A nurse at the Rambam Health Care Campus had her nursing license suspended for one year after a severe lapse in judgment in June 2020, where she administered a sedative to a patient without authorization, conducted an unapproved rectal examination, and failed to report his worsening condition, resulting in his death. The Ministry of Health imposed the penalty after a disciplinary review.
The nurse was convicted in disciplinary proceedings for injecting a psychiatric sedative medication into a patient without authorization and performing a rectal examination on him. The patient's condition subsequently deteriorated, but the nurse failed to report this development or monitor his status. Hours later, he was found dead in his bed in the internal medicine ward. The nurse initially concealed her actions but later admitted to administering the drug.
Confession came only after confrontation
The June 2020 incident unfolded during evening hours in Rambam's internal medicine ward, where the experienced nurse – with approximately ten years of service – was caring for multiple patients. Without medical orders and in violation of hospital protocols, she decided to conduct a rectal examination on the patient, first injecting him intravenously with Dormicum, a sedative and anesthetic medication.
The disciplinary complaint stated that "she performed the injection and rectal examination without proper authority, without physician orders and contrary to nursing administration directives and executive circulars."
Medical documentation revealed the patient suffered abnormal, below-normal blood pressure readings that should have triggered the "deteriorating patient protocol" – requiring immediate physician notification, continuous monitoring and systematic follow-up. None of these critical steps were implemented. The following day, staff found the patient without vital signs. Despite resuscitation attempts, medical personnel declared his death.
Hospital disciplinary authorities emphasized that "at shift's end, she failed to report the medication administration to supervisors or incoming staff; she neglected to record and document procedures in the medical chart, violating established guidelines and legal requirements."
When a supervising nurse later asked whether she had additional information about the deceased patient's care, she declined to share details. Only after the morning shift supervisor confronted her with an empty Dormicum vial discovered at the scene did she acknowledge injecting the medication.
"Integrity claims difficult to accept"
The incident prompted an internal Rambam hospital investigation and formal hearing where the nurse acknowledged the primary allegations. Her hospital employment terminated within two weeks of the incident.
Disciplinary charges included conduct unbecoming the nursing profession, failure to maintain professional responsibility and serious negligence. However, formal complaint filing was delayed pending completion of police investigation procedures.
Ministry of Health prosecutors and defense counsel reached a negotiated agreement requiring the nurse to admit responsibility in exchange for a consensual one-year license suspension.
Defense attorneys Tami Ulman and Yaakov Shlomowitz contended that "no causal connection existed between her actions and the patient's death, with police investigation files subsequently closed." They emphasized their client "accepted responsibility for her actions, expressed genuine remorse and has since changed employment while incorporating necessary lessons. Her attributed actions stemmed from good intentions aimed at alleviating patient suffering."
Ministry of Health disciplinary committee members characterized the case as "a cascading sequence of actions and omissions – the severity of the respondent's conduct cannot be overstated. Entrusted with patient care and welfare responsibilities, she initiated actions that created genuine health hazards."
Committee members – chairwoman Dr. Rina Shimonov, nurses' association representative Sara Efrati and government legal advisor attorney Arie Roter – observed that "upon learning of the patient's death, she demonstrated no urgency in disclosing her actions, revealing them only when confronted with physical evidence. Under these circumstances, claims of honest conduct appear questionable."
"While momentary judgment failures might be attributed to claimed benevolent intentions toward patient comfort, her subsequent behavior patterns prove difficult to accept. The respondent's conduct suggests not merely poor judgment and inadequate professionalism, but fundamental responsibility failures in mandatory reporting and deliberate incident concealment."
Committee members considered the agreed one-year suspension insufficiently severe, believing two-to-five-year suspension periods more appropriate for such violations, but ultimately endorsed the negotiated resolution.
Deputy Health Ministry Director General Dr. Safi Mendelowitz implemented the license revocation effective May, spanning one full year. His decision noted that "despite personal discomfort with the plea arrangement's leniency toward the respondent, I have accepted this agreement, recognizing that plea arrangements should face intervention only under exceptional circumstances, consistent with the disciplinary committee's recommendations."
