[Cite as Clayton v. Ohio Bd. of Nursing, 2014-Ohio-2077.]

                             IN THE COURT OF APPEALS OF OHIO

                                  TENTH APPELLATE DISTRICT


Beverly Clayton, C.N.P., R.N.,                         :

                Appellant-Appellant,                   :
                                                                        No. 13AP-726
v.                                                     :             (C.P.C. No. 12CV-13572)

Ohio Board of Nursing,                                 :           (REGULAR CALENDAR)

                Appellee-Appellee.                     :




                                           D E C I S I O N

                                      Rendered on May 15, 2014


                Sindell and Sindell, LLP, Steven A. Sindell and Rachel Sindell,
                for appellant.

                Michael DeWine, Attorney General, and Henry G. Appel, for
                appellee.

                  APPEAL from the Franklin County Court of Common Pleas

KLATT, J.
        {¶ 1} Appellant-appellant, Beverly Clayton, appeals a judgment of the Franklin
County Court of Common Pleas affirming the order of appellee-appellee, the Ohio Board
of Nursing ("Board"), that suspended Clayton's registered nursing license and certified
nurse practitioner certificate.         For the following reasons, we affirm the trial court's
judgment.
        {¶ 2} At approximately 4:10 p.m. on August 27, 2009, Patient 1, an 80-year-old
man, arrived at the emergency department of Mercy Franciscan Hospital – Western Hills
No. 13AP-726                                                                                              2

("Mercy").1 Patient 1 was in poor health; he suffered from congestive heart failure, atrial
fibrillation, chronic renal failure, and chronic obstructive pulmonary disease.                           He
presented at Mercy complaining of shortness of breath.
          {¶ 3} Dr. Jamelle Bowers, a Mercy hospitalist,2 was assigned as Patient 1's
attending physician. Bowers examined Patient 1 and decided to admit him to Mercy's
intensive care unit ("ICU"). At 6:15 p.m., Dr. Bowers handwrote a series of orders on a
single-page form marked "PHYSICIAN'S ORDERS."                          In relevant part, those orders
included:       the administration of 40 milligrams of the drug Lasix (also known as
furosemide) every eight hours to stimulate urine output; the administration of a 15
milligram bolus of the drug Cardizem (also known as diltiazem) and then an intravenous
Cardizem drip titrated to bring Patient 1's heart rate below 100 beats per minute; a
consultation with Dr. Kennealy, a pulmonologist; a consultation with Dr. Desai, a
cardiologist; and a saline lock, which precluded the administration of normal saline to
Patient 1. An emergency department nurse faxed Dr. Bowers' orders to the hospital
pharmacy.
          {¶ 4} Patient 1 was transferred to the ICU sometime between 6:30 and 6:50 p.m.
Soon after Patient 1 arrived at the ICU, Clayton's 7:00 p.m. to 7:00 a.m. shift as the ICU
charge nurse began. Patient 1 was assigned to Clayton's care.
          {¶ 5} According to Clayton, she was overloaded with responsibilities during her
shift. She was assigned the direct care of two patients. Additionally, she frequently had to
step in to assist two inexperienced nurses with the care of their patients. She also had to
act as unit secretary, which required her to enter physician's orders into the hospital
computer system, initiate consultations, and answer the ICU phone.
          {¶ 6} Clayton did not review the physician's orders for Patient 1. Instead, Clayton
relied on the information in the hospital computer system to care for Patient 1. Because a
hospital pharmacist had entered that information into the computer system, it related
solely to the medications that Dr. Bowers had ordered for Patient 1. Not only was the
information limited, it was also wrong. The pharmacist had incorrectly entered into the


1 We, like the Board and trial court, refer to the patient involved in this case as "Patient 1" to protect his

privacy.

2   Dr. Bowers is actually Mercy's lead hospitalist and directs Mercy's hospitalist program.
No. 13AP-726                                                                              3

computer Dr. Bowers' order for the administration of Cardizem. Rather than calling for a
15 milligram bolus and then a titrated dose to decrease Patient's 1 heart rate to less than
100 beats per minute, the information entered into the computer indicated that Patient 1
was to receive one 25 milligram bolus. Clayton administered a 25 milligram bolus of
Cardizem to Patient 1 at 10:16 p.m. She also administered one 40 milligram bolus of Lasix
at 10:16 p.m.
       {¶ 7} During the course of Clayton's shift, Patient 1 received 1,097 milliliters of
normal saline, despite the saline lock ordered by Dr. Bowers. In addition to failing to
maintain the saline lock, Clayton did not carry out Dr. Bowers' orders to: (1) administer
40 milligrams of Lasix every eight hours, (2) establish an intravenous Cardizem drip and
titrate the drip to achieve a reduction in Patient 1's heart rate to less than 100 beats per
minute, and (3) initiate the pulmonary and cardiology consultations.
       {¶ 8} Throughout the night, Patient 1's heart rate remained above 100 beats per
minute. At 2:00 a.m., his blood pressure had fallen to 99/45, and it continued to fall after
that point. Despite the administration of Lasix at 10:16 p.m., his fluid output did not
increase. The administration of Cardizem (also at 10:16 p.m.) was likewise ineffective.
       {¶ 9} At 4:00 a.m., Clayton notified the hospitalist on call, Dr. Kern Chaudhry, of
Patient 1's condition. Although Dr. Chaudhry treated Patient 1, his condition continued to
deteriorate.
       {¶ 10} Dr. Bowers arrived at the hospital at 7:00 a.m. on August 28, 2007. She
visited Patient 1 and found him unresponsive and near death.           Dr. Bowers became
agitated when she saw that her orders had not been followed. Patient 1 died at 11:17 a.m.
       {¶ 11} In a notice dated November 19, 2010, the Board informed Clayton that it
proposed to revoke, suspend, or restrict her registered nursing license and certified nurse
practitioner certificate because of the allegedly substandard care that Clayton had
provided to Patient 1. The notice asserted that the Board could take disciplinary action
against Clayton under R.C. 4723.28(B)(16), because she had violated rules adopted under
R.C. Chapter 4723, and (2) R.C. 4723.28(B)(19), because she had "[f]ail[ed] to practice in
accordance with acceptable and prevailing standards of safe nursing care." The notice
alleged that Clayton had violated:
No. 13AP-726                                                                                             4

                   Ohio Adm.Code 4723-4-06(H), which requires a licensed
                    nurse to "implement measures to promote a safe
                    environment for each patient;"

                   Ohio Adm.Code 4723-4-03(C), which requires a registered
                    nurse to "demonstrate competence and accountability in
                    all areas of practice in which the nurse is engaged
                    [including] (1) [c]onsistent performance of all aspects of
                    nursing care; and (2) [r]ecognition, referral or
                    consultation, and intervention, when a complication
                    arises;"

                   Ohio Adm.Code 4723-4-03(E), which requires a registered
                    nurse to, "in a timely manner: (1) [i]mplement any order
                    for a patient * * * [and] (2) [c]larify any order for a patient
                    when the registered nurse believes or should have reason
                    to believe the order is: (a) [i]nacurrate; (b) [n]ot properly
                    authorized; (c) [n]ot current or valid; (d) [h]armful, or
                    potentially harmful to a patient; or (e) [c]ontraindicated by
                    other documented information;" and

                   Ohio Adm.Code 4723-4-03(G), which requires a registered
                    nurse to, "in a timely manner, report to and consult as
                    necessary with other nurses or other members of the
                    health care team and make referrals as necessary."3

        {¶ 12} Clayton requested a hearing. At the hearing, Clayton testified that she
reviewed Patient 1's chart, but the physician's orders were missing from the chart. She
was too busy dealing to more urgent matters to seek out the physician's orders. Clayton
waited until 4:00 a.m. to request Dr. Chaudhry's intervention because Patient 1 was
awake and communicating with her prior to that time. Clayton claimed that she gave
Patient 1 1,097 milliliters of normal saline, despite the saline lock, because Dr. Chaudhry
verbally ordered it.4
        {¶ 13} The Board presented witness testimony that cast doubt on Clayton's
contention that she did not read the physician's orders because they were absent from the

3 Each of these rules appears in Ohio Adm.Code Chapter 4723-4, which establishes "[m]inimal acceptable
standards of safe and effective nursing practice for a registered nurse and a licensed practical nurse in any
setting." Ohio Adm.Code 4723-4-01(A)(1).

4 A subsequent physician's order will supercede a conflicting, earlier physician's order. Clayton,
therefore, could not be faulted for failing to maintain a saline lock if Dr. Chaudhry gave orders at 4:00
a.m. that contradicted the saline lock that Dr. Bowers ordered at 6:15 p.m. the prior day.
No. 13AP-726                                                                              5

chart. Joyce Keegan, the vice president for nursing at Mercy and Mt. Airy Hospital,
investigated the incident for Mercy. Keegan testified that Clayton had told her that she
lacked the time to look at Patient 1's chart, rather than, as Clayton testified at trial, that
she looked but could not find Patient 1's physician's orders in the chart. Diane Helferich,
a Board compliance agent, interviewed Clayton after the Board received a complaint
regarding her care of Patient 1. She also testified that Clayton had told her that she did
not review the physician's orders because she did not have the time to do so. Finally, Dr.
Bowers testified that on the morning of August 28, 2009, she "very easily" found the
physician's orders in Patient 1's chart. (Tr. 675.)
       {¶ 14} The Board also pointed out the absence of any written order from Dr.
Chaudhry directing the administration of normal saline.          The medical records only
include a nurse's note, written by Clayton at 4:00 a.m., that states, "IVF 'd to 250 cc
NS." In other words, Clayton increased Patient 1's receipt of intravenous fluids to 250
milliliters of normal saline at 4:00 a.m. Even if this nurse's note memorialized a verbal
order from Dr. Chaudhry to give Patient 1 a 250 milliliter bolus of normal saline, it did not
account for 847 milliliters of the total amount of 1,097 milliliters of normal saline
administered to Patient 1 during Clayton's shift.
       {¶ 15} To establish that Clayton did not meet the minimum standards of safe
nursing care, the Board offered the expert testimony of Lisa Klenke, a registered nurse.
Klenke testified that Clayton failed to practice in accordance with acceptable and
prevailing standards of safe nursing care when she did not review and implement the
physician's orders for the care of Patient 1. According to Klenke, if Clayton could not find
physician's orders for Patient 1 in his chart, she should have contacted the physician.
Keegan, the vice president of nursing at Mercy, testified similarly. Keegan explained that
the absence of physician's orders triggers an obligation to call the physician. As Keegan
stated, physician's orders are "the crux of everything [a nurse] ha[s] to do for that
patient[;] * * * a nurse only acts on orders from a physician for dependent care of that
patient." (Tr. 392.)
       {¶ 16} Klenke was also critical of Clayton's failure to timely recognize that Patient
1's deteriorating condition required intervention by a physician. Klenke testified that
Clayton should have notified a physician that Patient 1 had not responded to the Lasix
No. 13AP-726                                                                             6

administered at 10:16 p.m. Clayton should have also sought a physician's assistance when
she measured Patient 1's systolic blood pressure at 99 at 2:00 a.m. Dr. Bowers generally
concurred with Klenke's assessment. Dr. Bowers testified that Clayton should have called
for a physician by midnight because Patient 1 had not responded to the Cardizem, which
like the Lasix, was administered at 10:16 p.m.        Dr. Bowers also testified that, as a
physician, she would have expected Clayton to call at 2:00 a.m. when Patient 1's systolic
blood pressure dropped below 100.
       {¶ 17} Finally, Klenke rejected the opinion of Clayton's expert witness that it was
impossible for Clayton to comply with the standard of care for Patient 1. Klenke stated
that Clayton should have asked for help once she realized that she could not adequately
care for Patient 1 given the other demands on her time. Keegan testified to Mercy's
protocol for obtaining additional nursing assistance. According to Keegan, the charge
nurse should contact her supervisor, the clinical administrator, or, in the absence of the
clinical administrator, the emergency department charge nurse. Those individuals might
seek the assistance of an on-call nurse, switch a nurse from a different unit to the busy
unit, or call on other staff.
       {¶ 18} In a report and recommendation dated July 31, 2012, the hearing examiner
found that the physician's orders were in Patient 1's chart when Patient 1 was admitted to
the ICU from the emergency department and remained part of the chart throughout the
time Patient 1 was in the ICU. The hearing examiner also found that, after arriving at
Patient 1's bedside at approximately 4:00 a.m., Dr. Chaudhry gave Clayton an order to
give Patient 1 a 250 milliliter bolus of normal saline, but Dr. Chaudhry did not order any
additional normal saline from that point on. Finally, the hearing examiner found that
Clayton should have consulted with a physician as early as 10:16 p.m. after the bolus of
Cardizem failed to reduce Patient 1's heart rate, or at least by 2:00 a.m. due to Patient 1's
significant drop in blood pressure from the previous reading.
       {¶ 19} Based on the evidence, the hearing examiner determined that Clayton failed
to practice in accordance with acceptable and prevailing standards of safe nursing care
and violated the specified administrative rules by: (1) failing to locate and implement the
physician's orders, and (2) failing to timely consult with a Mercy physician about Patient
1's declining condition.        The hearing examiner also found that the chaotic and
No. 13AP-726                                                                              7

overwhelming circumstances of the ICU did not relieve Clayton of her duty to practice
within the acceptable and prevailing standards of safe nursing care. However, the hearing
examiner did consider the chaotic and overwhelming circumstances a mitigating factor in
determining the appropriate discipline.
       {¶ 20} The hearing examiner recommended that the Board suspend Clayton's
registered nursing license and certified nurse practitioner certificate indefinitely, but not
less than one year.     The hearing examiner specified conditions for reinstatement;
probationary terms, conditions, and limitations to apply for a minimum of two years after
the reinstatement of Clayton's license; and permanent practice restrictions.
       {¶ 21} In an adjudication order dated September 21, 2012, the Board accepted the
hearing examiner's findings of fact and conclusions of law. The Board modified the
recommended sanction by changing the conditions for reinstatement; altering the terms,
conditions, and limitations for the probationary period after reinstatement; and deleting
the permanent practice restrictions.
       {¶ 22} Clayton appealed the Board's order to the trial court. After considering
Clayton's assignments of error, the trial court affirmed the Board's order.
       {¶ 23} Clayton now appeals the July 25, 2013 final judgment of the trial court, and
she assigns the following errors:
                 (1) In an administrative evidentiary hearing held before a
                 Hearing Examiner (H.E.) of the Ohio Board of Nursing
                 (OBN) involving alleged nursing practice violations
                 against the license of Appellant Nurse, it is reversible
                 error, contrary to law and in violation of Due Process of
                 Law for the Hearing Examiner to prohibit and deny
                 Respondent Nurse the right to obtain by hearing subpoena
                 and present in the hearing evidence highly relevant and
                 material to her defense against the charges and to her
                 defense in mitigation of sanctions.

                 (2) There is no evidence in the record to support the
                 charge     against    Appellant    that    she   continued
                 uninterruptedly to administer IV saline to Patient 1 during
                 her shift, despite the fact that a physician had ordered a
                 saline lock * * *.

                 (3) Although not listed as an allegation in the Notice of
                 Opportunity for Hearing, there is scant if any evidence that
No. 13AP-726                                                                           8

                 Appellant gave Patient 1 a saline bolus without any
                 Physician Order.

                 (4) Appellant gave Patient 1 a 25 mg. Cardizem (also
                 known as Diltiazem) bolus and not a 15 mg. Cardizem drip
                 because she followed the erroneous pharmacy order to do
                 so which had been entered into the computer.

                 (5) The claimed violation in the Notice of Opportunity for
                 Hearing that Appellant waited too long, until 4:00 a.m. on
                 August 28, 2009, to notify the night hospitalist, Dr.
                 Chaudhry, is an unfounded exercise in 20/20 hindsight.

                 (6) The Hearing Examiner erroneously shifted the burden
                 of proof by a preponderance of the evidence from the
                 OBN/State to Appellant.

                 (7) It was reversible error to have permitted Nurse
                 Klenke, a member of the Board during its investigation
                 into the performance of Appellant, to testify as an expert
                 witness (when she was thereafter no longer a Board
                 member) and for the Board to deliberate and decide upon
                 its Adjudication Order in this case when Nurse Klenke had
                 returned to the Board and was a member of the Board
                 while the Board engaged in its deliberations and made its
                 decision in this case.

      {¶ 24} Pursuant to R.C. 119.12, when a common pleas court reviews an order of an
administrative agency, the court must consider the entire record to determine if the
agency's order is supported by reliable, probative, and substantial evidence and is in
accordance with law. To be "reliable," evidence must be dependable and true within a
reasonable probability. Our Place, Inc. v. Ohio Liquor Control Comm., 63 Ohio St.3d
570, 571 (1992). To be "probative," evidence must be relevant or, in other words, tend to
prove the issue in question. Id. To be "substantial," evidence must have some weight; it
must have importance and value. Id.
      {¶ 25} In reviewing the record for reliable, probative, and substantial evidence, the
trial court " 'must appraise all the evidence as to the credibility of the witnesses, the
probative character of the evidence, and the weight thereof.' " AmCare, Inc. v. Ohio Dept.
of Job & Family Servs., 161 Ohio App.3d 350, 2005-Ohio-2714, ¶ 9 (10th Dist.), quoting
Lies v. Ohio Veterinary Med. Bd., 2 Ohio App.3d 204, 207 (10th Dist.1981). In doing so,
No. 13AP-726                                                                            9

the trial court must give due deference to the administrative resolution of evidentiary
conflicts because the agency, as the fact finder, is in the best position to observe the
manner and demeanor of the witnesses. Univ. of Cincinnati v. Conrad, 63 Ohio St.2d
108, 111 (1980).
       {¶ 26} Unlike a trial court, an appellate court may not review the evidence. Pons v.
Ohio State Med. Bd., 66 Ohio St.3d 619, 621 (1993). An appellate court is limited to
determining whether the trial court abused its discretion. Id. Absent such an abuse of
discretion, an appellate court must affirm the trial court's judgment, even if the appellate
court would have arrived at a different conclusion than the trial court. Lorain City School
Dist. Bd. of Edn. v. State Emp. Relations Bd., 40 Ohio St.3d 257, 261 (1988). When
reviewing the trial court's judgment as to whether an agency's decision is in accordance
with law, an appellate court's review is plenary. Spitznagel v. State Bd. of Edn., 126 Ohio
St.3d 174, 2010-Ohio-2715, ¶ 14.
       {¶ 27} By her first assignment of error, Clayton argues that the hearing examiner
erred in refusing to fulfill her request to issue a subpoena for the medical records of the
other patients present in the ICU during her shift. Even if the hearing examiner erred as
alleged, Clayton is not entitled to reversal because she has not shown how that alleged
error prejudiced her.
       {¶ 28} Pursuant to R.C. 119.09:
                   the agency may, and upon the request of any party
                   receiving notice of the hearing as required by section
                   119.07 of the Revised Code shall, issue a subpoena for any
                   witness or a subpoena duces tecum to compel the
                   production of any books, records, or papers, directed to
                   the sheriff of the county where such witness resides or is
                   found, which shall be served and returned in the same
                   manner as a subpoena in a criminal case is served and
                   returned.

Thus, if requested by a party to an adjudicatory hearing, an administrative agency must
issue a subpoena to compel the attendance of a witness or the production of documents at
the hearing. Ohio State Bd. of Pharmacy v. Frantz, 51 Ohio St.3d 143, 145 (1990);
Walters v. Ohio State Dept. of Adm. Servs., 10th Dist. No. 06AP-472, 2006-Ohio-6739,
¶ 29; Northfield Park Assoc. v. Ohio State Racing Comm., 10th Dist. No. 05AP-749,
2006-Ohio-3446, ¶ 63. However, to secure a reversal on the basis that the administrative
No. 13AP-726                                                                           10

agency failed to issue a requested subpoena, a party must demonstrate that the failure
resulted in prejudice. Burneson v. Ohio State Racing Comm., 10th Dist. No. 08AP-794,
2009-Ohio-1103, ¶ 24; Korn v. Ohio State Med. Bd., 61 Ohio App.3d 677, 686 (10th
Dist.1988).
       {¶ 29} Here, Clayton sought the medical records of the other ICU patients in order
to show the care required by and provided to those patients during her shift. Clayton
wanted that information so she could point to circumstances involving those patients that
demanded her intervention. The hearing examiner denied Clayton's subpoena request to
avoid infringing on the privacy and confidentiality protections afforded to the other
patients and because the information Clayton sought could be obtained through other
sources.
       {¶ 30} Although the hearing examiner refused to issue a subpoena for the other
patients' medical records, he granted Clayton's request to issue subpoenas to two ICU
nurses who worked the overnight shift on August 27 and 28, 2009. Those nurses could
have testified regarding what occurred during the shift, including the assistance Clayton
had to provide to other patients. Clayton, however, did not call either nurse to testify.
The hearing examiner also allowed Clayton to testify regarding the care she provided to
other patients. Clayton stated that she "put[ ] I.V.s in for nurses that [could] not do that
themselves" and "start[ed] Amiodarone drips for another patient where a nurse did not
know what [an] Amiodarone drip was." (Tr. 81.) Because the hearing examiner afforded
Clayton the opportunity to present witness testimony regarding the needs of the other
patients, Clayton cannot now demonstrate prejudice due to the nondisclosure of the other
patients' medical records.
       {¶ 31} In a last ditch effort to show prejudice, Clayton argues that witnesses'
memories fade, and the medical records would have been necessary to refresh those
memories. If Clayton had established at the hearing deficiencies in her or the other
nurses' memories, this argument might have succeeded. However, Clayton failed to
establish any such deficiencies. Accordingly, we conclude that no prejudice resulted from
the hearing examiner's failure to issue the subpoena in question, and we overrule
Clayton's first assignment of error.
No. 13AP-726                                                                                11

       {¶ 32} Both Clayton's second and third assignments of error concern her
administration of normal saline to Patient 1. We will address them together. By her
second assignment of error, Clayton argues that the record does not contain any evidence
that she uninterruptedly administered normal saline to Patient 1 during her shift. By her
third assignment of error, Clayton argues that the record does not contain any evidence
that she administered normal saline to Patient 1 without a physician's order.
       {¶ 33} The Board did not find that Clayton uninterruptedly administered normal
saline to Patient 1 during her shift. Although medical records established that Clayton
gave Patient 1 a total of 1,097 milliliters of normal saline during her shift, the evidence
was equivocal regarding the exact time, or times, that Patient 1 received the normal saline.
Therefore, the Board made no findings tying the administration of normal saline to a
particular period during Clayton's shift. Rather, the Board simply found that Clayton
administered a total of 1,097 milliliters of normal saline to Patient 1 during her shift.
       {¶ 34} Clayton explained her administration of normal saline to Patient 1, despite
Dr. Bowers' order of a saline lock, by claiming that that Dr. Chaudhry ordered it. The
question before the Board, therefore, was whether Dr. Chaudhry had authorized the
administration of the 1,097 milliliters of normal saline, thus supplanting Dr. Bowers'
earlier order of a saline lock.
       {¶ 35} After considering the evidence, the Board found that Dr. Chaudhry only
ordered Clayton to administer a 250 milliliter bolus of normal saline to Patient 1. Clayton,
however, argues that the evidence shows that Dr. Chaudhry ordered Clayton to give
Patient 1 a 1,097 milliliter saline bolus. Clayton's testimony was the only evidence in the
record that Dr. Chaudhry authorized the administration of all 1,097 milliliters of normal
saline to Patient 1. The Board did not believe that testimony. We cannot second-guess
that credibility determination. Applegate v. State Med. Bd., 10th Dist. No. 07AP-78,
2007-Ohio-6384, ¶ 21.
       {¶ 36}   Subtracting 250 milliliters (the amount of normal saline ordered by Dr.
Chaudhry) from 1,097 milliliters (the total amount administered) yields the result of 847
milliliters. Therefore, Clayton administered 847 milliliters of normal saline to Patient 1
without a physician's order to do so and despite Dr. Bowers' prohibition against the
administration of normal saline. We thus find no abuse of discretion in the trial court's
No. 13AP-726                                                                               12

determination that reliable, probative, and substantial evidence supports the Board's
conclusion that Clayton did not comply with the physician's orders regarding the
administration of normal saline. Accordingly, we overrule Clayton's second and third
assignments of error.
         {¶ 37} By Clayton's fourth assignment of error, she argues that the trial court erred
in affirming the Board's decision to discipline her for failing to follow the physician's order
to administer a Cardizem drip to Patient 1 when that order did not appear in Mercy's
computer system. We disagree.
         {¶ 38} The Board concluded that the acceptable and prevailing standards of safe
nursing care require an ICU nurse to locate and implement the physician's orders for a
patient under the nurse's care. Clayton, admittedly, did not locate and implement the
physician's orders for Patient 1. Instead, she relied on the information entered by a
pharmacist into the hospital computer system to determine what kind of and how much
medication to administer.       The pharmacist failed to enter Dr. Bowers' order for an
intravenous Cardizem drip titrated to reduce Patient 1's heart rate below 100 beats per
minute.
         {¶ 39} Clayton argues that the error in the pharmacist's computer entry justifies
her failure to administer the intravenous Cardizem drip. We are not persuaded. The
physician's orders, not the pharmacist's entry, dictated the course of Patient's 1 care. As
the Board found, Clayton violated the standard of care and applicable administrative rules
when she failed to locate and implement the physician's order. The pharmacist's error
does not excuse this violation. Accordingly, we overrule Clayton's fourth assignment of
error.
         {¶ 40} By Clayton's fifth assignment of error, she argues that the trial court erred in
affirming the Board's decision to discipline her for waiting too long to seek a physician's
assistance with Patient 1. We disagree.
         {¶ 41} Both Klenke and Dr. Bowers testified that Clayton should have contacted a
hospitalist regarding Patient 1's condition when he did not respond to the medication
administered at 10:16 p.m. and when his systolic blood pressure dropped below 100 at
2:00 a.m. Relying on this testimony, the Board concluded that Clayton did not timely
recognize and notify a hospitalist of Patient 1's deteriorating condition, and, thus, she
No. 13AP-726                                                                          13

violated the acceptable and prevailing standards of safe nursing care and the specified
administrative rules.
       {¶ 42} Clayton argues that the trial court should have rejected Klenke's and Dr.
Bowers' testimony in favor of her testimony that a physician's intervention was not
necessary until 4:00 a.m., when Patient 1 became unable to interact with her. Our role,
however, is not to determine which testimony is more credible or worthy of greater
weight. Ressler v. Ohio Dept. of Transp., 10th Dist. No. 09AP-338, 2009-Ohio-5857, ¶ 13.
Rather, we only determine whether the trial court abused its discretion in determining
whether reliable, probative, and substantial evidence supported the administrative
agency's order. Id. Here, we find no such abuse of discretion. Accordingly, we overrule
Clayton's fifth assignment of error.
       {¶ 43} By Clayton's sixth assignment of error, she argues that the Board
erroneously shifted the burden of proof onto her. We disagree.
       {¶ 44} In an administrative proceeding, the party asserting the affirmative of an
issue bears the burden of proof. Nucklos v. State Med. Bd., 10th Dist. No. 09AP-406,
2010-Ohio-2973, ¶ 17. A burden of proof is a composite burden requiring the party on
whom it rests to go forward with the evidence (the burden of production) and to convince
the trier of fact by some quantum of evidence (the burden of persuasion). Chari v. Vore,
91 Ohio St.3d 323, 326 (2001).
       {¶ 45} Here, the Board had the burden of producing evidence and persuading the
finder of fact that Clayton failed to provide nursing care to Patient 1 in accordance with
the acceptable and prevailing standards of safe nursing care and the specified
administrative rules. The hearing examiner recognized that the Board had that burden of
proof, and he determined that the Board carried its burden.                  Report and
Recommendation of the Hearing Examiner, at ¶ F of the Conclusions of Law.
       {¶ 46} In the course of deciding whether the Board had satisfied its burden of
proof, the hearing examiner resolved a conflict in the evidence over whether the
physician's orders were contained in Patient 1's chart when he was admitted to the ICU.
In relevant part, the hearing examiner stated:
                 Respondent has contended that Dr. Bower[s'] Physician's
                 Orders were not part of Patient 1's chart when he was
                 admitted to the Hospital ICU from the [emergency
No. 13AP-726                                                                           14

                   department]. As noted in my Findings of Fact, I do not
                   find that this contention is supported by the
                   preponderance of the evidence.          Respondent's main
                   evidence to support this contention is Respondent's
                   hearing testimony where she contends that Physician's
                   Orders were not part of [ ] Patient 1's chart. (Tr. 95). I do
                   not find this testimony credible in that in both the
                   Hospital and Board investigation interviews shortly after
                   this incident Respondent openly admitted that she did not
                   look at the Physician's Orders during her shift and in
                   neither interview did she contend that the Physician's
                   Orders were not part of Patient 1's chart. The most direct
                   and compelling testimony on this issue came from the
                   author of the Physician's Orders, Dr. Bowers, who testified
                   that, upon arriving at the end of the Respondent's shift on
                   August 28 and seeing Patient 1 with an I.V. running in
                   direct violation of one item in the Physician's Order[s], she
                   "very easily" found the Physician's Orders in Patient 1's
                   chart.

(Footnote omitted.) Report and Recommendation of the Hearing Examiner, at 35-36.
         {¶ 47} The hearing examiner blundered when he used the phrase "preponderance
of the evidence" in evaluating contradictory evidence. The hearing examiner was not
determining whether Clayton's evidence satisfied a pre-set level of persuasiveness
necessary to carry a burden of proof. Rather, the hearing examiner was comparing
conflicting evidence and determining which evidence was more credible.             Although
erroneously expressed, read in context, the passage at issue communicates that Clayton's
evidence is not as convincing as the Board's evidence. As the Board's evidence directly
contradicted Clayton's evidence, the hearing examiner rejected Clayton's evidence and
made a factual finding based on the Board's evidence.
         {¶ 48} Although the hearing examiner inappropriately phrased his discussion of an
evidentiary conflict, he correctly held the Board to the burden of proving Clayton's
violation of the standard of care. Accordingly, we overrule Clayton's sixth assignment of
error.
         {¶ 49} By Clayton's seventh assignment of error, she argues that the trial court
erred in affirming the Board's decision to allow Klenke to testify as an expert witness. She
also argues that Klenke's participation as a witness biased the Board against her. We
disagree with both arguments.
No. 13AP-726                                                                          15

       {¶ 50} During the trial, Clayton objected to Klenke testifying as an expert witness
because Klenke was a member of the Board when the Board initiated its investigation into
the complaint regarding Clayton's care of Patient 1. Klenke's term as a Board member
ended approximately two years prior to her testimony at Clayton's hearing. Primarily,
Clayton asserted that Klenke's prior service on the Board created a conflict of interest.
The hearing examiner overruled the objection after Klenke testified that she was not
involved in or even aware of the investigation while a Board member. Like the trial court,
we perceive no error in this ruling.
       {¶ 51} After the close of the hearing, Klenke was reappointed to the Board. Klenke
was not present at the Board meeting when Clayton's attorney addressed the Board or
when the Board voted to adopt the hearing examiner's report and recommendation with
modifications. The Board added to its record a statement that it did "not give[ ] any
deferential regard, or heightened weight, to Ms. Klenke's testimony, and accepts that
testimony only to the extent that it was incorporated in the Findings of Fact and
Conclusions of Law made by the Hearing Examiner." Adjudication Order, at 2. Despite
the Board's explicit assurances of impartiality, Clayton now argues that Klenke's
participation in the matter biased the Board against her.
       {¶ 52} A reviewing court presumes that the decision of an administrative agency is
valid and was reached in a sound manner. West Virginia v. Ohio Hazardous Waste
Facility Approval Bd., 28 Ohio St.3d 83, 86 (1986); accord McRae v. State Med. Bd., 10th
Dist. No. 13AP-526, 2014-Ohio-667, ¶ 42 (" '[A] presumption of honesty and integrity on
the part of an administrative body exists, absent a showing to the contrary.' "). To
overcome this presumption, an appellant must show that an administrative agency
member was biased, partial, or prejudiced to such a degree that the member adversely
affected the agency's decision. ATS Inst. of Technology v. Ohio Bd. of Nursing, 10th Dist.
No. 12AP-385, 2012-Ohio-6030, ¶ 32.
       {¶ 53} Here, the Board members explicitly repudiated Clayton's supposition that
Klenke unduly influenced the Board's decision. We reject Clayton's argument that the
Board's statement actually proves the Board's bias. We think it more likely that the Board
definitively declared its impartiality to preempt the very argument that Clayton now
No. 13AP-726                                                                          16

asserts. In any event, Clayton has not established any facts to overcome the presumption
of validity. Accordingly, we overrule Clayton's seventh assignment of error.
       {¶ 54} For the foregoing reasons, we overrule all of Clayton's seven assignments of
error, and we affirm the judgment of the Franklin County Court of Common Pleas.
                                                                      Judgment affirmed.
                         CONNOR and T. BRYANT, JJ., concur.
                 T. BRYANT, J., retired, of the Third Appellate District,
                 assigned to active duty under authority of Ohio
                 Constitution, Article IV, Section 6(C).
