se~·e as a reminder to :~llow t~=ough o~
c.c c:::.~e:l t a ~ i on .
USE OF

"?~rlt

ON

~~::'L

r.:NE MED!CAT!ONS

~.

If the directions are not written as'p=~, the inwa:e
will be in==acted for ~ailure t~ c~me to pill line.

2.

Consider
written.

3.

If you write for a pill line medication, be su~e to let
the inmate ~~ow this so they uncers=and t~at they ~us~

whe~he=

come to pill

D.

this is your

li~e.

~~ample:

..

_ __ .. _-...., ...
;..,-~~ ... ~-"'!""'Il

....-

--.. _'-

~_.-

Flexe=il

MISS!NG PER'S

1.

Occasionally the oha=macv does not re~=ive a PER fo=
i:ems tha: mus~ be entered on the patient's computer
profile and accounted for by inver.co=y.

2.

Commonly missed items a=e:
i~jec:ic~s, T3 tests,
meds, crash cart or ER meds, office procedures .

.3.

If in doubt, write a PER and give the yellow copy to the
pharmacy.

~ssu~d

0845 .
r /<./d/Z1

'

..
Pha:macy ::tI1service Hema
March 1., 1.994Page 4

E.

NO MEDICATIONS TO STAFF

1.

No exceptions.
Field Instruction MICC 600-025 " ... medications will not
be issued to staff members by the institution medical
department for personal use. 'I

2.

PER's written by our prescribers for staff de not meet
legal requirements of OERA regulations --according to
. the State Board of Pha=rnacy.

3.

eme=gencf aid may be rendereq pursuant, ~o pacie~~
removal from the island by bca= cr ~ed-i-vac to anot~er
emerge~cy =aci:~ty.
Example:
heart attack, stroke,
broken leg.

4.

~hese

Or~y

same regulations apply to Eeal.th Se=-"ices
':
Personal use of any medication from this
facility ~y ~ staff is prohib:'=ed.
~ersonnel.

r:-EMS A..':(.E NO~ TO E~ ISSUED FROM T~E A.F7ER - EOL-'R.S
r:r=: MA:N PEA..~PwtAcr IS OP~~.

;.. .

PEA.?_~CY

ff~!!:a

~f a stat dose is needed (other tr.an a controlled
sU=star.ce) get it from the main pcarmacy.

\:..,...a.

A

.~

?~~ ~~ST

BE

HOtJ"'RS ?F.A.~ACY

i\

~~!.~~~

FOR

~~

!TEM

~SS~:w

FROM

(OR ER) &'ID SIGNED 3'£ PA/MD.

~~

"'---

r't..: ... ::':'.. -

~

Be sure to indicaee how manv tablets, bottles, tubes,
etc.
Be specific always! . Example: Maalox 30cc prp,
Ace=arn:'~cphen 5 gr. take 1 or 2 tab~ets q4 i£ needed.
Issued. - What was issued here? Hew many?

2.

Be sure t:o write "issued" so that the pharmacy dces
couble issue t~e prescription.

3.

All of these issued prescriptions are entered on the
i~ma:e's pharmacy computer profile and the inventory
accounted for and replaced. Therefore, it is very
imporeant that these PER's are tu=ned in to the
pharmacy.

no~

0841)

Pharmacy :tnservice Memo
March 1, 1994
Page 5

C.

THE MINI-PHARMACY IS A RESTRICTED AREA.

~.

Do not use this area for a break room or to work on
projects.

2.

Do not prop the door open.

3.

Do not allow inmates physical or
area.

4.

Limi~ use of
~~ extension

~.
I •

visua~

access to

th~s

the phone in this room beca~se i t ~s o~lv
of t~e main pharmacy li~e and rescric~s the
pharmacy's ability to place or receive calls if sc~eone
is us~ng the pcc~e.
TACKLE BOX

,

1.

A sr.all ~~~~ity of various medica~icns
prepackaged are kep~ in the tack:e box.

2.

C~ly l~ce~sed p=escri~ers (?A or MO} nay la=el
mec~cat~c~s ==om ~he tackle box ~o ~e ~ss~ed
(chis is a dispens~ng fur.c~ion) .

wr.~c~

are co:

=0

~==a~s~

3.

Nurses way ecly aCrninis~er a s:ac cese from t~e ~a~Kle
bex. They may not label a package =or ~~e i~ate ~o
take wi:~ them. Nurses may not' dispense.

4.

Labeli~g a package is
:~e ~row= bags on the

~.

a dispensing f~nc:ion, th~s is wr.y
peg-board are pre-labeled.

a PER for a~y~~ing tha~ was re~oved fro~ :~e
tackle box and ~he bottle tha~ was used in the ref~ll
box under the pill line cart along wi~h the broken seal.

~eave

1.

!f a

2.

Do noe use the emergency stock for routine refills.

3.

If yeu must use an emergency bottle, please leave a no:e
for the pharmacy so that we have accountability and ca~
enter this on the appropriate computer profile and
replace stock.

4.

bc~:le of insulin is nL~~icg low, please re~~es~ a
re=ill =rom the pharmacy. Include the ir~te's nu~~e=
~~c/or prescription number.

Date all bottles when opened.
'bottle is one month old

Re~~est

a new refill if a

..-

..

'

•

Phaxmacy J:nservice Memo
HaX'ch 1., 1.994
Page 6

F.

RETURNS OR GO-BACKS VS. REFILLS
Note - there are two separate boxes in the minipharmacy.

1..

a) Put refills and PER's in the box under the pill line
cart..
b) Put retur~s (go-backs) in the box on t.he
left COr:'1er.

. . - . . - -- --I -__,- __ ,

w~ll soon
~cdicat~o~s.

We

~GENCY

.

..'-

be go~ng to a two-label
More on t~is later.

syste~

ALL

~ss~ed

for

Stock i~ the mini-pha~cy is bein; reassessed
be reduced.
Staff input is solicited.

2.

.~

'- '- . . . .. . _-,

Do not leave medicat~ons i~ the break room, ~?s:ai=5
areas, or medical records. These are not secure areas.
Put the ·items in the return box in ~he mini-pca=macy.

3.

--

far

Please i~dicate some reason for a re:~~ or so-bac~.
Leave a note or write on the label. Examoles:
~-a-s~e--=~ ,=~~ MT~C sen~ ~o ~-,,~~~ w-er~ to .I"'\...
~~._~_c_.v.,
refused, c~5contir.ued, confiscated, e~c.

2.

r ·-"T' .

cou~t.er,

a~d ~i:l

ROOM

STOC~ USED OR.ISSUE~ F~OM TEE EME~GE~CY R~CM,
OR RESPONSE BAG NEEDS TO 3E ACCO~~ED FOR 3Y ~
PER.
Exceptions: Lidocaine injections, Hydrogen ?e=cx~ce
(unless
the bot:le is issued
to the inmat.e) and toci~al
.
.
an:i-infectives used for dressings .
PF~~~~CY
C~~T,

CRASH

-

....
.,

An inven::ory of pharmacy items

in the eye

:"5

taped to the top of the box.

'.

2.

The eye t~ay will be kept sealec so that pharmacy knows
the s~ock is complete.

3.

If an item is used or issued, wri::e a PER for the
pharmacy and indicate "issued from eye tray".

0845

,H+~~hment //7d 27

.. ..
~

'0

Pharmacy l:nservic:e Memo

March 1, 1994
Page 7
IV. Pl:LL LDm ISSUES RELATED TO ISSUED MEDS

A new policy will soon go into effec~ which will require
inmates to pick up their prescriptions within 24 hou~s or
be infracted. We are waiting for policy rewrite/okay =o~
inmate notification before this becomes official.

A.

s~ar~ letting
writ~en.

1. In the meantime,

new orders are

i~mates ~ow

of

th~s

as

2. 'S;:art let~ing ne·.... chain inmates k..-:.cw.

--.

WHEN A PRESCRIPTION IS NO'!'

I~ T:~E

ISSUE BOX

. Most. o==s~=i=t:i=::s ::~=:lec in fc= ===':'ll a.=s =eac:~· b:,,'
1~:30-pi~~ l~=e, and mas: new p=esc=~~t~o~s ~~=~e~ ~~

that mo~~~g are ready by 1::30. Al~ prescrip~ic~s. a=;
finishec before t~e 9ha~acy closes (u~less ~he orde= is
tu~ed In after 3:15 p.m.).

T~er=fc=e, ~=

some:~~ng appe~rs to ~e ~issing cr no~
filled, make a =ote of i~ so c~at it can be t=acke~ CCH~
or call ~~e pha~cy du=~~g nooc ?~:l ~~~e ~= ~~~e
~ll-::'''''s .

3.

!t is not

ac=e=t~le ~o ~e~l

the

in~a~e

to c=eck

~a=~

late~ w~=hou~ fcllow-u~ because c::en the c=de= c~c ~==
ge~ pulled from t~:.prOfile, .o~ a~ order was C?t

wr~t:e~,

or

t~e

=e:~ll

bag

d~d ~Ct

get

tu=~ee ~r. ~o

t~e

pha~a=y.

4: .

I:

:~= SOGle

reas=~

==e

~ha~acv

ca~~=~

f~:l

o:::esc:::.-i=tion (~ecause it is too soon, or an
oreer, etc), the ?ha=.nacy will wrice a note
inma~e ·.... ~ich ~ill ~e ?ut ~n the issue box,

a
~tem

:.s

to. t:~e

r'H:'-"-:;'U':1ent

0849
,I /qtJjZf

Fra~

MCNEiL. ISLf
CORRECTIONS
PO BOX Sa91O~
STEILACOOM, WA 9S3SS
.r.!I~.1
as of
NOe I : 00172-2907-80

12/19/94 through OS/25/95
for : FUROSEMIDE 40MG ZENITH

ntity an hand: 7S7
~cnedule : &
~ackage Si:e:
1000

.....********************************************************************++*********************
+.~++**~*******+****************

Patient Inforsation
Phar':aacist

R~ numoe~

I

Price

Doctor Infor:aation

Date' Filled

QlJan~i~

..........************++++***********************************************************+****+**.~
•
•*++++**+***************************

~!G

-) STAT DO~CKLEBOX
211175 . ~
0.02
L/J
M ICC
HOLD

_.

12.17.94
BARTRAM, PA/CPE

~S

BB172500i

a. t'"\

n---~ c.c...~C

1

,

:r.d of audit trail - Total quantity dispensed

* Ih.\ ~

)f
12/1~/'14

r-.

\;l/ ,,/qy

<:!. 'r"\~

't> clo-J.L.

~~

=

e-. ~

OC---te-o..1 1

A-4-u..t"cJ...o..~

1

0

c..Crr-.

\~SLs...Q.cl

fLee..:CY--.

od"A (b.&1:.'.

(jU'~

('j 850

'l"~-':~;;lent

.

/

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.

,,~

&I

·.
.',:

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~..

,

,.~",
~

.~

~

/r'
"

~:"".,

~".:.'.'
\'

.'

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,_

.'

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,

"

.

,

MCNEIL ISLAND CORRECTIONS
DELIVERY RE~ORT FOR : 08/01/1995
FACILITY
CITY, ST, ZIP
PHONE
BEDS

RU

ROOM NO.

M ICC
STEILAcaOM,WA
206 -588-528 1
1 TO 2000

98388

DRUG NAME

PATI:::NT

QTY

*************+****++*******************++****
ANALGESIC BAw~ 30GM FOU
DIMETAPP EXTENTABS
IBUPROFEN 600MG BOOTS
CYCLOBENZAPRINE 10MG 56
PHENVLGESIC TAB
ACETAMINOPHEN 500MG
MC~7~MrNO~HEN

5~0MG

30

10
20

{Jr

~C~Er

500MG ~C~E:
~SEUDCE~~EJR:~E S0MG GL
TnI~MTE~ENEJhCTZ 75/50 3C
5ENZ~YL ~E~CX.GEL l~~ RUG
AC~TAMrNOPMEN

E;Y-T~B

~~AL~X

:::Zl0MG
5uS~ENSIGN

5 OZ.

~~VTtrt:V

,/'Y'I'vC'-/'!J;t.'u

~ /~ULJtl.. :.~ YO-;

0852
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CHASE R'VELANO
Sect4lary
STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
McNEIL ISLAND CORRECTIONS CENTER
P. O. Box 900.

StStlaCQom. Washlngron g8388,09CO

July 13, 1995

T~~: ~SP Gteation ~tion

Fr?~oper,J'corr~nal'tnvestigator

Subject: Identification of Fingerprints

This office is currently conducting an investigation into stolenimissing medications from
the Mini Pharmacy, McNeil Island HospaitaJ.
Between 05-25-95 and 06-27-95, person(s) unknown have removed a total of
approximately
tablets from a vial containing furosemide 40mg tablets. This vial is
kept in a tacklelJox, which is sealed, and is behind locked doors of the ~fini Pharmacy.
Every time the seal of the box is broken the contents of the 'box is counted by th~
pharmacis~ and m~t is who discovered these tablets to be missing.

¥e

This office is submitting the vial that contained the tablets to see if fingerprints can be
lifted from it, and also a list of all personnel that have access to the Mini Pharmacy
for comparison to any prints found on the vial.
List of personnel having access to Mini Pharmacy:
~

........... Roben Cloke
Harper Buck
~ Bruce Barrett
Perry Bartram
Lynn Housewonh
Dinah Sacav
""'" Ricky Silv~rman
Patricia Callaghan
Nancy Armstrong
Patricia Arnold
Sherre Badders
William Dalton
Pamela Davenpon
PrimaDonna Ems

~

DQB.

5-12-38
7-13-34
8-6-42
1-6-45
1-1-48
3-24-50
7-31-45
12-25-46
5-28-46
10-29-21
1-2-54
11-5-42
8-29-52
10-29-57

0854

:·.~::.:hment

.
I t3t?:j21

............ Kenneth Haire
""'- cMoIHoke
Lenora Horton
Barbara Jackson
Donna Lake
'Judy Lobdell
~

~ Kim Mattson
Deena .Oestman
Yosbi Parker
.......... Sharon Stephens
. . . . Diana Stoddard
-...... Sherry VanHorn
Linda PaulsOn
.......... Jan White
Dennis Noel
Maurice Emery
Sherry Race

6-2243
4-1543
11-7-54
1-16-47
7-2748
4-27-55
OQB.
5-13-60
2-4-52
10-14-50
2-1-62
7-23-66
11-748
5-21-55
1-7-52
9-7-55
8-10-52
3-23-45

That is the complete list of personnel who have known access to the Zvfini Pharmacy.

Thank you for your asistance in this matter.

08~

t-"t~chMent IZ/!tiZtt

Washington State Identification Section
PO BOX 42633
Olympia, WA 98504-2633
~elephone

Date Received : 08/16/95
WASIS LP #
: 95-12448
Agency case #
Ol0095IOl

(206) 705-5128
LA~ENT PRIN~

Requesting Agency : MCNEIL ISLAND CORR CNTR
By : JIM COOPER
Address: P. o. BOX 900 STEILACOOM WA 98388
Evidence Description

Title

REPORT
Agency No.
INVEST

WA02706SC

7-LATENT LIFTS.

Received:
Processing

MAIL (Certified #
Requir~d:

UPS reg. #

~N

) IN

Type

P~RSON

_

~y

-----------------------------------------------------------------------------------------------DOB

suspects:

DOB

05/12/38

01/06/45

07/13/34

01/01/48

08/06/42

03/24/50

------------------------------------------------------------------------------------------------

Examination Results:
The latent lift I marked "1" contains one identifiable latent
impression whi=h is identified as the right palm of Donr.a EV~~S,
~~/ TU~lER, WL~, deb: 07-23-48.

The latent lift I marked "2" contains one identifiable latent
impressicn which is identified as the right palm of EV~~S. The latent lift
I marked -2" is a relift of the latent lift I marked "1-.
The rem~ining lift contains no latent impressions
identification purposes.

0:

value for

The three lifts were recovered from pill bottle 11.
The latent lift I marked "2" contains one identifiable latent
impression which is negative in comparison to the inked fingerprint and
inked major case prints of all suspects.
The three remaining lifts contain no latent impressions of value for
identification purposes.
Date 08-30-95
Date 08-30-95
Date 08-30-95

"Examiner
Eileen Slavin
Reviewed By Geor e C. Millar
Reviewed Sy Robert S. Johnson
Photo Taken:

~Y

By SLAVIN

If examination and comparison of this evidence will require a court appearance,
at least one week's notice is necessary for the preparation of presentation
materials.

Washington State Identification Section
PO BOX' 42633
olympia, WA 98504-2633
Telephone (206) 705-5128

Date Received
WASIS LP #
Agency Case #

08/16/95
95-1244B
010095IOl

LATENT PRINT REPORT
Requesting Agency

MCNEIL ISLAND CORR CNTR

Suspects

OOB

Agency No.

WA027065C

(Continued)

07/31/45
12/25/46
OS/28/46
10/29/21
01/02/54
11/05/42
08/29/52
10/29/57.
06/22/43
04/15/43
11/07/54
01/16/47
01/27/48
04/27/55
05/13/50
02/04/52
10/14/50
02/01/52
01/23/56
11/07/48
OS/21/55
01/07/52
09/07/55
08/10/52
03/23/45

~xami~aticn

Results :

(Continued)

The four lifts were recovered from pill bottle #2.

085{

IUZ29

MCNEIL
PO BOX

Sep " , 1'1'15

F'.111

li~;:

ing

IS~ND

STEI~COO/l1

~
History
~

'- .•REcnONS

aa~00

WA

~S38a

Roo": HOLD
DOB : ·01/e1l1q01

It:

+.*.*~.+~~*~**~++***++***++++++++*+**+*++
••+*****++*++*+*+*••+*++++.+++
Rx no

Drug name

NDC It

Date

RiF Doctor

Qty

Price RPM

**++*+++*++*++*++*+**+*+++++++++++~+**+++·+***tt++++****+********+++++*++++***+

211175 001722~0760 FUROSEMIDE 40MG ZE 12/1~/~~0
BARTRAM,
Slg-}STAT DOSE GIVEN FROM TACKLEBOX 12.17.94
a10~~4 0e172290780 FUROSEMIDE 40MG ZE 1~i15/~4 ~
HOUSEWCRT
Slg-IT1T QAM PL
210920 00574000210 ASPIRIN EC 325MG
12/1~/~4 0
HOUSEWORT
Sig-) (ISSUED BY PA)12.14.94
210919 00641036225 FUROSEMIDE 20MG/2M 12/15/~4 0
HOUSEWORT
Sig-)20MG INJECTION GIVEN 12. 14.~4
210903 00187074&31 INSTA-GLUCOSE
12/14/940
HOUSEWORT
Sig-) (ISSUED BY PAi 12.14.94
~10731 0130060713&8 11ASOTEC 10111g
12/13/C;4 0
SACAY, PA
Sig-)T1T BID -NOTE INCR~qSE IN STR~~GTH210635 001722~0780 FUROSEMIDE 40MG ZE 12/12/~4 0
SACAY, PA
Sig-)1 TABLET <40 MG) GAM DURING DIABETiC PL
210634 00172290760 FUROSEMIDE 40MG ZE 12/12/C;~ 0
SACAY, PA
Sig-) ISSUED STAT DOSE FROM PHARMACY 12.12.94 AT 1&45/ME
210521 00172290780 FUROSEMIDE 40MG IE 12/12/C;4 0
SACAY, PA
5tg-}1/2 TABLET 120MG) STAT DOSE GIVEN
2'a~~23 001a7~74631 rNSTA-GLUCOSE
12/0S/Q4 0
SACAY, PH
5ig-} <ISSUED BY PAl 12.4.Q4
20q770 001ai0740~1 INSTA-GLUC~SE
12!01!~* 2
MOUSE~ORT
Stg-)PRN FOLLOW DIRECTIONS ON T~BE
<Cash)
la/05/~4
~C~S~!

4
20

1
&2
20
3
1
1
02
02
62
2

12i0~/~~

00003183310 NOVOLIN REGULAR (H 11/2~/C;4 0
Sig-)FOLLOW DIABETIC LOG SHEET
20C;5~1 00002631501 HUMULIN NPH INSULI 11/2~/C;4 ~
Sig-)FOLLOW DIABETIC LOG SHEET
20QS85 00574000210 ASPIRIN EC 325MG
1~/2~/C;4 0
Sig-}T1T QD~MAY T 1-2 GeM PRN
2'a~S83 00456032501 LElJOTHYROXINE 0.15 11/2,,/C;4 111
Sig-}T1T QAM
2~~S78 ~0~0&07126a VASOTEC Sag
11/2~i~~ 0
5ig-)T2T GAM & 1 TABLET HS
20~574 001722Q07S0 FURCSEMIDE 40MG ZE 11/2~/C;4 111
5ig-)T 1/2 TABLET <20MG) QAM
End of proflle-------Toeal Charge1 = ~
11S.75
Total Credl~S = $
~.00
20~5~b

0.~2 L/J

1

I

BUCK, MD

10

BUCK, MD

10

BUCK, MD

40

BUCK, MD

30

(Cash)
0.09
<Cash)
0.14
(Cash)
0.75
(Cash)
4.77
(Cash)
19.15
(Cash)
0.06
(Cash)
0.02
(Cash)
0.02
<Cash)
4.77
(Cash)

LIS

L/J
LIS
L/J

LlA

ME
ME
LP.
L/J

0. 1= L/A
,Cash)
4.77 L/J
0. 15 L/~
16.32 MIA
(Cash)
14.83 MIA
(Casn)
0.29 MIA
,Cash)
&.72 MiA

(Cash)
BUCK, MD

50

45.5~ MIA
(Cash)
7
0.15 MIA
(Cash)

BUCK, MD

lta.75

}f

e." 1-<" '3

Oc-~

C l'"

'oe..\ov.' -:

c.er-w-~\"'-~~

-

o.c...~c.... d..~fel"\~'2.... dc-~

\~/ll/'iLt - So.."h..s...t"OOtY

.

\~

\:~

Jct 03, 1q95
:ro.:05.01.95 To:08.03.Q5
~ ICC
_
iistory I:

MCNEIL ISLAND CORRECTIONS
PO BOX SS900
STEILACOOM WR 9838S
Room: In9
DOB : 03/24/19~8

~**

•••••• " ••••• ""~***********************'*I*"'*********************1*1****

~.*

••••••••••••••••••• *****.* ••••••**.* •••*********++*********•••••****** •• ****

Rx no

NDC 1

Drug name

Date

R/F

Doctor

Qty

Price RPh

22Q964 0007477&313 POTASSIUM CL 10MEa 07/2&/95 2 BRRTRAM,
10
3.37
Sig-)TIT aD PL
(Cash)
(Cash)
08/02/95
10
3.37
2299&3 00172a~0780 FUROSEMIDE 40MG ZE~07/2&/~5 2 BARTRAM,
5
0.11
Sig-H 1/2 TABLET (20MG) DAILY PI_ '--~.
(Cash)
(Cash)
08/02/95
5
0.11
229S90 00182175110 TRIPROL/PSEUOO TAB 07/25/95 0
BUCK, MD
20
0.45
Sig-)T 1/2 OR 1 TRBLET Q6H PRNF HAY FEVER
(Cash)
228190 001S2175110 TRIPROL/PSEUDO TAB 07/03/95 1 SACAY, PA
&
0.13
Sig-)T 1/2 TABLET Q6H OR 1 TRBLET BID ( Q 12 HOURS) PRN
(Cash)
07/10/95
6
0.13
(Cash)
227949 0007477&313 POTASSIUM CL 10MEQ 06/29/95 1 SACAY, PR
15
4.63
Sig-)T1T QD ON AM OR NOON PILL LINE (STRRTING &/30) PL
<Cash)
(Cash)
07/13/95
15
5.0&
227947 001722Q0780 FUROSEMIDE 40MG lE1f&/29/9S'2 SACAY, PA
5
0.11
Sig-)T 1/2 TABLET (20MG) QD ON AM OR NOON PILL LINE <STARTING••• (Cash)
<Cash)
07/13/95
5
0.11
(Cash)
07/05/95
5
0.!l
End of profile-------Total Charges = $
17.75
0.00
Total Credits = $
:ash

A/J

L/J

A/J
L/J

ME
MID
L/J

MID
MID
M/D
MID
MID

17.75

085~

Oct 04,

1~~S

Fro.:0&.2~.9S

To:10/04/95

~

C'R'O~'~--::)

MCNEIL ISLAND CORRECTIONS
PO BOX a8900
STEILACOOM WA 98388

~istory t: tIIIIIIIII
DOB : ~3/31/1~33
*********** ••••****************************************************************
Rx no

NDC t

Dryg name

Date

RIF Doctor

Qty

Price RPh

+*+*** ••••••• *******************************.****•••••••*•••• 1 • • • **************

231&8S ~0172290780 FUROSEMIDE 40MG z~ 0 SILVERMAN '7
0. 15 LID
Sig-)T 1/2 TABLET (20MG) GAM
.
(Cash)
2304~~ 00172290780 FUROSEMIDE 40MG Z~· 08/01~ 0 BUCK, MD
11
0.24- LID
Sig-H II? (20MG) GA~ PL
,-.
--....
(Cash)
230340 00172290780 FUROSEMIDE 4-0MG ·Z~ 07/31(,j$ 0 BARTRA
_ 06 LP'.
Sig-)TIT DAILY IN THE MORNING OR NOON FOR 3 DAYS BEGINNING 07 ~~ ~h)
230069 00677112501 AP~P/ISOMETH/DICH 07/27/95 2 BARTRA,
~
. 2 ME.
Sig-)M I D R
(Cashi
230067 00067033079 MAALOX SUSP~~SION 07/27/95 6M BARTRAM,
150
0.39 ME.
Sig-)SW AND T 2 TSPS aID (MAY REFILL ONCE A WEEKJ
(Cash)
228216 00045045170 ACEiAMINOPH8~ 500M 07/03/95 1 SILVERMAN
20
1.18 MID
Sig-)TIT GO PRN PL
(Cash)
(Cash)
07/19/95
20
1.18 MID
228015 00173034442 ZANTAC 150MG
. 0G/30/~5 5 SILVERMAN
30
49.60 L/J
Sig-)TIT GAM & EVENING PL
(Cash)
(Cash)
08/15/95
28
46.29 LID
(Cash)
08/0"2/~5
30
4~. &0 LP.
(Cash)
07/13/~5
30
4~.&a ~:D
228014 57267090542 NITRO PATCHES 0.2M 06/30/95 5 SILVERMAN
15
21.91 L/J
Sig-)AP 1 PATCH QAM ,WEAR FOR 12 HOURS, THEN REMOVE PL
(Cash)
08/15/~5
14
21.27 LID
(Cash)
(Cash)
08/09/95
15
22.78 LI J
(Cash)
07/2&/95
15
22.78 MID
(Cash)
07/10/95
15
21.91 L/J
228013 0002&884151 ADALAT CC 30MG E/R 0G/30/~5 5 SILVERMAN 30
2&. 11 LIS
Sig-)T2T GAM PL
(Cash)
(Cash)
08/15/95
28
24.37 LID
(Cash)
08/09/95
30
2&.11 LID
(Cash)
07/2&/95
30
2&.11 MID
(Cash)
07/13/~5
30
2&.11 MID
228012 00781137101 METOPROLOL 50MG GE 0&/30/95 5 SILVERMAN
15
&.6~ L/J
Sig-)TIT GAM PL
(Cash)
(Cash)
08/15/95
14
&.25 LID
(Cash)
08/09/95
15
G. G9 LID
(Cash)
07/2&/~5
15
&. &9 MID
(Cash)
07/13/95
15
G.69 MID
227901 00071057013 NITROSTAT 0.4MG iZ 0&/29/95 3M SACAY, PA 25
3.51 DIM
Sig-)TIT SL PRN FOR 90 DAYS
(Cash)
08/15/95
25
3.51 LID
(Cash)
227900 000&7033079 MAALOX SUSPENSION 06/29/95 1M SACAY, PA 150
0.39 DIM
Sig-)TAKE 2 TSS a4H PRN FOR 30 DAYS
(Cash)
150
0.39 MID
(Cash)
227899 00172290780 FUROSEMIDE 40MG ZE 0&/29/95 2 SACAY, PA
10
0.22 DIM
Sig-)STARTING 6/30 TIT GO FOR 30 DAY
NING OR NOON PILL••. (Cash)
07/13/95
10
0.22 MID
(Cash)
(Cash)
07/05/95
10
0.22 MID
End of profile-----:-!o~a: Charges = S 480.24
At~~chiT1ent

08EO

.

"

,

.1

Pharmacy InseJ:Vice Hemo
Harch 1., 1.994
Page :2
1:.

PRESCR1:PT1:0N

1..

Patient name and ID number.

2.

Birthdate.

3.

·Allergies.

~~46-875-020 lists mi~imum required infc=mation C~ a

-- .

record. '" II A..-:y pa::ier:t alle==:'es,
idiosyr.c:::as:'es, or chronic condition whi~~ may relate -'"
~_...:'.:-a ...--~on
T~ \..•
"""e-~
~_u.,:: ....... -:--.:7
"
_.:.
-- is .no ='~a"'';':''''c.
.... __ ••• a"lo-~
, ----?=.
"
da~a. , . :.::c.:.-::ate none 0::: "N':{A II
(no k.."1c·....n a..:...:.erS"'iJ
pa::ien~ r::ec.:'~ac.ion

\

r.
~

;

,~

....

(PElt' s)

REQUIRED ELEMENTS ON E.AQl PER

.~.

.

ORDE..~

--

.. 1 . .

.'

. 4.

Ccmple~e

c.:'rectiens.

W~C 2~G:a75-020 n~e c~molete

c.:-,,~g.

direc::icr.s fer use

0=

::~e

The :e~ "as di=ect:ed u is ~=-:Jh'::'=:'t:~~ pu=sua::.:. to

:tCI"'i !. 3 - 6 ~ 2 4: :)

and 69.41. 050 . II

:<.~;.;

13.64.2.0;;0 liTo e"-a=1J' bex, bct~:;'=: "';a=, t"~e c= ct:.::'e=
co~tai:1er of a prescription.whic~ is ~i:pe~sed ther 7.

s~all ~e fixed a label
his c.i:::ec::icns ... "

•

bea=~~g ...

r.ane

Prescriptions which do not list

t~e

prescr:.=er,

•
_
..J ...... _ _
.........
__
.........
_~o~
_
_
_ _ 0.'-_....
c~-~'Qte
~~-cc-~o~s
moc.·i~--~~n
a •~~/o-

allergies
__
_.....
use w~'l
-0·

..J

•• _ _

pa~ient

~

..".
_ ..__ pha--~cv
• • lr.cJ, • •
~e ~~,,=~ ~'J
~"Q
_~.

(ac=o:::~ing ::0 the Stac~
~s~ ~:::ocess eve=V:hin~

-

5.

0=

~~::::::er.t

-

.1.
_:.._
••,
O~C
~-~~s

--0

CL _ _

~n~

.. _ •••
e·<o~~-

Beard ef Pha~acy) because we
here as a p:::esc:::i=tior..
-

-.

-

medications.

T~e pha~acy computer is not tie~ i~ ~o OETS.
We
to ~cw whe:::e to send the presc=ip:ic~ ~~d we ge~
i~=o~a~ion from the PER.

7.

~'-

~eed
t~is

Spec:':ic quantity to be dispensed.
This is especially important if the dosage is variable
and pm. Example: 1-2 tablets Q 4-GH pm x 7 days.
'These directions are acceptable, but a specific quantity
to issue must be written.

8.

Signa~ure

of prescriber.

8S61

Phaxmacy Ins ervice Memo
Karch 1., l.g94

Page 3

* Scan each PER for these elements before turning it into the
Pharmacy. This will save time and efforts to back-track.
B.

There have been problems with changes being made on the
yellow PER but not documented in the profile.
Examples:
Lisinopril changed to Vasotec or Erythromycin changed to
Tetracycline.
~.

2.
3.

. The prescriber who makes the change must
on documentation.
The

c~anges

must be

i~itialed

fo~lo'''''

tl:::oug:::'

or signed.

.....WAC 24:6-875-040 ... ".:my o::cer moc.if:"ec. in. t::e s::s~e!':\ ",1..:.5:'
ca::::y in the audit t::ai~ the unique identi:ie::
t~e
oerson who mcci:ied the crde:: ... thac the chances be

0:

accurately documented in the record syste~, wi~~out"
dest=oy':ng the origi:lal ::ecord or its audit trail."

USE OF

C.

1.

2.

II

?R.N" ON

__

?::.~

\...

LINE

__ ._

... _

::- _ _

..... _ _ ....J

_

~J)!CAT!ONS

!~ the directicns a::e not w::itcen as'p::n, the
will be i:l:=ac=ec. fer failu::e to ccme to pill

Co~side= whet~e~

a==

.

_

_

_

_

...

~

will photocopy a ..y ~$~'s wi=h c~ar:.ge5
put t ~e coo~es ;~ ~~e a~~~otl'~':a~~ ~-~s--':~e~'s ~~x
This is to se~Je as a remi~der to :o:low th::ough c~
,1oc~=e:'l~a:ic::'
..
~

T~e pha~cy

~

4.

this is ycu=

i~ate
li~e.

in:=~~i=~ ~~e~ =~

is

w::itten.
3.

D.

If you w=ite for a pill line medica:ion, be s~=e to le~
the inmate ~~cw this so they understand that chey ~ust
come to pill li~e. ~~ample: Flexe::il

MISSING PER'S
1.

Occasionally the pharmacy does not receive a PE~ fo::
items that must be ente::ed on the pa:ient's compute::
profile and accounted for by invento~.

2.

Commonly missed items are:
meds, c=ash car: or ~~ meds,

.3.

I: in doubt, write a PER and give the yellow copy to the
pharmacy.

injectic~s, TS tests,
of~ice procedures .

iS5U=.d

086~

Pharmacy l:nservice Hema
March 1, 1.994
Page 4

E.

NO MEDICATIONS TO STAFF

1.

No exceptions.
Field Instruction MICC 600-025 " ... medications will not
be issued to staff members by the institution medical
depart.ment for personal use."

2.

P~~'s written by our prescribers ~or staff do r.ct meet
legal requirements of OERA regulations - 'according co
. the State Board of Pha=macy.

3.

Only emergency aid may be rence=e~ pursuan~ ~o pat~=~=
re~oval from the isl~~d by boac cr ~ec-i-vac to anct~e=
eme=gency facility. Example: hea== at~ack, s~=oke,
b:::-::ken leg.

4: •

These same reculations aoolv to Healt:l Se=-vices
oersor.nel. Personal use-of·ar.v medication from this
facili~y by gny staf= is prohibited.

-.

I'"

No

ex=e~tior:s.

I~EMS ~~E

.r\..

NOT TO BE ISSu:m FROM

WHILE T:-!E MAIN

PEA..~cr

~3

A=~ER-:Ot7~

?EA-~~CY

IS OPEN.

If a stat dose is needed (otne= thar. a controlled
get it from the main pharmacy .

subs~ance)

y. .

A PER
HCu~S

1\

~uST 3E'WRI~~
?~CY

FOR ANY ITEM ISSU-~ FROM
(OR ER) AND SIGNED BY PA/MD.

~~~ A:--~~­

:.

Be sure to indicate how manv tablets, bottles, tubes,
etc. Be speci=ic always! . Example: Maalox 30cc Pql,
Ace=amincphen 5 gr. take 1 or 2 tablets q4 i= needed.
Issued. - Wha~ was issued here? How many?

2.

Be sure to w=i~e "issued" so that: the pharmacy does no::
couble issue the prescription.

3.

All of these issued presc:::-iptions are entered on the
inmate's pharmacy computer profile and the inventory
accounted for and reolaced. Therefore, it is ve=y
important that these-PER's are turned in to the
pha=macy.

(186'3
. ~tt~chmer1t

2· 3;)6 h_

Pha.:macy J:nservice Hemo
Harch 1, 1994
Page 5

c.

THE MINI-PHARMACY IS A RESTRICTED AREA.
~.

Do not use this area for a break room or to work on
projects.

2.

Do not prop the door open.

3.

Do not allow inmates physical or visual access to
area.

4.

Limic use of the chone in this room because i~ is o~lv
~~ extension of the main oha~acv line and =es~=iccs ~he
~ha~~cy's abi~ity to place or receive cal:s i= sc~eone
~s

~ ~.
'~.'

~s~~g c~e pco~e.

sex

T;"C~LE

1.

-., .
3.

A s~all ~ancity of various medications
pre;ackaged are kept in the tackle box.

~~ic~

are nc:

o~:v licer:.sec. c=esc=i~ers <?A cr :-ID} ~a'J' la:.el
rned~cacions from che tackle box ::0 ~e iss~ed ::0 ~~~a~=s
(~~is is a dispensi~g f~~c::ion) .

Nc=ses
~cx.

~ay c~~y ad~~~iste=
T~ey

a

s=a~

may noe label a package

cake wi::h chern.
4.

th~s

ccse

=c=

==cm
the

=~e

~a=kl=

i~mate ~o

Nurses may nce-dispense.

~a=eli~g a package is
:he ~row~ bags o~ t~e

a dispensi~g :~~ction, this is why
peg-beard are pre-la=eled.

-""a'- O a -':;'r ... ,t(. -.
~o'"
a"'y"hi..,-e
...
II,."'-._::J tna"
•• _ was -_....
-~"'oved 1:__ 0 ",
'.r. "n""
_ •• w
cackle bex and the bottle thac was used in the refi.llbox ~~der ~he pill li~e cart along with che broken seal.
~1l;;;iO

,,_

1.

!: a bcc:le of insulin is ru~_~i~g low, please re~~esc a
refill =rom che pha=macy.
Include the ir~te's nu~~er
a~c./cr prescription number.

2.

Do not use the emergency stock for

r~u:ine

refills.

!=

you muse use an emergency bo::le, please leave a no:e
for :he pharmacy so chat we have accouncabilicy and can
encer this on the appropriate computer profile and
replace scock .

.
'

4.

Date all bottles when opened.
bottle is one month old

Request a new refill if a

0864
Z. .t/ ~~ h

...
•
pharmacy J:nservice Memo'
)!arch 1., 1.994
Pa.ge Ii

F.

RETURNS OR GO - BACKS VS. REFILLS
~.

-

chere are Cwo separaCe boxes in Che miniNoce
pharmacy.
a} PuC refills and PER's in the box under Che pill line
care.
b) Puc retu~s (go-backs) in che box on ehe COlmter,
'left corne:.-.

fa::-

2.

Pleas~ indicate some reason for a re~~~ or go-back.
Leave a note or write on the :abel. Examo~es:
~=a=s=e==ec, left:. M!Ce, sent to F-\.:.:l:'=, f"e::~ t.o A.::::'=:~,
ref~sed, c~scontin~ed, cenfiscated, e~=.

3.

Do not leave mecicat~ons in the break =co~, ~ps~a~=s
areas, 0= medical records. These a:.-e nee secure areas.
Put t~e 'items in the return box in ~~e mini-pharmacy.

w~ll soen
mec~=at~c~s.

We
2.

be go~ng to a two-label
Mc=e en this lat~=.

sys~eo

:or

Stock ~n the mini-pha~cy is bei=g reassessed
be reduced. Staff input: is solic~:ec.

~ss~ec

~~~ ~i::

I::.

.....

A~L PF~~~CY STOCK uSED
C~Sr. CA-~7, OR RESPONS~

OR.ISSUED F?OM TEE EMERGENCY ROCM,
BAG NEEDS TO 3E ACCOu~~~ FO~ 3Y ~
P~R.
Except~ons:
Lidocaine injeceicns, Hyd=ogen P=r~xice
(unless the bottle is issued co the inmate) and topical
an:i-i~fec:ives used =c=·dress~ngs.

....
,

~,

inven:o~f of pharmacy items kept in the eye tray
taped to the top of the box.

~s

2.

The eye ~=ay will be kept sealec so that pharmacy knows
the s:ock is complete.

J.

If an item is used or issued, write a PER for'the
pharmacy and indicate "issued from eye eray".

8865

t 5 tb
0

..-, ..
~

Pharmacy Inservice Hemo
March 1., 1.994

Page 7

rv.

PILL LINE ISSUES RELAXED TO ISStT.ED DDS

A.

A new policy will soon go into effect which will require
inmates to pick up their prescriptions withi~ 24 hours or
be infracted. We are waiting for policy rewrite/okay :or
inmate notification before this becomes official.
•
1. In the mea~time, start letting inmates
new orders are writ~en.

~ow

of

t~is

ss

.-..
Mos~ ~=ss::=~;t:.::::=.s
1~:3a

::':'=:1ec in

~i:~

::0=

===:'11 a=e ==ac!·

,:j:'

li=e, and mos: new pres=ri?cic=s c~==ec ~~
thac ~c==i=g are ready by 11:30. A~~ prescripciC~3. a=~
fi~ished be=ore :~e pharmacy closes (~nless c~e o=~e= ~3
:u~ed ~= after 3:l5 p.m.).

Tnere=cre, if sc~ec~ins appears to =e ~~ss~=: cr ~=:
filled, make a ::oce of ic so· t~a:: :':. ca:: ~e ::ra=:':e~ ,:::::..,,~
or ca:l :'~e pha=.Macy during noor. p:':l l:'=e if :i~e
a:l=",rls.

3.

•

It is ==~ ac=e~table to tel~ the ~~~a~e ~~ c~eck =a=%
lacer wi:.~oue follow-u~ because of::en the order c:..c .~ ... _
__
J::I'----_..." ..
\,.•
'" ....
t.1'~,4 ..
&:--m
"\.oe
"""....-or'; '::0 or a- 'o--'le- "as ,...- ..
ce
w=it=e~t 0= ~~e =2=ill bag d~d ~ot get tu=~ed ~~ ~o :~e
.A.

~

I

_.

_~..;..

>ftI

•• _'-

pha~a=:.'.

I:: :~= s=~e ~=as~~ :~e oha=macv ca~~oc f~ll a
pres==i;:ion {~ecause i~ ~s too soen, or an ~~em is
o=de=, e~c) :he pha~cy will w:~~e a noee to_ e~e
i~r::a :: -= ~·J:"i en. w~ll ce pu~ ~~ the issue box.
I

246-838.020

P.r:u:dc::l1

to meet the basic needs of the client. and gives nursing c:JrC
under the direction and supervision of Ihc registered nurse or
licensed physician to cJienrs in routine nursing sinwions. In
more complex siw:uions the licensed practical nurse functions as an assisunt to the registered nurse and c:u'ries OUt
selected aspects of the design:lled nursing regimen.
A routine nursing siwation is one that is relatively free
of scientific complexiry. The c1inic:lI and behavioral state of
the client is relatively suble and requires abilities based
upon a comparatively fixed and limited body of knowledge.
In complex situations, the licensed practical nurse
facilitates client care by meeting spet:ific nursing requirements to assist the registered nurse in the performance of
nursing care.
The functions of the licensed practical nurse makes
practic:1l nursing a distinct occupation within the profession
of nursing. The licensed practic:1l nurse has specific roles in
nursing in diret:t relation to the length. scope and depth of
his or her fonnal educ:ltion and experience. In the basic
program of practical nursing education. the emphasis is on
direct client care.
With additional prepar.nion. through continuing education and practice. the licensed practical nurse prepares to
assume progressively more complex nursing responsibilities.
(Sl.1lUIOry Aumoril)': RC.v 18.78.050. 91-01./)78 (Order 1098). t=ldilied
§ 246·838..:)20. riled 12117190. elTccuvc 1131191; 8~1~1 (Order PL
4S2). § 308-117-020. filed 12I19I8J. Formerly WAC 308-116-010.1

:IS

'-

Nu~

(2) The licensed practiC:11 nurse sh:1l1 practice Pr:lCtical
nursing in the state of Washington only with a current
Washington license.
(3) The licensed practic:l1 nurse shall not pennit his or
her license to be used by another person for any purpose.
(4) The licensed practic:U nurse shall have knowledge of
the statutes and rules governing licensed practic:l.l nurse
pr:lCtice and sh:1l1 function within the leg:1l scope of licensed
pr:1ctic:1l nurse practice.
(5) The licensed practic31 nurse shall not aid. 3bet or
assist any other person in violating or circumventing the
laws or rules pertaining to the conduct :lnd pr3ctice of
licensed practic:l1 nursing.
(6) The licensed practical nurse shall not disclose the
contents of any licensing examination or solicit, accept or
compile infonnation regarding the contents of any ex:unination before. during or after its administf:ltion.
(7) The licensed practic:1l :1urse shall delegate activities
only to persons who are competent and qu:1lified to undertake and perform the delegated activities, and shall not
delegate to unlicensed persons those functions that are to be
perfonned only by licensed nurses.
(8) The licensed practic:l1 nurse. in delegating functions.
shall supervise the persons to whom the functions have been
delegated.
(9) The licensed practical nurse shall act to safeguard
clients from unsafe pr:lCtices or .:onditions. abusive acts. and
~~

WAC 246-838.026 Mancbtory reporting. The board
of practical nursing docs not intend to C:luse ever! nursing
error to be reported or th:lt mandatory reporting mke away
the disciplin:u-y ability and responsibility from the employer
of the pr:lCtic:l1 nurse.
(I) Any llerson. including health C:lre facilities and
agencies and state or local government. who is aware of a
conviction or has made a determination or finding that a
practic:1l nurse has committed an :lct constituting unprofessional conduct as defined in RCW 18.130.180. including
violation of c!lapter 246-83S WAC. shall report such
conviction. determination or finding to the board.
(2) Any person. including health c:l.re facilities and
agencies and smte or loc:1l government. who has infonnation
that a pr3c:ic:1I nurse may not be able to pr3ctice with
reasonable skill and safety as a result of a menw or physic:1l
condition. shall report such infonn:1tion to the board.
(SwulOry AUlhonlY: RCW 18.78.0S4 3IId 18.130.070. 91-IJ~..J (Order
•758). § 201(j·8J8-oZ6. filed 6111191. e{(cclivc 7/'~1.1

~

WAC 246·838·030 St:lndards of conduct for
discipline. The sundards of conduct for discipline serve as
guidelines for the licensed practic:l1 nurse. Violation of these
standards may be grounds for disciplinary action pursuant to
RCW 18.130.ISO(i). The licensed practic:l1 nurse assumes
a measure of responsibility. trust and the corresponding
obligation to adhere to the standards of conduct, which
include. but are not limited to the following:
(I) The licensed pr:lctic:l.1 nurse. functioning under the
di-rection and supervision of other licensed health care
professionals as provided in RCW IS.iS.OIO(S), shall be
responsible and accountable for his or her own nursing
judgments. actions and competence.
[Ch. 2A6-8J8 WAC-po 21

;
:
'.

~

~
;
~
•

!

I

}

(10) The licensed practic:ll :lurse shall report unsafe ac:s ~
and practices. unsafe practice conditions. :lnd illegal acts to •
the appr.opri:lte supervisor! pe:-3Qnne! or to the appropriate
state disciplinar! board.
(II) The Iicensed practical nurse sh:lll respect the
c!ie:lt's privacy by protecting confide:lti:1l information. unless
required by law to disclose such inionnation.
(11) The licensed practic3l nurse shall make accurate.
intelligible <:naies into records required by law. employment :
or custom:lry practice of nursing. and shall not falsify.
destroy. alter or knowingly make incorret:t or unintelligible
entries into client's records or employer or employee
records.
(13) The licensed pr:lctic:l1 nurse shall not sign any
record attesting to the wastage of controlled subst:l.nces
unless the wast:lge was personally witnessed.
(I ~) The licensed practical nurse shall observe and
!.
record the conditions of :1 clie:lt. :lnd report significant •
changes to appropriate persons.
(15) The licensed practical nurse may withhold or
modify client care which has b~n authorized by an approi
priate he:llth care provider. only after receiving directions
from an appropriate person. unless in a life threatening
situation.
(16) The licensed practical nurse shall le:lve a nursing
assignment only after properly reporting to and notifying
appropriate persons and shall not abandon clients.
(17) The licensed pr:lctic:l1 nurse shall not misreprese:1t
his or her educ:ltion and ability to perform nursing proce·
dures safely.
(IS) The licensed pr3ctic31 nurse shall respect the
property of the client and employer and shall not take
equipment. materials. property or drugs for his or her own

1
1

I

\I.

D86'7

Pr:1ctic:d Nurses
use or benefit nor shaJl the licensed practic:li nurse solicit or
borrow money, materials or property from clients.
(19) The licensed practical nurse shall not obtain.
possess, disaibute or administer legend drugs or controlled
subsunces to any person. including self. except as directed
by a person authorized by law to prescribe drugs.
(20) The licensed practical nurse shall not practice
nursing while affected by alcohol or drugs. or by a mental.
physical or emotional condition to the extent that there is an
undue risk that he or she. as a licensed practic:l1 nurse.
would cause harm to him or herself or other persons.
(21) It is inconsistent for a licensed pr.1ctical nurse to
perform functions below the minimum standards of compe·
tency as. expressed in WAC 246-838-260.
ISwulory AulhorilY: ROV 18.78.050. 92-17.023 (Older 296B). § :w;838~30. filed 8/10192, effectivc 9110192.' SWUIOI}' AumorilY: RCW
18.78.0503Ad 18.130.050. 92~-046 (Order 23IB). § 246·838-030. filed
12127/91. effective 1121192. St:IlulOry AUlhorilY: RCW 18.78.050. 91.{)1·
078 (OldC;' I09B), n:coditied 3S § 246·838-030, tiled 12117190. effeclive
1/31/91. StIIUlOl}' AudlcriKY: RCW 18.78.050. 18.130.~ (I) _ (12) md
1986 C 259 § § 19.128 31Id 131. 86-18-4)31 (OrdC;' PM 612). § J08·117OU. tiled Br.7186. StatulOry AUlhorily: RCW IS.iS.050. 86.{)I-084
(Older PL 514), § 308-117~, filed 12118185.1

WAC 246-838.040 Licensure qu.:l1ifications. (1) In
order to be eligibJe for licensure by ex:unination the appli.
cant shaH have satisfactorily completed an approved ?&.Ictic1
nursing program. fulfilling all the basic course conte:lt as
stated in WAC 246-838-240. or its equivalent as determined
by the board. Every applicant must have satisfactorily
completed an approved Pr.1cticaJ nursing program within two
ye:us of the date of the first examination :aken or the
applicant must meet other requirements of the board 10
determine current theoretical and clinical knowledge of
pr.1ctical nursing pr:lc:icc.
(2) An applicant who has not completed an agproved
practic1 nurse progr;un must cst:1blish c·tidence of suc::::ssf.Ji
completion of nursing and related courses at an approved
school prei'aring persons for licensure as registered nurses.
which courses include personal and voc:uional relationships
of the practical nurse. basic science and psychosocial
concepts. th~ry and c1inic:u P&.lcticc in medications and the
nursing process, and th~ry and clinical pr::lctice in medical.
surgical. geriatric. pediatric, obstetric and mental health
nursing. These courses must be equivalent 10 those same
courses in a practical nursing program approved by the
board.
(3) A notice of eligibility for admission to the licensing
examination may be issued to all new graduates from board
approved pr3ctical nursing progr3ms after the filing of a
completed application. payment of the application fee. and
official notification from the program certifying that the
individual has satisfactorily completed all requirements for
the dip loma/ceni fic:1tion.
(4) All other requirements of the stalute and regulations
shall be met.
(S~IUIOI)' AUlhorilY: RCW 18.130.050 md 18.73.050. 94-08..1 50 ~ :.:6.
838.Q40. filed olIl194. ef(cc:rive sr..J94; 91·13-023 (Orde:' liSBI. ~ :.I6..3J8·
040. filed 6111191. effective 7112/91. SIJlutory .~Ulhorily: RCW 18.i8.050.
91.01-078 (Order 1098). n:eodilied .u § 246-S38·040. filed t 2117/90.
effeclive 1/31/91. SI:lIUIOI}' AUlhority: RCW 13.i8.050. 18.73.05-l.
18.7S.060. 18.;8.on. 18.i8.090. 18.78.225. 18.130.050 md 70.2.a ::70. ~8·
24-0li (Older PM 768). § 308·1 17.{)30. tiled 1211/38. $IJlUtaty AUlhority:
RCW 18.78050. 18.i8.0S-l. 1878.060. 18.1 30.050 ~d SHB 14('~. 1988 C

(41119.t1

246-838-030

211. S~18~5 (On1c;- PM 768). § 308-117-030. filed 812S188. SI:llUlOl}'
AlIlhorily: 18.78.0sa. t8.78.060 3Ad 18.130.050. 88~8-o34 (0n1c;- PM
718). § 308·117~30. filed 411118. SWUlOl}' AlIthorilY: RCW 18.78.050
84-01-061 (Onlcr PL 452). § 308·117-030. filed 12119113. FolTl\crly WAC
308-116-295.1

WAC 246-838-050 Licensing examination. (I) In
order to be licensed in this state. aU Pr.1ctical nurse applicants shalt take and pass Ihe National Council Licensure
Examination (NCLE..'X) for PracticaJ Nurses.
(2) The executive secretary of the board shaJl negotiate
with the National Council of State Boards of Nursing, Inc.
(NCSBN) for the use of the NCLEX.
(3) The examination shalt be administered in accord
with the NCSBN security measures and contract. All
appeals of examination results shall be managed in accord
with policies in the NCSBN contr.1ct.
(SLllIIIOl)' AUlhorilY: RCW IS.i8.050. 93-21-006. § 246-a38.{)50. filed
1017/93. effectivc IInJ9J; 92·17'{)2J (Onlc;- 296B). § 246-a38.{)SO. filed
8110192. cCfccrive 9110192: 91.{)1.{)78 (Older I09B). ~oditied u § 246.
838-050. filed 12117190. effectivc 1131191. SUlulOry AUlhorily: RCW
IS.78.0s0. 18.78.054. 18.78.060. 18.130.050 3Ad SHB 1*. 1988 c 211.
88-18·00S (Order PM 768). § 308-117-040. tiled 8/25/88. StatulOI}'
AulhorilY: RC'.11 18.78.050. 84-Q1-061 Calder PL .a5!). § ~08.117.Q40.
filed 12119/831

WAC 246-838-060 Rele:lSe of results of eX3mination. (1) Applicants shall be notified regarding the examination results by mail only. The results will not be released
until the candidate's offic:al tr.1nscript is on file with the
board.
(2) Applicants who pass shall receive a license to
practice as a licensed practical nurse provided all other
requirements are met.
(3) Applicants who fail shall receive a letter of notification regarding their eligibility to retake the examination.
(4) [n addition to a 'listing of the names of graduates
indicating whether each passed or failed the examination.
each pr:lctical nursing progr:un in Washington shaH receive
a statistical report of the examination results of applicants
from that school and a repon of state and national statistics.
(5) Examination results for :111 candidates will be
maintained in the applic3tion files in the division of professional licensing services. department of health.
(SLllulory Aulhorily: RCW 18.iS.050 md 18.130.050. 9t·13.{):!3 (Older
li581. § 2ol6-83S.{)6(). flied 6111191. cffcc::ive 7/1:!t91. SLllUIOry Aurhonly:
RCW 18.7S.050. 91.{)1.{)7S (Order 100B), recodified .u § 2.16·838-060.
filed 12117190. effective 1131191. StJlUlory Authorily: RCW 18.78.050.
IS.78.054. IS.i8.060. 18.130.050:tlld SHB 1404. 1985 c 211. 88-18.005
(Onler PM i68). § 308·1 17.{)50. filed SI2SISS. SWUIOry Aulhorily: RCW
18.iS.050. &4-01-061 (Older PL 452). § J08·lli.{)50. filed 12I19183.j

WAC 246-838-070 Filing oCappliction for licensing
e.umination. (l) All applicants shaH file with the WashingIon state board of practical nursing a completed application.
with the required fee. The fee is not refundable.
(2) Applicants shalt submit with the Jpplic:llion one
recent U.S. passPOrt identification photogrJph of the applicant unmounted and signed by the Jpplicam across the front.
(3) Applicants shall request the school of nursing to
send an official tr.:msc:ipt directly to the board of practic:lI
nursing. The transcript shall contain adequale documentation
to verify that statutory requirements are met and shall

..
18.130.175

monitoring records reponed to the disciplining :lumority for
Quse ~ detined in subsection (3) of this section. Monitoring records rel:uing 10 license holders referred 10 Ihe program by Ihe disciplining authority or rel:lting to license
holders reponed to me disciplining :lumority by the progr:un
for C:luse. shall be released to the disciplining :luthority at
me request of the disciplining authority. Records held by the
. di~iplining :lumority under mis section shall be exempt from
RCW 42.17.250 Ihrough 42.17,450 :lnd shall not be subject
to discovery by subpoena except by the license holder.
(5) "Substance abuse:' as used in this section. mc:ms the
impairment. as determined by the disciplining authority. of
a license holder's protessional services by an addiction to. :I
dependency on. or Ihe use of alcohol. legend drugs. or
controlled substances,
(6) This section does not affect an employer's right or
ability to m:lke employment-related decisions regarding a
license holder. This section does not restrict the aumority of
me disciplining :lumority to take disciplinary 3clion for any
other unprofessional conduct.
(i) A person who. in good faith. reportS information or
takes action in connection with this section is immune from
civil liability for reporting information or taking the action,
(3) The immunity from civil Ii:lbility provided by this
section shall be liberally construed to accomplish the
purposes of this section :lnd the persons entilled to immunity
sh:1J1 include:
(i) An approved monitoring tre:ume:'ll progr:Jm:
(ii) rne profession:ll ~soci3tion oper:Jting the prog~m:
(iii) Members. employees. or 3gents of the program or
associ:uion:
(iv) Persons re;Jorring J license holde:- as being imp:lired
or providing information about [he license holder's imp:urment: and
(v) Profession31s supervising or monitoring the course
of the impaired license holder's tre:ument or rehabilitalion.
(b) The immunity orovided in this section is in addition
to any other immunity' provided by law. (1993 c 36i § 3:
1991 c 3 § 270: 1988 c 247 § 2.)
Legislative intcnt-1988 c ~~7: "ExlSling law docs not provide for
a progr.un ior ~l1iL1llon oi hc=J1h professionals whose competenc)' rna)'
be imp:lircd due 10 the JIluse of .:dcohol :JlId OIllet' dNgs.
It is Ihe inlent of Ihe 1~I$I:llurc lhal the disciplining Jlllhonucs seck
ways to idenufy :JlId suppan Ihe rehabilitalion of hc:lIlh profession:lls whose
prxtice or compelency m:lY be imp:urcd due 10 Ihe lbuse of drugs or
alcohol. The leglslouun: intends 1~1 such heallh profcsslonals be IlC:llcd so
Ih:u they C:lII relurn 10 or o:onunue 10 pl':lcuce lhelr proiession ,n J 'Nay
which s:Uegu:lrds Ille public. The !eglsl:llure spccilic:l.lly Inlends lhal Ihe
disciplining :lulhorilics csIJlllisll 1Il .lllcm:llive progl':lm 10 lhe l~illon:l.l
:ldrntnisll':llivc proceedings 19:unsl such hcallh profession:l.ls." (1988 c 2oS7
§ 1.1·

~

RCW 18.130.180 Unprofessional conduct. The
~Iowing conduct. acts. or conditions constitute unprofessional conduct for any license holder or 3pplicant under the
jurisdiction of this ch3pter:
(I) The commission of any act involving mor:lI turpi"
tude. dishonesty, or corruption relating to the pr:lclice of the
person's profession. whelher the act constitutes a crime or
not If the act constitutes a crime. conviction in 3 criminal
proceeding is not a condition precedent to disciplinary
:lction. Upon such a conviction. however. the judgment and
sentence is conclusive evidence at the ensuing disciplinary
(Ch. 18.JJG-p.

.

...._t:ul:ation of He:llth Professions-Uniform Disciplinary Act

he:uing of the guilt of the license holder or :lpplic:l{lt of the \
crime described in the indictment or information. :lnd of the ,
person's violation of the statute on which it is based. For
the purposes of this section. conviction includes 311 instances •
in which a ple:l of guilty or nolo contendere is the basis for I
the conviction and all proceedings in which the sentence has ~
been defetTed or suspended. Nothing in this section :lbrog:ltes righLS guaranteed under chapter 9.96A RCW:
(2) Misrepresent3tion or conce:llment of a material f:lct
in obt3ining a license or in reinstatement thereof:
(3) All advertising which is false. fraudulent. or mis- ~
le:lding:
(4) Incompetence. negligcnce. or malpractice which
results in injury to a patient or which cre:lles :In unreason~
3ble risk thaI 3 patient may be h3rmed. The use of a
nontr:1ditional tre:llmc:nt by itself shall not constitute unprofessional conduct. provided that it do.:s not result in injury
to :I patient or create :In unrcasonable risk th:u a patient may
be harmed:
(5) Suspension. revoc3tion. or restriction of the
individu:ll' s lic~nse to pr3ctice the profo:ssion by competent
:luthority in 3ny state, federal. or foreign jurisdiction. 3
certified copy of the order. stipulation. or ;lgreemem being
conclusive <:\ ience of the rcvoc:ltion. suspension. or
restriction:
(6) The po
ion. use, prescription for use. or disoibution of control • substances or legend drugs in any way
other than for legitim3te or ther3peutic purposes. diversion
of cont.rolled substances or legend drugs. the violation of any
drug 13w, or prescribing controlled subst:lnc::s for oneself:
:/(7) Violation of any st:lte or feder3l St3lute or administl';}tive rule regui3ting the profession in question. including
;lny St;ltule or rule defining or establishing standards of
patient care or professional conduct or pr:lctice:
(8) Failure to cooperate with the disciplining authorily
by:
(a) :-Sot furnishing any papers or documents:
(b) Not furnishing in writing a full :lnd comple:e ~
explanation covering the matter comained in the complaint ..
filed with the disciplining authority; or
(c) Not responding to subpoenas issued by the disciplin.
ing authority, whether or not the retipiem of the subpoena is "

f

!

i

the accused in [he proceeding:

. -

..

(9) Failure to comply with an order issued by the
disciplinary 3uthOrity or a stipul3tion for informal disposition
entered into with the disciplinary 3uthority:
(10) Aiding or 3beuing an unlicensed person to pr:lctice
when a license is required:
0/( II) Violations of rules established by Jny health
agency:
(12) Practice beyond the scope of practice as derined by
law or rule:
(13) Misrepresent:ltion or fr:lud in any aspect of the
conduct of the business or proiession:
(14) F:lilure to adequately supervise auxili:uy slaif to the
extent that the consumer's he:llth or safety is :It risk:
(15) Engaging in 3 profession involving contact with the
public while suffering from a contagious or infectious
disease involving serious risk to public health:
(16) Promotion for person:ll g:lin of any unnecessary or
ineffic:lcious drug, device. tre:1tment. procecluO'gr~ice:
'19941'

31
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,

'ation of He:alth Professions-UniConn
(17) Conviction of any gross misdeme:ll1or or felony
relating to the pr:u:tice of the person's profession. For the
purposes of this subsection. conviction includes all insunces
in which a ple:1 of guilty or nolo contendere is the basis for
conviction :lnd all proceedings in which the sentence has
been deferred or suspended. Nothing in this section abrog:ues rights guat:lntccd under chapter 9.96A RCW:
(18) The procuring. or aiding or abetting in procuring.
a criminal abortion.
(19) The offering. undertaking, or agreeing to cure or
treat disease by a secret method. procedure. treatment. or
medicine. or the treating. operating. or prescribing for any
he:1lth condition by a method. mc:ms. or proc.;cdure which the
licenSee refuses to divulge upon demand of the disciplining
authority;
(20) The willful betrayal of a practitioner-patient
privilege as recognized by law:
(21) Violation of chapter 19.68 RCW;
(22) Interference with an investigation or disciplinary
proceeding by willfUl misrepresenGltion of facts before the
disciplining :luthority or its authorized representative, or by
the use of threats or har:1Ssment against any patient or
witness to prevent them from providing evidence in :I
disciplinnry proceeding or :lny other legal action;
(23) Current misuse of:
(a) Alcohol:
(b) Controlled substances; or
(c) Legend drugs:
(24) Abuse of :I client or patient or sexual contact with
:I client or patient:
(25) Acceptance of more than a nominal gratuity.
hospitality. or subsidy offered by a representative or vendor
of medic:lI or health-related produclS or servic::s ~ntended for
patients. in contempiation of a sale or for use in rese:lrch
pUblishable in professional journals. where :l conflict of
interest is presented. as detined by rules of the disciplining
authoritv. in consultation with the departme:1t. based on
recogni~d professional ethical standards. (1993 c 36; § :2.
Prior: 1991 c 332 § 34: 1991 c 215 § 3: 1989 c 270 § 33:
1986 c 259 § 10; 1984 c 279 § 18.)
AppliCltion 10 scope oC pr.aC1ice--C~ptions not law-1991 c 332:
Sec nOles follOWIng ReW 18.130.010.
Scvcr.ability-1986 c :59: See :IOIC follOWing ReW 18.130.010.

RCW 18.130.185 Injunctive relief for violations of
RCW 18.130.1iO or 18.130.180. If a person or business
regulated by this chapter violates RCW 18.130.170 or
18.130.180. the attorney gener:ll. any prosecuting ;morney.
the secretary. the board. or any olher person may maintain
an action in the name of the state of Washington to <:njoin
Ihe person from committing the violations. The injunction
shall not relieve the offender from crimin:ll prosecution. bUI
the remedy by injunction shall be in addition 10 the liaoility
of the offender to criminal prosecution and disciplinary
action. (1993 c 367 § 8: 1987 c 150 § S: 1986 c 259 § 15.)
Sevcr:lhilily-19117 c ISO: S= ReW IS.122.901.
Scvcr:lllilily-19116 c :59: S<:c nOle iollowing RCW 18.130.010.

RCW 18.130.186 Voluntary substance abuse
monitoring progr:1m-Contcnt-liccnse surcharge. (I)
To implemem a substance .lbuse monitoring progr.lm for
(1'.1'.14)

r

nary Act

18.130.180

license holders specified under RCW 18.130.040. who arc
impaired by substance abuse. the disciplinary authority may
enter into a contr:1ct with a voluntary substance abuse
progr:1m under RCW 18.130.175. The progr:un may include
any or :III of the following:
.
(a) Contr.1cting with providers of treatment programs;
(b) Receiving and evaluating reports of suspected
impairment from any source~
(c) Intervening in C:lSes of verified impairment;
(d) Referring impaired license holders to treatment
progr:uns;
(e) Monitoring the treatment and rehabilitation of
impaired license holders including those: ordered by the
disciplinary authority:
(f) Providing education. prevention of impairment.
posttreatment monitoring. and support of rehabilit:lled
impaired license holders; and
(g) Performing other activities as agreed upon by the
disciplinary authority.
(2) A contract entered into under subsection (I) of this
section may be financed by :I surcharge on each license
issuance or renewal to be collected by the department of
he:lllh from [he license holders of the same regulated health
profession. These moneys shall be placed in the health
professions account to be used soie!y for the implemenution
of the program. (1993 c 367 § 9: 1989 c 125 § 3.)
RCW 18.130.190 Practice without licenseInvestig:ltion or complaints-eellSe and desist ordersInjunctions-Penalties. (I) Tne secreury shall investigate
complaints concerning prac:ice by unlicensed persons of a
profession or business ior which .l license is required by the
Chapters specified in RCW 18.1 ::0.040. In the investig:llion
of the complaints. the SeCrel:lr! shall have the same .lumority
as provided the secretary u"nd.er RCW 18.130.050.
(2) The secretary may issue a notice of intention [0
issue a ce:lse and des ist orde:- to .lny person whom the
secretary has reason to believe is engaged in the unlicensed
practice of :I proiession or business for which a license is
required by the chapters specified in RCW 18.130.040. The
person to whom such notice is issued may request an
adjudicative proceeding to contest the charges. The request
for hearing must be tiled within twenty days after service of
the notice of intention to issue a ce:lSC :lnd desist order. The
failure to request :I he:aring constitutes a default. whereupon
the secretary may enter :I penn::ment cellSe and desist order.
which may include a civil fine. All proceedings shall be
conducled in accord:lnce with chapter 34.05 RCW.
(3) If the secretary makes a final detennination that J
person has engaged or is engaging in unlicensed pr:ICtice. the
secretJry m:lY issue :I cease and desist order. In addition. the
secretary may impose a .;ivil tine in an amount not exceeding one thousand dollars for e::1ch day upon which the person
engaged in unlicensed pr:lctice of :I business or profession
for which :I license is required by one or more of the
chaplers specified in RCW 18.130.040. The proceeds of
such fines shall be deposited to the he31th professions
account.
(4) If the secretary makes a written finding of fact that
the public interest will be irrepar:lbly harmed by dela.y in
issuing an order. Ihe: secretary may issue :I lempor~ ce:lSC

88(0

leb. 11l.lJO-..:1J. 91

18.19.240

Nursing

nurse anesmetist. "Protocol" mc:lns a st:uement regarding
practice and do.cumentatio~ concern~ng.such items as
categories of pauentS. categones of medications. or categories of procedures rather than detailed case-specific fonnulas
for the practice of nurse anesthesia.
(2) In me context of the definition of licensed practical
nursing practice. mis chapter shall not be construed ?S:
(a) Prohibiting the incidental care of the Sick by
domestic servantS or persons primarily employed as housekeepers. so long as they do not practice practical nursing
within the m~ing of mis chapter.
(b) Preventing a person from the domestic adminisuation of family remedies or the furnishing of nursing assistance in case of emergency:
(c) PrOhibiting the practice of practical nursing by
students enrolled in approved schools as may be incidental
to meir course of study or prohibiling the students from
working as nursing assistantS;.
.
(d) Prohibiting auxiliary services provIded by persons
carrying OUt duties necessary for t~e suppo~ of nurs~ng
services. including mose duties that Involve minor nursing
services for persons perfonned in hospirals. nursing homes.
or e1sewhete under the direaion of licensed physicians or the
supervision of licensed registe:ed nurses; .
..
(e) Prohibiting or preventing me practice of nursang In
this state by a legally qualified nurse of another state or
territory whose engagement requires. him ~r ~er ~O' ac~ompa­
ny and care for a patient temporarily resldtng In thiS sra~e
during the period of one such engagement. not to exceed SIX
months in length. if the person does not represent or hold
himself or herself OUt as a licensed practical nurse licensed
to practice in this state:
.
.
(f) Prohibiting nursing or care of the s~ck. ~Ith or
wimout compensation. when done in connectlon With the
. practice of me religious tenets of a church by adhe:Cnls of
the church so long 3S they do not engage in licensed
practic:lI nurse practice as de.tined in this chapter::
(0) Prohibiting the practice of a legally qualified nurse
of an~ther state who is employed by the United States
govemment or 3ny burc:w. divisio~. or a~ency thereof. while
in the discharge of his or her offiCial duties. [1994 1st sp.s.
c 9 § 424.)
RCW 18.19.250 Advanced registered nurse pr:u:titioner-Activities allowed. An advanced registered nurse
practitioner under his or her license ~ay perform for
compensation nursing C:lre. as that term IS usually understood. of me ill. injured. or infirm. and in the course thereof.
she or he may do me following things that sha!1 not. be done
by a person not so licensed. except as prOVided IR RCW
18.79.260 and 18.79.270:
(I) Perform specialized and advanced levels of nursing
as recognized jointly by me medical and nursing professions.
as defined by the commission;
(2) Prescribe legend drugs and Schedule V controlled
subStances. as defined in the Uniform Controlled SubsWlccs
Act. chapter 69.50 RCW. within the scope of practice
defined by the commission:
(3) Pert"onn all acts provided in RCW 18.7?260; .
(4) Hold herself or himself out to me pu!>hc or desIgnate herself or himself as an advanced registered nurse
(Ch. 18.79-p.

61

~re

practitioner or as a nurse practitioner. [1994 1st sp.s. c 9 §
425.)
RCW 18.19.260 Registered nurse-Activities
allowed. A registered nurse under his or her license may
perform for compensation nursing care. as that term is
usually understood. of me ill. injured. or infinn. and in me
course mereof. she or he may do the following Utings that
'shall not be done by a person not so licensed. except as
provided in RCW 18.79.270:
(1) At or under the general direction of a licensed
physician and surgeon. dentist. osteopathic physician and
surgeon. podiatric physician and surgeon. physician assistant.
ostcopathic physician assistant. or advanced registered nurse
practitioner acting within the scope of his or her license.
administer medications. treatmentS. tests. and inoculations.
whether or not the severing or penetrating of tissues is
involved and whether or not a degree of independent
ludgment 3nd skill is required;
(2) Delegate to other persons engaged in nursing, the
functions outlined in subsection (I) of this section:
(3) Instruct nurses in technical subjects pertaining to
nursing:
(4) Hold herself or himself out to the public or designarc herself or himself as a registered nurse. [1994 1st sp.s.
c 9 §,~26.)

~CW
18.19.270 Licensed pl':1ctical n~:\~vities
allowed. A licensed practical nurse under his or her hcense
may perform nursing c:ue. as that teon is usually understood.
of the· ill. injured. or infinn. and in the: course thereof may.
under the direction of a licensed physician and surgeon.
osteopathic physician 3nd surgeon. dentist. podiatric physician and surgeon. physician assistant. osteopathic physician
assistant. advanced registered nurse practitioner acting under
the scope of his or her license. or at the direction and under
the supervision of a registered nurse. administer drugs.
medications. treatmenrs. tests. injections.•md inoculations.
whether or not the piercing of tissues is involved and
whether or not a degree of independent judgment and skill
is required. when selected to do so by one of the licensed
practitioners designated in mis section. or by a regiStered
nurse who need not be physically present: if the order given
is reduced to writing within a reasonable time and made a
part of the patient's record. [1994 1st sp.s. C 9 § 427.)
RCW 18.79.280 Administration of dnag5. injections,
inoculations, tests, treatment allowed. It is not a violation
of chapter 1S. 71 RCW or of chapter 18.57 RCW for a
registered nurse. at or under the general. direct.i~n of a
licensed physician and surgeon. or ostcopathlc phySICian and
surgeon. to administer prescribed drugs. injections. inoculations. tests. or treatment whether or not the piercing of
tissues is involved. [1994 1st sp.s. c 9 § ~28.1
RCW 18.79.290 Catheteriz:ation of public and
priv3te school studen ts-Ru1es. (1 ~ In 3ccor~an~e with
rules adopted by the commission. public school dls~etS 3nd
private schools that offer classes for any of grades kindergarten throuah twelve may provide for clean. intermittent
bladder ca:>theteriution of studenrs or 3SSisted selhc~ei'. 0 &"9"*)
r.....'\.~-....."-

_.

...,~~'!

::'2

~tf

Employee Narne (please Print)

ACKNOWLEDGEMENT OF RECEIPT OF
DOC EMPLOYEE HAJ.'IDBOOK

I adOlowledge receipt of the June 1993 Washington State Deparnnent
of Corrections Employee Handbook and agree to become familiar
with and have a thorough knowledge and understanding of the
contents.

Employee Signature

Original - Personnel File

r-:~ II'LOY EE II. \ NIJIU)() I{ .

• Report all rersonal contact from offenders, lhelr families. or
known associates. outside yourJob In accordance WIUl departmen~
procedures;
00

• Provide for reJt1tullon~
• Be accountable to the dtlzens of the Slate;

• Meet the nallonal standards appropriate to ~e State of Washington.

• Report Ulrougb tlIC' proper chain of command any corrupt or
unethical bebavlor wldcb could affect an offender or the
department's Integrity;

CODE OF ETHICS
Hllb moml and etblca1slandards among correctional employees nre
essential for tbe 'UcxelS ortbe department's programs. The Dcpart.ment oCCorrecllonllubscrlbes to a code of unfailing honesty,
respect Cor dignity and IndIviduality of human beings. and a commit·
ment 10 professional and compassionate service.
DEPARTMENTEXPECfATIONS

As. new employee of the department. you wllJ have many things to
learn, not tile least of whleb will be the expectations or your supervi.
101', your co--workers, and the Rgency a5 a whole. To Rssist you with
this responslbUlty, following Is a list of some departmental expccta·
lions for your study. Famillarlze younelf with the list so that you
may understand and fulfilllhe dulles of your position.

As. representallve of the Dep~ent of Conecllons. )'OU will be
"peded Co:

• Positively represent Washington Slate lovemment to everyone you
meet You are our besl public relations agenl;

o

• ReDlain Conslmilly alert In all situations;
I .

• Custody starr: remain at yourJob/post until properly relieved;
• Let your sUl'ervi~or know about any personal, emergency use of

equipment or phones;
• Obtain appropriate pennisslon before removing Rny state property
from state premises;

• Conduct yourself and rerform your dulles safely;
• Smoke only in designated smoking areas.
It is also Important RS a new employee. dial you understand some of .
tJte sl'ccinc prohibitions IhBt the department must enforce. You Dre
nol allowed 10:

• Discriminate ag~lnsl any ofrender. employee. prospective em·
ployee. or volunteer on the basis of race, color. religion. gender.
seJtuRl oricntatJon, age, creed, naUonai origin, marital status,
veleran status or disability;

• Dress appropriately for yourJob cJasslOcalion and dudes. Clothing
may not have moU()s, logol, or advertisements that may be offensive or In oonOid with the goals of the Departtnent;

• Use profanity or illnammatory remarks with offenders or Individu.
als wi th whom you work;

• Wear Issued uniforms only as aulhorized;

• Report 10 work under the InOuence of alcohol or drugs;

• Be a good citizen, obey lawl while on and off-duty. Your conduct
off dUly may reflect on your Rtness for duty;

• Trame or bring any article of cOllllaband into an InstltuUon.
facility or office;

• Treat fellow staff wJth dignity and respect;

• Darter or mRke personal deals wllh offenders, offender famUfes or

• Be Impartial, understanding and respeclCullo offenders;
• Serve each offender with appropriate concern for their welfare and .
wJIh DO purpose or penonallaJn;

visitors:

• Engage In personal relaUonshlps with offenders, their CamOy
members, .or close personal associates;

I

_ .,.......

'1

POLICY
ETHICS

POUCY NUMBER

801.001
Page 1 of3

EfFECTlVE DATE: January 1, 1995

AUTHORITY:
General authority of the Secretary of Corrections to manage and direct the Department. ACW
72.09.050.

PURPOSE:
This policy provides direction to Department of Corrections employees to assist them in making
appropriate choices, acting in a manner that demonstrates high ethical standards, and complying with
provisions of the State Ethics Law, Chapter 42.52 RCW.
This poficy is not intended to supplant other directions provided employees in the form of policies,
procedures, field instrUctions, the Employee Handbook. desk manuals, and other official doc:uments
of the Department.
.

APPLICABILITY:
All employees of the DepatttTlent

DEFINITION:

Gift • A gift is defined as anything of economic value for whic." no consideration is given in retum. For
purposes of this policy, the following items are excluded from the definition of gift

a.

Items from family, friends, or other employees if their clear purpose is not to influence the
employee's perfcnnance or non-pertormance of their offi~ duties.

b.

Unsolicited plaques and awards of appreciation.

c.

Items ot nominal value, regularty and normally offered by an organization (to customers, potential
customers, or the general public) as samples or for public relations or advertising purposes.

d. Food and beverages on infrequent occasions in the ordinary course of meals, when related to
offidal duties.

POLICY:
In keeping with the Department role of responsibly serving the people of the state of Washington,
Department employees are expected to maintain high professional and ethical standards at all times.
The Department has adopted a statement ot values that exemplifies standards and principles that
serves to guide individual lJehavior. (The Employee Handbook contains information on these and
other areas at responsibility and expec-.ations.)
The State Ethics Law, Chapter 42.52 ACW provides specific requirements that, when followed, will
help ensure that no employees obtain personal gain or private advantage from their official position.
Employees are to avoid actions that create even the appearance of using their position for personal
gain or private advantage for themselves or another person.
Restrictions;
The following tour restrictions provide overall direction. Any specific situation must be viewed within
the context ot these general provisions.
1. Employees shall not have a financial or other interest. or engage in any business or professional
activity that is in conflict with their official duties.

2. Employees shall not use their official position to secure special privileges for themselves or any
other person.
3. Employees shall not receive any compensation from a source except the state. for performing or
deterring tne performance at any official dUty.

087-4

POLICY
Employees shall not accept any gifts.

POUCY NUMBER

801.001
Page 2013

ETHICS
4.

-

jI

Additional restrictions placed upon employees include, but are not limited to. the following:

1. Employees shall not disclose confidential information to an unauthorized person or use
confidential information for personal benefit or to benefit another.
2. Employees shall not use state resources tor personal benefit or to benefit another except as may
be required dUring the execution of their official duties.
3. Employees shall not use state resources for political campaigns.

4. Former employees shall not accept employment or compensation from an employer contracting
with the Department (within one year of leaving state employment) if during the tWo years
immediately preceding termination of state employment they negotiated or administered a
contract with the new employer in excess of $10,000 and their duties with the new employer
would include fulfilling or implementing that contract.

5. Former employees shall not (within two years folloWing the termination of state employment) have
a beneficial interest in a contract or grant which
action in which the employee participated.

was expressly auttlorized or funded by executive

6. Employees may not assist another person in a transaction involving the state it they participated in
that transaction or such transaction was within their job responsibilities anytime within the past two
years except as may be required dUring the execution of their official duties.
Responsibilities;
Employees are responsible for knowing and adhering to applicable ethics laws. policies. and
directives and for making choices that exemplify an adherence to high ethical standards. It is
incumbent upon employees to bring to the attention of their supervisor any actual or potential
violations of this policy. When in doubt. employees should consult with their supervisor and/or
personnel officer.
Violations of the State Ethics Law and/or this policy may lead to corrective or disciplinary action up to
and including dismissal.
Appointing authorities or their designees will be a single point of contact in their organization who will
respond to questions and/or complaints regarding this policy and other ethics-related issues.
The personnel office will assist in the identification and resolution ot potential problems and
interpretation of ethics-related laws. policies, and directives.
Alleged violation(s) of the State Ethics Law may also be filed direcUy with the EXeclJtive Ethics Board
at the following address:
Executive Ethics Board
1125 Washington Street
Post Office Box 40100
Olympia, Washington 98SQ4.01 00
The Board has the authority and responsibility for investigating such complaints and may take punitive
action against the employee and/or agency if violations occurred.

087'5 .

-~."

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POLICY
ETHICS

.

-. _...... _...... _-

..

POUCY NUMBER

801.001 .
Page3of3

REFERENCE:

The State Ethics Law (Chapter 42.52 RCW); DOC Employee Handbook; DOC Polley 857.00S Conedive ActfonlOfsdpfinary ActIon.
Other related polfdes: 210.060 - Donations; 280.515 - Records Management - Disclosure of Public
Records; 806.005 - Memberships in Professional and Nonprofit Organizations; 81 S.oos - Criminal
Record Olscfosure and Util1zation: 816.010 • Employment of Relatives; 854.025 - Outside
Employment; 854.0S0 - Employee Participation as Board Members: 854.075 - Employee
Relationships with DOC Offendefs.
SUPERSESSION:

DOC Policy 854.005 Conffld of Interest-Employees, Offenders, and Organizations dated January 1,
1993: and OQ<; Policy 100.600 Confidentiality dated December 1, 1987.
.

087S

"'-~c:

" • .,CLJ".... u

Sec:rel3tY

....,/

RECEIVE-I-

STATE OF WASHINGTON

JAN 0 9 1996

DEPARTMENTOFCORAECTIONS
P.

McNEIL ISLAND CORRECTIONS CENTER
• Steilacoom. WashingtOn 98388-0900

o. Sox 9CtJ

OQ~ofCo~
MSlllll of Human RescuIr~

January 3. 1996

Donna L. Evans

--

PERSONAL SERVICE -

CONFIDENTIAL

Ms. Evans:

This is official notification of your immediate suspension, at 12:01 a.m. on January 8,
1996 through 12:00 midnight on January 22, 1996, followed by your dismissal effective
at 12:01 a.m. on January 23. 1996, from your position as a Licensed Practical Nurse 3
with the Department of Corrections (DOC), McNeil Island Corrections Center (MICC).
This disciplinary action is taken pursuant to the authority of the Civil Service Laws of
Washington State, Chapter 41.06, RCW, and the Merit System Rules, Title 356 WAC
(MSR), Section 356-34-010 Disciplinary actions - Causes fer demotion-SuspensionReducdon in salary-Dismissal. (1) (a) Neglect of duty, (h) Gross misconduct and (i)
Willful violation of published employing agency or Depal1ment of Personnel rules and
regUlations. RCW 356-34-040 Dismissal - Notification and RC'"" 356-34-050 Suspension
- Followed by dismissal. ~
Specifically. you neglected your duty, committed act(s) of gross misconduct and willfully
violated published employing agency rules when you, by your own admission during the
administrative review of this incident. accessed and dispensed medication
inappropriately, and without proper documentation (Le., Primary Encounter Report, PER),
from the MICC mini-pharmacy tackle box when you removed 10 Furosemide 40 mg
tablets sometime between June 28, 1995, and July 14, 1995. without having been
directed or ordered to do so by a PA or Physician. This incident is described in detail
in the Employee Conduct Report (ECR) completed on December 5, 1995 (Attachment
1).
The mini-pharmacy is a restricted area, providing accessibility to narcotics and
prescriptionilegend drugs on an emergency basis for appropriately licensed health
services staff from 6 p.m. to 6 a.m. (during off duty hours for pharmacy staff). Pharmacy
staff began tracking medications, that were not documented with an associated PER,
beginning in May. 1995. Specifically, Pharmacy Assistant Jan White was tasked with
daily checking of the tackle box, that was located in the mini pharmacy, documenting
when the tamper-evident seal was broken. When the seal was broken, she checked the

0877 .

CHASE RIVE1J\NO
Secretary

J

RECEIVE.L.

STATE OF WASHINGTON

DEPARTMENT OF CORRECTIONS
McNEIL ISLAND CORRECTIONS CENTER
P. O. Box 900 •

SIBllac:oom. Washington 98388.0900

JAN 0 9 1996
of Co~
OP~arttnent
MSIan of Hwnan Resourr'

January 3, 1996

Donna L. Evans

PERSONAL SERVICE CONFIDENTIAL

Ms. Evans:
This is official notification of your immediate suspension, at 12:01 a.m. on January 8,
1996 through 12:00 midnight on January 22, 1996, followed by your dismissal effective
at 12:01 a.m. on January 23, 1996, from your position as a Licensed Practical Nurse 3
with the Department of Corrections (DOC), McNeil Island Corrections Center (MICC).
This disciplinary action is taken pursuant to the authority of the Civil Service Laws of
Washington State, Chapter 41.06, RCW, and the Merit System Rules, Title 356 WAC
(MSR), Section 356-34-010 D!sciplinar'j actions -- Causes for demot!on-Suspension-Reduc.ion in salary-Dismissal. (1) (a) Neglect of duty, (h) Gross misconduct and (i)
'Nillful violation· of published employing agency or Depal1ment of Personnel rules and
regulations, RCW 356-34-040 Dismissal -- Notification and RCW 356-34-050 Suspension
- Followed by dismissal.;
Specifically, you neglected your duty, committed act(s) of gross misconduct and willfully
violated published employing agency rules when you, by your own admission during the
administrative review of this incident, accessed and dispensed medication
inappropriately, and without proper documentation (Le., Primary Encounter Report, PER),
from the MICC mini-pharmacy tackle box when you removed 10 Furosemide 40 mg
tablets sometime between June 28, 1995, and July 14, 1995, without having been
directed or ordered to do so by a PA or Physician. This incident is described in detail
in the Employee Conduct Report (ECR) completed on December 5, 1995 (Attachment
1).
The mini-pharmacy is a restricted area, providing accessibility to narcotics and
prescriptionllegend drugs on an emergency basis for appropriately licensed health
services staff from 6 p.m. to 6 a.m. (during off duty hours for pharmacy staff). Pharmacy
staff began tracking medications, that were not documented with an associated PER,
beginning in May, 1995. Specifically, Pharmacy Assistant Jan White was tasked with
daily checking of the tackle box, that was located in the mini pharmacy, documenting
when the tamper-evident seal was broken. When the seal was broken, she checked the

0878·

Donna L Evans
January 3, 1996
Page 2 of 5
enclosed vials for replenishment of medications as needed. She also noted and reported
to her supervisor, any discrepancies in the number of tablets that were undocumented
(i.e., no PER was completed). On June 27, 1995, Ms. White found the tamper-evident
seal broken and found that seven Furosemide tablets were missing (between June 5,
1995 and June 27, 1995). No PER's were written during this time for the drug. On June
28, 1995, Ms. White restocked the tackle box in Vial No.2 with 25 tablets of Furosemide
40mg. On July 14, 1995, Ms. White found the tamper-evident seal on the tackle box
broken. She counted the tablets and found only 15 of the 25 that had been placed in
the vial. No PER's were written for the missing 10 tablets.
Vial No.2, when the final discrepancy was discovered on July 14, 1995, was proper.ly
stored and delivered to James Cooper of the MICC Intelligence and Investigations office.
When checked, it yielded clear fingerprints that were identified as your own.
There is no documentation establishing the medication that you removed was dispensed
appropriately to the MICC inmate population, nor have you provided any supporting
documentation of legitimate reasons you would have taken the tablets. In fact, you
admitted to me that you failed to follow procedure by preparing the PERS for signature
when you gathered medications upon the direction of a PA or Physician.
A Pharmacy In-Service Memorandum, dated March 3, 1994, (Attachment 2), which you
admit having knowledge of, states, in pertinent part:
"A PER must be written for any item issued from the after-hours Pharmacy
(or ER) and signed by a PA/MD.
Leave a PER for anything that was removed from the tackle box and the
bottle that was used in the refill box under the pill line cart along with the
broken seaL"

WAC 246-838-030 Standards of conduct for discipline, which outlines the level of
standards of professional conduct for licensed practical nurses, (Attachment 3). states,
in pertinent part:

a

''The licensed practical nurse assumes measure of responsibility, trust
and the corresponding obligation to adhere to the standards of conduct,
which include, but are not limited to the following:
(1) ... shall be responsible and accountable for his or her own nursing
judgements, actions ...
(5) The licensed practical nurse shall not abide, abet or assist any other
person in violating or circumventing the laws or rules pertaining to the
conduct and practice of licensed practical nursing.

0879·

Donna l. Evans
January 3, 1996
Page 3 of 5
(10) The licensed practical nurse shall report unsafe acts and practices,
unsafe practice conditions, and illegal acts to the appropriate supervisory
personnel ...
(12) The licensed practical nurse shall make accurate, intelligible entries
into records required by law, employment, or customary practice ...
(18) The licensed practical nurse shall respect the property of the ...
employer and shall not take . . . drugs for his or her own use or benefit.
(19) The licensed practical nurse shall not obtain, possess, distribute or
administer legend drugs . . . to any person, including self, except as
directed by a person authorized by law to prescribe drugs.
RCW 18.130.180 Unprofessional Conduct (Attachment 4) states, in pertinent part:
''The following conduct, acts, or conditions constitute unprofessional
conduct for any license holder ... under the jurisdiction of this chapter.
Which states in pertinent part, but is not limited to the following:
(1) The commission of any act involVing morai turpitude, dishonesty, or
corruption relating to the practice of the person's profession, whether the
ac~ constitutes a crime or not.
(7) Violation of any state or federal statute or administrative rule regulating
the profession in question including any ... rule defining or establishing
standards of ... professional conduct or practice.
(23) Current misuse of:
(c) Legend drugs."
RCW 18.79.270 Licensed Practical Nurse - Activities allowed (Attachment 5) states, in
pertinent part:
"A licensed practical nurse under his or her license may perform nursing
care, ... and in the course thereof may, under the direction of a licensed
physician ... physician assistant, . . . administer drugs, medications, . . .
when selected to do so by one of the licensed practitioners designated in
this section, ... if the order given is reduced to writing within a reasonable
time and made a part of the patient's record."
On September 10, 1993, you signed for your receipt (Attachment 6) of the DOC
Employee Handbook, which states, in pertinent part on pages two through four
(Attachment 7):

0880

Donna L Evans
January 3, 1996
Page 4 of 5
"CODe OF ETHICS
High moral and ethical standards among correctional employees are
essential for the success of the departmenfs progran:'ls. The Department
of Corrections subscribes to a code of unfailing honesty, respect for dignity
and individuality of human beings, and a commitment to professional and
compassionate service."
DOC Policy 801.001 Ethics (Attachment 8) states, in pertinent part:
"POLICY.
Restrictions:
Additional restriction placed upon employees include, but are not limited to
the following:
2. Employees shall not use state resources for personal benefit or to
benefit another except as may be required during the execution of their
official duties.
Resoonsibilities
Violations of the State Ethics Law and/or this policy may lead to corrective
or disciplinary action up to and inclUding dismissal."
You have a duty to follow the licensing standards and uphold the professional conduct
entrusted to you as a licensed practical nurse. You also have a duty to follow procedure
that is designed to support you in accomplishment of your professional service to the
DOC inmate population, using resources properly and not for your personal use.
Your actions in this matter were irresponsible, unprofessional, unethical and
counterproductive to achieving the Departmenfs mission to provide fair and equitable
treatment to inmates while they are under our supervision. You neglected your duty to
follow the professional standards of your licensure which includes honest and
responsible execution of your duties and the expectations of your employer. By your
actions you did not properly complete associated paperwork when you accessed drugs
in the mini-pharmacy tackle box and lied about accessing the medications. Your
behavior was a willful violation of published agency rules and regulations as identified,
a neglect of your dUty as outlined in the licensing guidelines cited and rises to the level
of gross misconduct.
As a result of the administrative review held on November 17, 1995, I determined, and
verbally notified you and your representatives at that time, that misconduct had occurred.
We convened in a Loudermill hearing on November 20, 1995, to discuss your possible

0831·

Donna L. Evans
January 3, 1996
Page 5 of 5
termination. You were allowed an opportunity to fully discuss and refute the charges
and/or to present reasons why your termination was not appropriate. Throughout that
meeting you demonstrated that you do not accept your responsibilities in this matter,
stating that everyone was lax and that's just the way it was done. By your actions and
your repeated failure to recognize your lack of responsibility in this matter, you have lost
my trust in your ability to honestly and professionally perform your duties. I find your
attitude and defense of your actions and admitted failure to follow procedure intolerable
and unprofessional. This is not the standard of professional performance that I expect
of staff, especially staff with access to controlled substances and who are responsible
for the medical health and welfare of the inmate population.
In addition, you provided.no defense or plausible explanation for your fingerprints to be
on Vial No.2, when the 10 missing Furosemide tablets were discovered. I can only
conclude that you have lied about your contention that you did not access the vial, and
you stole the tablets and used them inappropriately.
Therefore. I find that your
immediate 'suspension, followed by termination is fully warranted.
Attachments one through eight are attached hereto and by this reference, made a part
of as though fully set forth herein.
Under the provisions of WAC 358-20-010 and 358-20-040, you have the right to appeal
this action OR to file a grievance per Article 10 of the Collective Bargaining Agreement
between the Department of Corrections and the Washington State Corrections Employee
Association. If you file an appeal, it must be filed in writing at the Office of the Personnel
Appeals Board, 2828 Capitol Boulevard, Oiympia, Washington 98501, within thirty (30)
days after the effective date stated in the first paragraph of this letter.
The Merit System Rules, WAC's, Department of Corrections policies and the Collective
Bargaining Agreement are available for your review upon request.

leu -}a'·tt~·~

t2'n/~

Belinda D. Stewart, Superintendent
McNeil Island Corrections Center

Attachment(s)
cc:

Tom Rolfs, Director, Division of Prisons
Jennie Adkins, Director, Division of Human Resources
Donna Grazzini, \NVVC Area Personnel Manager
Linda Dalton, Sr. Assistant Attorney General
Katherine Deuel, MICC Personnel Officer
Employee Personnel File

0882

*** CONFIDENTIAL ***

-

DEPARTMENT OF CORRECTIONS

_

\\

~'

.

DISCIPLINARY ACTION AUTHORIZATI~~ ~
~illJ
DEC 15 1995
'.:::::.-

l50W

~.::!

Donna
:~:.
.: .

L EVANS

OFFICE OF ATIORNEY GENERAL '.
LABOR & P.ERSONNEL DIVISION ~

EmpIayee's Name

.'. '"

.

,

~,,;:.....: .~; .. ar:~;'
.'.- ...
...

12/14195
Data Received at Headquarters

.~

-

,. '

RECOMMENDED ACTION:
Reducticn in Pay:

LPN3
EtnpIoyee's Job Classifleatton

.• t,·: •• ·~

.

'

..
_..

...•

.. ~ ~ .. :

•••••••:0, •• -

MICC

.

.-

Suspension:

Employee's Job LccaUon

Dismissal:
Kathy Deuel2Q6.512~OS

! 1//1~

I"/1f;

-//

-"""-i-'--=---f--:i-+-'-~----j
l
r (L!ngth)

1/16/96

------:=:--.'~-----

(Effective)

Assigned Personnel Officer/Phone II

The attached disciplinaJY action has been reviewed as noted beloW. '"This infonnation is provided under the
attomey/dient relationship and invokes that privilege. It should be considered CONFIDENTIAL in nature."
InitialslTiUe

Date

Approve

Disapprove

Comments

I

.. .
'

........
,

'.

_......
;', .

Please hand deliver to all reviewers and return to Kristi Walters, DHR, 8th Aocr, MS: 41102.
"~

0883 .

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0884

.

12/14/1995

17:84

MIce PERSONNEL

206-512-66a9

December 14, 1995

PAGE

02

80 Cays ~ Feb. 5, 1996

IMMEOIATE SUSP/OISMISSAL
WPO ~ NS

PERSONAL SERVICECONF10ENT1AL

Ms. Evans:
This is official notification of your immediate suspension. at 12:01 a.m. on January 1,
1996 through 12:00 midnight on January 15, 1996. followed by your dismissal effective
at 12:01 a.m. on January 16, 1996. from your position as a Licsnsed Practical Nurse 3
with the Department of Corrections (DOC), McNeil Island Corrections Center (MiCe).
This disciplinary action is taken pursuant to the authority of the Civil Service Laws of
Washington State, Chapter 41.06, RCW, and the Merit System Rules. Title 356 WAC
(MSR). Section 356-34-010 DisciplinarJ actions - Causes for demotion-Suspension-Reduction in salary-Dismissal. (1) (a) Neglect of dUty, (h) Gross misconduct and (i)
Willful violation of published employing agency or Department of Personnel rules and
regulations, RCW 356-34-040 Dismissal - Notification and RCW 356-34-050 Suspension
- FollOWed by dismissal.
Specifically, you neglected your duty. committed act(s) of gross misconduct and willfully
violated published employing agency rules when you, by your own admission dUring the
administrative

review

of

this

incident,

accessed

;.a11~~J

I

inappropriately, and without proper documentation

i',...iVH~(~C)/

medication

(Le., Personal" Encounter Report,

PER). from the MICC mini-pharmacy tackle box when

'I....

YOu're~o Furosemide 40

mg tablets sometime between June 28. 1995, and JUly 14, 1995, without having been
directed or ordered to do so by a PA or Physician, apparently taking the tablets for your
personal use. This incident is described in detail in the Employee Conduct Report (ECR)
completed on December 5. 1995 (Attachment 1).

0885

1828 ~tal Blvd.
PO Box 40911
Olympia. WA 98504-0911

•

STATE OF WASHINGTON

PERSONNEL APPEALS BOARD

(360) 586-1481
FAX (360) 7SJ.Q139

qE:CF:1V:=' .

SEP 25 1996
September 25, 1996

Qe~~ .•

_.

CM$CI1 'Ji Hllrr~~ '-_ •..

Robert F. Spaulding
Attomey at Law'
P.O. Box 7846
Olympia. WA 98507-7846

RE:

Donna L. Evans v. Department of Corrections, Dismissal Appeal,
Case No. DISM-96-Q005

Dear Mr. Spaulding:
Enclosed is a copy of the order of the Personnel Appeals Board in the above-referenced matter.
The order was entered by the Board on September 25, 1996.
Sincerely,

?.f;:&<{..

KenneJ~ch

Executive Secretary
KJL:tmp

Enclosure
cc:

Donna L. Evans
Valerie B. Petrie, AAG
Jennie Adkins, PO
Kirk Hanson, REP

oes£

·'

.1
2

3

"'~

4

.. - .'

.,

5

DONNA L:

BEFORE THE PERSONNEL APPEALS BOARD
STATE OF WASHINGTON

EvANs',

6

)
)
)

Appellant,
v.

)
)
)
)

7
DEPAR~

a

OF CORRECTIONS,

Respondent.

9

NO.

DISM 96-0005

MOTION AND ORDER OF DISMISSAL

MOTJ:ON

The appellant hereby notifies the Personnel Aooeals Board that
she wishes to withdraw the above-entitled appeal.
'71
DATED this ~ day of
1996.

10

l,CM ;or,

11

~

12

SW~,

PAJL~,

CORDES,

13

YOUNGLOVE ,,~<;:;;;.

14

'>.

?,,~~-

lS

16

ORDER

This matter came on regularly before the Personnel Appeals Board
on the consideration of the reauest of the acoellant to withdraw her
appeal. The Board having reviewed the files ar.d records herein, being
i fully advised in the premises, and it appearing to the 30ard that the
19 appellant has requested to withdraw her appeal, now, therefore,
1

20

IT IS HEREBY ORDERED that the appellant s request to withdraw her
appeal is granted and the appeal is dismissed.
I

DATED thisas

M

day of

~,j..u , 191d,.
WASHINGTON STATE PERSONNEL APPEALS BOARD

23

24

=ct:

25

26

SWAH$CH, PARA. CCAtlE5.
'lOUHGLQVI! • PEEPUS. P.s.
ATTCIQEYS AT VoW

EAS'l'SU PFlCFESSICNAL PlAZA. SUITE A
92. EAST seveHTl1 AII£NUE
pc.acx~

OI.'noCPlA, wAm1INGTON

FACSlMlJ! ~

_.n.e

~

~~.n.t

MOTION AND ORDER OF DISMISSAL

0887

2828 Clpitol Blyd.
PO 80. 40911
Ol¥mpia. WA 911S04-0911

STATE OF WASHINGTON

PERSONNEL APPEALS BOARD

(360) 586·1481
FAX (360) 7S3..Q139

June 5, 1996
Robert F. Spaulding
Swanson, Parr, Cordes, et al
P.O. Box 7846
Olympi~ WA 98507-7846
Valerie B. Petrie
Assistant Attorney General

P.O. Box 40145
Olympia, WA 98504-0145

Re:

Donna 1. Evans v. Deparanent of Corrections, Dismissal Appeal,
Case No.: DISM-96-0005

Dear Counsel:
This confirms that a settlement/pre-hearing conference has been scheduled on June 21, 1996 at
10:00 a.m., at the offices of Swanson, Parr, Cordes, et ai, 924 East Seventh Avenue, Olympia
WA.

The reason for the conference is to attempt to settle the issue on appeal to the mutual satisfaction
of the parties without the need for a hearing on the matter.

If the settlement efforts are unsuccessful, we will attempt to narrow the scope of the issues to go
before the Board for bearing. We will discuss such things as wimess lists, possible stipulations,
briefing schedules, and a hearing date.

If you have any questions, please call me.
~n~~.~ely.

, ....;.-)..
"

';1""
~l
. "",l.l ... ~ ~"",

t'}CrL/L,-,
.

ICenneth 1. Latsen
Executive Secretary

I

~V

KJL:py
cc:
Donna 1. Evans
Jennie Adkins
Kirk Hanson
Z:',pl"lett:n'prehmg\EvOUIs.doc

--e-·

}J. ~~Mrlfo

'Nfl(

.v ~

RECEIVEi.

Nllc.L

APR - 8 1996
~artment of Corredions
DIVISIon of Human Rescurr

2828 ~itol Blvd.
PO 80. 40911
Olympi~ WA 98504-4911

STATE OF WASHINGTON

PERSONNEL APPEALS BOARD

(360) 586-1481
FJ\X(36O) 75~139

April 5, 1996

CERTIFIED P 334 178 357
P 334 178 358
Robert F. Spaulding
P.O. Box 7845
Olympia, Washington 98507-7846
Re:

Donna L. Evans v. Department of
Appeal, Case No. DISM-96-0005

Cor~ections,

Dismissal

Dear Mr. Spaulding:

a

Enclosed is
copy of the Order Denying Appellant's Motion To
Set Aside Disciplina~ Action of the Personnel Appeals Board
in t~e above-referenced matter. The order was entered by the
Board on April 5, 1995.
~relY,

~~lLl~r~u\,tL~~
Kenneth J. Latsch
:,~

Executive Secretary
KJL/gmh

Enclosure
cc:

Donna L. Evans, APP
Valerie B. Petrie, AAG
Jennie A~~ins, DOC
Kirk Hanson, WFSE

0889

o

1

BEFORE TIm PERSONNEL APPEALS BOARD

2

STATE OF WASHINGTON

3
4

)
)

DONNA L. EVANS,

5

Appellant,

~ Case No. DISM-96-0005

6

v.

~

7

DEPARTMENT OF CORRECTIONS,
Respondent

8

ORDER DENYING APPELLANTS
) MOTION TO SET ASIDE
) DISCIPLINARY ACTION
)
)

9

I. INTRODUCTION

10
II

1.1

12

ALEXAJ.'\j1)ER, Chair, and ART WAJ.'\fG, Member, for hearing oral argument on Appellant's

13

Motion to Set Aside Disciplinary Action. The hearing was held at the office of the Personnel

14

Appeals Board in Olympia, Washington. on March 18, 1996. NORA REYNOLDS, Vice Chair, did

15

not participate in the hearing or in the decision in this matter.

Hearing on Motion. This matter came before the Personnel Appeals Board, CHARLES

16

Appearances. Appellant Donna L Evans was represented by Robert Frank Spaulding,

17

1.2

18

Swanson, Parr, Cordes, Younglove & Peeples, P.S. Respondent Department of Corrections was

19

represented by Valerie B. Petrie, Assistant Attorney General.

20

Documents Considered. The Board considered the files and documents in this matter,

21

1.3

22

including:

23

(a)

24
2S

(b)
(c)

[Appellant's] Motion to Set Aside Disciplinary Action, including attached
disciplinary letter, filed February 6, 1996;
[Appellant's] Memorandum. of Authorities, filed February 6, 1996;
Department of Carrections' Response ta Motion ta Set Aside Disciplinary
Action, filed March 8, 1996;

26

Personnel Appe:lls Board
2S28 Dpilol Boulevard
Olympia. W3Shington 98504
hg:c:winword::vad600S.mol

0890

(d)
(e)

Declaration of Belinda D. Stewart, filed March 8,1996; and
Declaration of lacquelene Campbell. filed March 8, 1996.

2
l

II. SUMlVl-illY

4

2.1

s

Nurse 3 with Respondent Deparnnem of Corrections by disciplinary tetter signed by a designee

6

"for" the appointing a,uthoney, the Superintendent of McNeil [sland Corrections Center.

7

handwrinen signarure was in the name of the person the superintendent had designated to be in

8

charge of the institution while she was on holiday leave. The handwritten word "for". appe:lred over

9

the [)1Jed signarure block. containing the name and tide of the appointing authoricy. The terms of the

\0

disciplinary lener ma.ke it clear tha.t the superintendent conducted the predisciplinary he:lring and

11

made the decision to tennin::He Appellant. The superintendent's affid:l.Vit provides that she reviewed

\2

and approved

\]

The designee had not panicipated in the personnel decisions involved here. It is undisputed thilt the

F3Cts. Appellant Donna L. Evans was dismissed from her position as a Licensed. Practical

[h~

suoerintendent's
.

The

lener, directed that it be processed. and directed that it be signed by her designee.

aooointim~
authority
..

-

N:l(Ure of Appe:ll.

-

could not be delelZ,:Hed to her designee.

Appellant moved to set aside the disciplinary sanction of dismissal

16

2.2

17

based on the lack of sign~rure by the appointing authority.

\8
\9

,.

20

not valid bec:lUSC it lacked the appointing authority's signature. pursuant to Carrell.

_.0

Summary of Appellant's Argument. Appellant contends that the disciplinary lener was

2\

Summary of Respondent's Argument. Respondent contends that no signarure is required,

I!

2.4

23

pursuant to Georgjan, and that the designee's signature was merely a ministerial act, pursuant to

"

Personnel :"ppe:lls Board
23'23 Capilol Boulevard
OlymFi;r,. W::l.Shinglon 98'04

2

OS91

2.5
2

Primary Issue. Whether a disciplinary sanction is valid when it is imposed in a disciplinaIy

letter which is not personally signed by the appointing authority.

3
'4

2.6

s

045; Nichols v, pep't of Agriculture. PAB No. 082-65 (1982), ~ Thurston Co. Super. Ct. No.

6

82-2-01501-3 (1984); Carrell v, Dep't of Social & Health Services,

7

cwpeal dismissed as moot. Thurston Co. Super. Ct No. 91-2-02786-9 (1992) [Carrell is ovemtled

8

insofar as it is inconsistent with this decision}; Geo[ii an v Dep't of Social & Health Services. PAB

9

No. S91-002 (1993); David v, De.p't of Corrections. PAB No. 092-008 (1993); Burkett v.

Citations Discussed. RCW 41.06.170(2),42.23.005.42.23.100; WAC 356-34-020, 356-34-

10

Washin~n

11

01534-1).

PAB

No. 090-116 (1991).

State Patrol, PAB No. L93-051 (1995), appeal filed Thurston Co. Sucer. Ct. No. 95-2-

12

Summary of Board's Decision. The Board traces the history of precedents on the issue of

13

2.7

14

disciplinary letters not personally signed by the appo'inting authority. In Nichols, the Board's

L5

approval of the signature of a deputy director was reversed on other grounds in Superior Court. In

16

Carrell, a majority of the Board ruled that the handwritten signature "'for" the superintendent by a

17

person who lacked appointing authority voided the disciplinary action. It is unclear from the record

18

whether the Board was aware that the designee had merely signed for the superintendent without

19

otherwise participating in the decision. In Georiian. a majority of the Board held that a signature

20

was not required by an appellant or union representative in filing an appeal. In

21

upheld discipline in which the appointing authority made the disciplinary decisions and a

22

subordinate signed the letter as an authorized ministerial act.

~

the Board

23

24

The requirements in RCW 41.06.170(2) and in WAC 356-34-020 et seq. are for "specified charges

2S

in writing:' not for a specific personal signature by the appointing authority. Moreover, in contrast

26

PcrsOMel Appe3Js Board
2828 Capitol Boulevard
Olympia. Washington 98504
hg:c:\Vin\Von1:evad600S.mol

3

0892.

1

to the decision-making function which ini~ directs, and is responsible for the contents of the

2

letter, the act of signing "for" the appointing authority is merely a ministerial act.

3

overruled insofar as it is inconsistent with this decision.

Carrell is

4

s 2.8

Conclusion. Appellant's motion to set aside the disciplinary action is denied

6

ID. DISCUSSION

7

This plotion presents the Board squarely with the issue of whether a disciplinary sanction is

8

3.1

9

valid when it is imposed in a disciplinary letter which is not personally ~ by' the appointing

10

authority.

11
12

By disciplinary .letter dated January 3, 1996, Appellant Donna L. Evans was notified of her

13

immediate suspension and dismissal as a Licensed Practical Nurse 3 with Respondent Department

14

of Corrections at the McNeil Island Corrections Center.

15

signarure block:

16
17

The letter concluded with the typed

Belinda D. Stewart. Superintendent
McNeil Island Corrections Center

18

19

20
21
22
23

24
2S

Above the signature block in handwritten script appear the words "for - Jacquelene Campbell."
Jacquelene Campbell, who was designated to be in charge of the institution while Stewart was on
holiday leave, signed the letter "for" Belinda D. Stewart, but otherwise was not involved with the
disciplinary action. (Declaration of Campbell). Although not personally signed by her, the terms of
the letter make it explicitly clear that Stewart conducted the predisciplinary hearing in this matter
and made the decision to tenninate Appellant. Moreover, her affidavit further provides that she
reviewed and approved the letter, directed that it be processed, and directed that it be issued under

PersoMel Appe:Us Board
2828 Capitol Boulevard
Olympia. Washington 98504
hg:c:winwOnf:cvad600S .mOI

4

0883

1

her signature while she was on holiday leave by the person she left in charge. (Declaration of

2

SteWart).

3
4

It is undisputed that Stewart was the appointing authority and that appointing authority could not be

5

delegated to Campbell.

6

7

This issue has come before the Personnel Appeals Board on several occasions, although not as

8

clearly and directly ~ here. We take this opportunity to attempt to clarify our interpretation.

9
10

.. "J

~.-

In Nichols v. Dep't of Asuiculture, PAB No. 082-65 (1982), rev'd Thurston Co. Super. Ct

11

No. 82-2-01501-3 (1984), the appellant moved to set aside a suspension on the basis that the Deputy

12

Director had signed the letter while the Director was out of state. The Board denied the motion. It

13

considered RCW 42.23.005, which authorized the Director to appoint a Deputy Director to have

14

general supervision over the department in the Director's absence. The Board simply stated: "'In the

15

absence of the Director, the signature of the Deputy Director on the notice of suspension was

16

appropriate:'

11

Superior Court reinstated the Appellant "for the reason that neither the Director ... nor the Deputy

18

Director, in the Director's absence, is the appointing authority of the appellant for purposes of

19

appoinunent or discipline."

20

supervisor of grain was the appointing authority, although discipline may require the approval of the

21

Director.

However, the Board's decision was reversed on appeal.

The Thurston County

Instead, the court held that, under former RCW 43.23.100, the

22

In Carrell v. Dep't ofSocjal & Health Services, P.A.B No. 090-116 (1991), appeal dismissed

23

3.3

24

as IDoot, Thurston Co. Super. Ct. No. 91-2-02786-9 (1992), the disciplinary letter for a reduction in

25

26

PersoMel Appe:l1s Board
2828 ClpilOI Boulevard
Olympia. WashingtOn 98504
hg:c:winword:evad600S.mOl

5

0894 .

1

pay bad a typed signature block for Thomas Fritz, Superintendent of Eastern State Hospital, but the

2

handwritten signature was "Alden H. Miller, M.D. for Thomas Fritz, Superintendent."

3
4

Appellant moved to dismiss for failure of the Respondent to perfect the disciplinary action bC1:ause

s

Dr. Miller was not the appointing authority..The Hearings Examiner granted the motion, ruling that

6

"[t]he failure of DSHS to exercise the disciplinary authority through a proper subdelegate voids its

7

action."

8

RC1:onsider, .slip op. at 4 (Vache', Hrgs. Exam.)(199 I)).

(Disposition of Motion, Disposition of Case on Motion, Disposition of Motion to

9

10

Respondent moved for reconsideration and provided an affidavit from Fritz that he personally

11

conducted the Personnel Conduct Report hearing, determined that misconduct had occurred,

12

determined the level of discipline, directed the disciplinary lener to be prepared, reviewed the lener,

13

and approved its content.

14

involved in the matter in any way except that he was Fritz·s '·official designee orily for the purpose

IS

of signature," bC1:ause Fritz was gone that day.

The affidavit also stated that Acting Superintendent Miller was not

16

"r

17

The Hearings Examiner acknowledged the "close question," but denied the motion to reconsider:

18

conclude that the anempt to delegate even the signing authority is improper; under WAC 356-34-

19

010, all. I am guided by Judge Doren's [sic] decision in Nichols ... reversing the Personnel

20

Appeals Board on a strikingly similar set of facts." ld.. at 5-6.

21

Examiner was aware of the result in the Nichols appeal, but did not have the benefit of knowing that

22

the court's reasoning was significantly different.

We assume that the Hearings

23

24

Following a hearing on exceptions to the Board, the majority affinned the Hearings E.xaminer's

2S

ruling on the original motion without reference to the motion for reconsideration. The Board ruled:

26

Personnel Appe31s Board
2828 C1pilOl Boulcvud
Olympia. Washinglon 98504
hg:e: w inwon1:evad600S.mOI

6

0895.

One motion dealt with the failure of the Appointing Authority to sign the disciplinary
letter. The Hearings Examiner ruled that the failure of Department of Social and
Health Services (DSHS) to exercise disciplinary authority through as [sic] proper
subdelegation voids its action. For this reason, he granted the Appellant's motion
and set aside the Respondent's disciplinary action against the Appellant. We affirm,
however we make no ruling regarding the ability of the Appointing Authority to take
action.

1
2

3
4

s
Findings, Conclusions and Order of Board Following Hearing on Exceptions, at 1-2.
6
1

It is unclear from the record whether the Board was aware that Dr. Miller had merely signed for the
8

Superintendent without otherwise participating in the decision. A dissenting op~on cited RCW
9

41.06.170(2), WAC 356-34-020, and WAC 356-34-045 that there must be "specified charges in
10

writing," but that there was no requirement for a signature. It also argued that the statute required
11

the employee's appeal to be in writing, but that the Board accepted appeals signed by an employee's
12

representative and had never required a signarure from the employee.
13

w.. (Wilson, dissenting).

14

In an Intennediate Order Denying Motion to Dismiss in Georgian

15

3.4

16

Health Services, PAB No. S91-002 (1993), the Board considered a converse scenario suggested by

17

the dissent in Nichols, in which neither the appellant nor a union representative signed the appeal.

18

A majority of the Board held that "there is no rule which requires any signature."

19

distinguished Carrell, stating: "It was not the fact that Dr. Nfiller signed the action letter which was

20

determinative of the outcome, but rather that Dr. ~filler took the disciplinary action."

21

statement appears to be based on the majority decision in Carrell, but not on the underlying decision

22

of the Hearings Examiner in that case. A concurring opinion in Georgian recommended overruling

23

Carrell.

~ (Wilson,

v.

Dep't of Social &

The majority

This

concurring).

24
2S

26

PersoMel Appe:lls Board
2828 C.lpitol Boulevard
Olympia. W~hington 98504
hg:c::winword:evad600S.mot

7

089:

1

3.5

1

reduction in pay was signed in handwriting "D.A. Dunnington for" over the typewritten signature

3

block "Richard Bosse, Superintendent." The Superintendent testified that he made the finding of

4

misconduct, determined which sanction to impose, and reviewed preHrninary drafts of the

s

disciplinary letter.

6

Dunnington in his absence. The Hearings Examiner denied Appellant's motion to set aside the

7

discipline, concluding that the delegation and exercise of the appointing authority by the Associate

8

Superintend~nt

9

(Woods, Hrgs. Exam.). After a hearing on exceptions, the Board modified the decision, concluding

In David v, D«:11't of Cgqections. PAB No. D92-OO8 (1993), the disciplinary letter for a

He delegated, in writing, appointing authority to Associate Superintendent

was proper.

Findings of Fact, Conclusions of Law and Recommended Decision

nm have authority to delegate his appointing authority.

However, the

10

that the Superintendent did

11

Board upheld the discipline, noting only that the signatUre was "an authorized ministerial act."

12

There is no indication in the record that Nichgls, Carrell, or Georgian were brought to the Board's

13

attention. The Board's decision merely states:

l4

IS

16
l7

In this case, it was the appointing authority' who determined that misconduct
occurred and instructed that the Appellant should be reduced in pay. The subsequent
signing of the disciplinary letter "fur Richard Bosse" (emphasis added) in
Superintendent Bosse's absence was an authorized ministerial act.

hi. (emphasis in original).

18

19

In Burkett v. Wasbinitgn State patrol, PAB No. L93-051 (1995), appeal filed Thurston Co. Super.

20

C1. No. 95-2-01534-1, a reduction in force notice was signed by the Deputy Chief, who had

21

appointing authority, although the agency policy provided that "(nlorification shall be signed by the

22

Chief." The Board denied Appellant's motion for summary reinstatement because the Deputy Chief

23

had delegated authority, as opposed to being only the Chiefs designee.

24

precedents discussed above were brought to the Board's attention.

Again, none of the

2S

26

Personnel Appe:als' Board
2828 C1picol BouJeV3J'd
Olympia. Washington 98504
hg:c:winw ord:evad6005.mOl

8

08 g.'(

3.6

We conclude that Appellant's motion $ould be denied. As noted in the dissenting opinion

2

in Carrell and in the majority opinion in GeQI2ian, the requirements in RCW 41.06.170(2) and in

3

WAC 356-34-020 ~ are for "specified charges in writing," not for a specific personal signature

4

by the appointing authority. Moreover, in contrast to the decision-making function which initiates,

s directs, and is responsible for the contents of the letter, the act of signing "for" the appointing
6

authority is merely a ministerial act. Dmd. Cauell is OVerruled insofar as it is inconsistent with

7

this decision.

8
9

10

Having reviewed the files and records in this matter and being fully advised in the premises, the
Board enters the following:

11

u

~o~m

13

NOW, THEREFORE, IT IS HEREBY ORDERED that Appellant's Motion to Set Aside

14

Disciplinary Action is denied.

15
16

DATED this

.5

d
day

Of_=~~~~=:;..:,·_====-_-,.

1996.

17

WASHINGTON STATE PERSONNEL APPEALS BOARD

18
19
20

21
22
2J

24
2S

26
Personnel Appeals Board
2S28 DpilOl Boulevard
hg:c:winword:cvad6005.mot

Olympia. WashinglOR 98504

9

089!
/'

RECEI V t:.~

JAN 23 1996
ofCo~
O~af
MSlOl1 tUnaQ. ResQlIl'"
2828 Capit~ Blvd.
PO Box 40911

STATE OF WASHINGTON

PERSONNEL APPEALS BOARD

Olympia. WA 98S04-mn

(360) 586-1481
FAX (360) 753-0139

January 22, 1996

Mr. Kirk Hans~n
Washington Federation of State Employees
10116 - 36th Avenue Ct SW #205
Tacoma. WA 98499

RE:

Donna L. Evans v. Deparonent of Corrections, Dismissal Appeal,
Case No. DISM-96-000S

Dear !vIr. Hanson:
This letter is to acknowledge receipt of the above entitled appeal by the Personnel Appeals Board
on January 10, 1996.

'J..Lc..Llr(ljf-1lL /erineth J. Latsch
Executive Secretary

~

KJL:unp
cc:
Donna L. Evans
Swanso~ Parr, Cordes, et. aI.
Linda A. Dalto~ AAG
Jennie Adkins, PO

.. ;

Z:\lmp\nc:wappl\cvans.doc
.~

°0

IJ\ .... l"\- ..,

WASHINGTON STATE PERSONNEL APPEALS BOARD
2828 Capitol Boulevard
PH:
P. O. Box 40911
Olympia, WA 98504-0911
FAX:

(.

~©~~W~IID

U\l

APPEAL FORM

\.D-t."uL..;~

JAN 10 1998
SCAN 321-1481
(206)
586-1481
(206)
753-0139

PERSONNE~

APPEALS BOARD

This form will help you provide necessary infonnation to the Personnel Appeals Board when you file an appeal. You are Jl.Q{ required
to use this fonn; however. appeals II11W be tiled in accordance with the requirements. set forth in Chapter 358-20 WAC.

If me space on the fonn is insufficient or if you wish to provide additional information. you may attach additional pages.
PRINT OR TYPE - SIGN ON PAGE 2
PARTL·

APPELLA!Vf IDENTIFICATION

NAME: Donna L. Evans (AKA Turner, Lake)
(Last name; ursf name. muldle 1D1tiii)
HOME ADORES

....

~----------------------

PHONE NUMBERS:

(Off-SCAN): (206)588-5281

WORK: (SCAN):
HOME:

(Include

area cOde)

_

EMPLOYING AGENCY OR INSTITUTION: McNeil Island Corrections Center/DOC
Agency or institution that took action you are appealing: Department of Corrections

PART II.

REPRESENTATIVE'S NAME, ADDRESS .-\!'ID TELEPHONE

~UMBER

Swanson. Parr. Cordes, Younglove, Peeples,P.S.
PO Box 1846
Olympia, WA 98507
(360)351-1191

Kirk Hanson
10116 36th Ave Ct., Suite 205
Tacoma, WA 98499
(206)581-l402

An Appellant may authorize a representative to act on his/her behalf.
The Board must be notified of any change in representation.

PART

m.

TYPE OF APPEAL
Check one of me following to indicate the type of appeal you are filing:
X

a. Disciplinary: (check applic30le action(s».

X Dismissal

X Suspension

Demotion

Reduction in P3Y.

b. Disability Separation
c. Rule or Law Violation (complete PART IV. of this form)
d. Reduction in ForceJ1.:lyoff (complete PART IV. of this form)
e. Allocation (position classification) (complete PART V. of this form)
f. Declaratory Ruling (see WAC 358-20-050)
g. Exemption of Position

0900

,

'

fOR RULE VIOLATION OR REDUCIION-llf4ORCE APPEALS ONLY

PARTIV.

What Rule(s) or Law(s) do you believe were violated?

Explain the particular circumstaD~ ofthe alIeged-violation.

HO?N were you adversely aff'ecte! by :he alleged violation?

What remedy an: you requ~g in this case?

F.OR.ALLOCAnON APPEALS ONLY

PARTV.

Yes or

Has there been a review ofyour allocation?
Is so. by whom.,?

r,

No

.,.,._'.....;..
. .;:.'.

~,

.

..•_... ... -ilI...
.' •.

~..
~

v., .

"

~"~;:l
::z

.
.' ~
--.;.'..;.;._'
•.

What is your present classificadon?

_

To which class do you thinJc your position should be alIocated?:-~~~I~;~

.• .:.:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _E2'W"'W1jj;,j·
~1iiirO.i..:._".;:;,..r-_

_
~~---------------

//"&6

DA"FE SIGNED

..