Facts and Procedural History In September 2014, DPH sent Palmore, who was employed by DPH as a staff nurse in Walker County, a "Notice of Pretermination Conference" notifying her that her supervisors had recommended that she be dismissed from her employment with DPH because, her supervisors said, on July 7, 2014, she had not taken the blood pressure of a patient ("the patient") or calculated the patient's body mass index ("BMI") before giving the patient an intramuscular injection
("the injection"); because, her supervisors said, she had not properly recorded the patient's blood pressure and BMI in the patient's chart when she saw the patient; and because, her supervisors said, she had subsequently entered false blood-pressure and BMI information in the patient's chart. On October 8, 2014, DPH held a pretermination conference at which Palmore was afforded the opportunity to respond to the charges and to present evidence in opposition to the charges. On October 15, 2014, DPH sent Palmore a letter notifying her that her employment as a staff nurse with DPH would be terminated at the close of business on October 16, 2014.
Thereafter, Palmore timely appealed to the Board. Her appeal was assigned to an administrative-law judge ("the ALJ"), who conducted a de novo hearing. On January 1, 2015, the ALJ sent the Board a recommended order in which he recommended that the Board uphold Palmore's dismissal. In his recommended order, the ALJ made the following findings of fact:
"Having reviewed the documentary evidence, having heard the witnesses' testimony, having observed the witnesses' demeanor, and assessed their credibility, the undersigned finds the greater weight of the evidence supports the following findings of fact:
"....
"C. Facts Forming the Basis of Dismissal
"Palmore has been a Registered Nurse (‘RN’) since 1999. Palmore had prior experience working as a Staff Nurse at Cooper Green Hospital (1994-1999); Birmingham Veterans Administration Hospital (1991-1993); and Baptist Medical Center-Princeton (1990-1991).
"Palmore taught nursing classes for Fortis, a proprietary School of Nursing in 2014, during her employment at DPH Walker County. Palmore also taught nursing at Bevill State Community College (‘Bevill’) during 2011, while employed by DPH at the [Walker County Health Department] Clinic [ (‘the Clinic’) ].
"Palmore's lateral transfer from case management to providing direct patient care at the Clinic was accompanied by training and orientation in the health care modules utilized by the Clinic. From October 2013 until February 2014, Palmore had written protocol materials and preceptor oversight in transitioning into her clinical role. Palmore insists that her training was inadequate and that her guidance by preceptors was compromised by the retirements of two of her preceptors. Her third preceptor, Karla Legg (‘Legg’), was present at the Clinic from the time of Palmore's clinical activities in October 2013 until the termination of her employment in [October] 2014. Legg provided direct preceptor guidance to Palmore from March 2014 until July 2014. DPH provided training and then retraining to Palmore when she expressed her discomfort over the training DPH had given her. Nurse Educator Marilyn Knight and Dr. John Hankins (‘Dr. Hankins’) responded to Palmore by having her retrained in the extant modules.
"Dr. Hankins testified that an RN, by virtue of the training required to achieve that designation, should be competent to follow protocols and to recognize the critical importance of accurate documentation in a patient's chart.
"Considering her lengthy experience as an RN and her teaching of nursing at Fortis and Bevill, one could expect that Palmore could accurately take vital signs and properly record them in a patient's chart. With written protocols to guide her activities at the Clinic, one could expect that a nurse with Palmore's experience could deliver nursing services consistent with established protocols.
"Palmore failed to follow the DPH written protocols in providing services to patients. When Palmore failed to give hemoglobin tests to five [Women Infants and Children Program (‘WIC’) ] patients at the Clinic in March 2014, Dr. Hankins ordered that Palmore be retrained in various modules. Palmore acknowledged her mistake with the WIC patients. Palmore said she could not remember all the protocols. Palmore was removed from providing clinical services to WIC patients in March 2014. Palmore received training in providing WIC services to patients by LeAnn Colvin, a Registered Dietician at the Clinic. Palmore insists that she was not ‘certified’ in the WIC Program.
"On July 7, 2014, Palmore gave a birth control shot of Depo-Provera to a Clinic patient. Palmore did not follow the Family Planning Clinic Protocol in that she gave the shot without recording a blood pressure and BMI in the patient's chart as required. The patient, with her Clinic chart, next went to a Clinic Social Worker, Melanie Aldeen (‘Aldeen’). Aldeen determined from talking to the patient and looking at the chart that Palmore had not taken the patient's blood pressure. Ramona Hawkins, CRNP and Palmore's supervisor, confirmed with the patient on July 8, 2014, that Palmore had not taken the patient's blood pressure during her visit to the Clinic on July 7, 2014.
"At some point after the patient left the Clinic, Palmore retrieved the patient's chart and recorded a blood pressure and a BMI. Palmore insists she had taken the blood pressure and had recorded it on a ‘sticky note’ instead of in the patient's chart. Palmore never provided the ‘sticky note’ when questioned by her supervisors and did not provide it during her pre-termination hearing. Palmore says they never asked for it. Palmore, at this hearing, offered Hearing Exhibit 2 which is a copy of a page from Palmore's Daily Patient Log. The Daily Patient Log was a document kept by Palmore for her personal use and was not a DPH record kept in the normal course of business. Line number 8 on page 1 is a reference to the patient to whom Palmore gave the shot on July 7, 2014. Interestingly, the purported ‘sticky note’ has a transposed and inaccurate number for the patient's chart and appears in two places. There are no similar entries in Hearing Exhibit 2. The evidence does not reflect when the note was put in Palmore's Daily Patient Log. Palmore did make a progress note in the patient's chart, which established that Palmore had the chart available to properly document the blood pressure and the BMI if she had taken them. With the chart clearly present during the time of the exam, there would have been no need for a ‘sticky note.’ When Kathi Bailey (‘Bailey’), CRNP, saw the patient's chart on July 7, 2014, there was no blood pressure or BMI recorded in it. Palmore told Bailey she had written the information in the patient's chart after the patient had left the Clinic. Palmore did not offer to show Bailey the note where Palmore said she had written the information. The proper procedure for supplying the missing information would have been for Palmore to record a ‘late entry’ in the patient's chart and acknowledge the late entry or to do an ‘addendum’ explaining the matter.
"Palmore had been counseled by ... Legg ... on numerous (twenty) occasions about her failure to properly document information directly in patient charts and other protocol violations. Failure to properly document patient charts is a serious and dangerous practice. Other health care providers rely on a patient's chart to decide, plan, and deliver safe and effective health care services. Proper and accurate charting is critical. Dr. Hankins testified that such charting failures can result in harm to a patient up to and including death. Dr. Hankins testified that Palmore ‘exhibited a consistent pattern of poor nursing practices.’ Dr. Hankins said an RN should, by virtue of being an RN, be able to properly chart, document and follow written protocols. Dr. Hankins has reported Palmore to the State Board of Nursing indicating Palmore falsified information in a patient's chart and that ‘he considered Palmore a danger to patients and that she was an unsafe nurse for not following protocols.’ "
(Footnotes omitted.)
Palmore submitted exceptions to the ALJ's recommended order; DPH submitted a response. Palmore also requested and was granted an opportunity to present oral argument to the Board. On February 18, 2015, the Board issued an order incorporating the ALJ's findings of fact and conclusions of law and upholding Palmore's dismissal.
Thereafter, Palmore timely filed a notice of appeal and cost bond with the Board. On April 10, 2015, Palmore petitioned the circuit court for judicial review of the Board's decision. The Board transmitted the record on appeal to the circuit court and answered Palmore's petition. In December 2016, the circuit court entered an order establishing a schedule for the parties to submit briefs and set the final hearing for February 21, 2017. Thereafter, the parties submitted their briefs. On February 21, 2017, the circuit court held a final hearing at which the parties were afforded an opportunity to present oral argument. On September 19, 2017, the circuit court entered a final judgment in which it found that the Board's decision to uphold the termination of Palmore's employment was...
