SENDERS RECORD . STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 02-01-0112-RM O1- 200W. RITA MACK, Respondent. / ADMINISTRATIVE COMPLAINT Petitioner, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“Agency”), by and through its undersigned counsel, files this administrative complaint against Respondent, RITA MACK (“RESPONDENT”), for violations of Chapter 395, Florida Statutes, governing risk management licensure. In support thereof, the Agency states the following: 1. Petitioner is the state agency charged with regulating the practice of risk management pursuant to Chapter 395, Florida Statutes, and Rule 59A-10, Florida Administrative Code. 2. RESPONDENT, is and has been at all times material hereto, a licensed Risk Manager in the State of Florida, having been issued license number 5500482 on certificate number 2174. 3. RESPONDENT's last known address is 3204 Pin Oak Court, Palm Beach Gardens, Florida 33410-4494. as | giertified Article Number ru0b 4575 1294 2044 Buny i i i i | 4. At all times material hereto, RESPONDENT was employed by Palm Beach Gardens Medical Center (“Palm Beach”), located at 3360 Burns Road, Palm Beach Gardens, Florida 33410. The employer facility’s license number is 4127. 5. The Agency conducted a complaint investigation survey of Palm Beach on or about April 27, 2000. 6. Pursuant to section 395.0197(5)(a)(1), Florida Statutes, for purposes of reporting to the Agency, the term "adverse incident" means an event over which health care personnel could exercise control and which is associated in whole or in part with medical intervention, rather than the condition for which such intervention occurred, and which results in death. 7. Risk Managers are required to report adverse incidents which result in death occurring in the facility to the Agency within fifteen (15) calendar days after their occurrence, pursuant to §395.0197(8)(a), Florida Statutes. 8. The complaint survey revealed that patient S.D. died in the facility on January 18, 2000, as a result of a surgical incident at Palm Beach. . 9. 8.D.’s death constituted a reportable event within the definition in §395.0197(8)(a), Florida Statutes. 10. RESPONDENT did not report the patient’s death to the Agency until September 26, 2000. 11. Through .- negligence, “incompetence, or misconduct, RESPONDENT failed to report S.D.’s death to the Agency as required by §395.0197(8){a), Florida Statutes. 12. Based on the foregoing, RESPONDENT'S license to practice risk management is subject to discipline pursuant to §395.10975(1) & (2), Florida Statutes, for violation of §395.0197(8)(a), Florida Statutes, by failing to report S.D.’s death to the Agency. 13. The Agency intends to issue a final order that imposes one or more of the following penalties against Respondent's license: administrative fine not to exceed $2,500 for each count or separate offense; revocation; suspension; issuance of a reprimand; or probation for a period of time subject to such conditions as the Agency may specify. NOTICE Respondent is notified that she has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel (at her own expense), to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute material issues of fact in the request for a hearing, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the Agency for Health Care Administration, Attention: Sam Power, Agency Clerk, Senior Attorney, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Issued thisc/s tuay of _ MH axl , 2001. Anna Polk, Manager Risk Management Unit Agency for Health Care Administration Managed Care & Health Quality 2727 Mahan Drive, Bldg. 1 Tallahassee, Florida 32308 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original complaint was sent by U.S. Mail, Return Receipt Requested, to: Rita Mack, 3204 Pin Oak Court, Palm Beach Gardens, Florida 33410-4494 on this4/s day of Mest , 2001. . . Christine T. Messana, Esquire

Docket for Case No: 01-002506PL