Od STATE OF FLORIDA ae : “Fe AGENCY FOR HEALTH CARE ADMINISTRATION OS, AGENCY FOR HEALTH CARE “GOCE ADMINISTRATION, oY Me oO an Petitioner, oe on vs. ; AHCA No: 09-01-0031 H LAWNWOOD MEDICAL CENTER, O\- 29 aS) INC., d/b/a LAWNWOOD REGIONAL MEDICAL CENTER, Respondent. ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty one (21) days from the receipt of this complaint, the Agency for Health Care Administration (hereinafter referred to as the "Agency”) intends to impose an administrative fine in the amount of Twelve Thousand ($12,000) dollars, upon Lawnwood Medical Center, Inc., d/b/a Lawnwood Regional Medical Center (hereinafter referred to as "Respondent"). As grounds for this administrative fine the Department alleges as follows: 1. The Agency has jurisdiction over Respondent pursuant to the provisions of Chapter 395, Part I, Florida Statutes (F.S.) and Chapter 59A-3, Florida Administrative Code (F.A.C.). 2. Respondent is licensed to operate at 1700 South 23" Street, Fort Pierce, Florida 34950- 0188, as a hospital in compliance with Chapter 395, Part I, (F.S.), and Chapter 59A-3, (F.A. C.). 3. The Respondent has violated the Provisions ¢ of Chapter 395, Part I, (F.S.), and the provisions of |! Chapter 530A: 3, (F.A.C.) in n that: 7 (A) The facility did not meet the minimum requirements for the Comprehensive Emergency Management plan. tne AOR a (1) While conducting a document review of the facility's Emergency Management Plan, with the Engineering Director, on 4/27/99, between 7:30 a.m. and 4:00 p.m., it was noted that the facility had not prepared the required documentation, nor submitted these documents to the county for review. It is required that all medical facilities implement an approved Emergency management Plan (Section 395.1055(1)(c), Florida Statutes). In addition, it is required by the National Protection Code (NFPA 99, for Health Care Facilities), that a disaster plan be implemented and tested with all staff twice yearly. (2A) During the survey of 7101/99, the facility was unable to produce an accepted current annual Comprehensive Emergency Management Plan accepted by the local County Emergency Agency. This is in violation of Section 395.1055 (1) (c) and Rule 59A-3.078, F.A.C., and NFPA 99, 101 carrying in this instance a $2,000 fine. This deficiency incorporates Tag K-048. (B) The facility did not meet the minimum requirements for electrical safety as required by the National Electric Code. During the survey conducted on 4/26 and 4/27/99 and during tour of the facility with engineering staff, between 7:30 a.m. and 4:00 p.m., the following areas of concern were observed. (1) The lighting protection system on the main tower roof had various areas in which the bonding wire was disconnected, or there was no protection. In addition, there were various areas in which the wire had been knocked loose from the roof bonding clamps. (2) It was observed that in several areas of the building, there were electrical boxed in which there were knocked out covers missing, or there were no labels identifying where the circuits were located, poet mt RANGER a TT (3) The line isolation devices located in the ER had not been tested as required, and were required to be documented as tested monthly. (4) The main OR Suite operating floors had not had their conductivity tests done. NEPA 99-12-4.1.2.4 requires hat the OR floors be tested for proper ground conductivity. (5) There were GFT’s missing in the following areas: (Pavilion) all patients’ areas of Psych unit; Adult unit activity room; Adult exam room, Rehab Administrator’s room, Rehab nourishment room; Occupational therapy and therapy room #2 hydroculators must be GFI’s. (6) Transformer in ceiling rear of OR Suite holding not in electrical box. (7) Anesthesia workroom ganged surge suppressors being used as extension devices. (8) ORroom 5 — broken wires on surge suppressor. (9) 1-8 elect box missing blank panel. (10) Panel k-3/36 missing identification for circuit locations. (11) Extension cord in phone room hanging by plug. (12) Respiratory therapy needs GFI receptacle for equipment in wet area. (13) Panel 202a needs locator card in panel. : (2B) During the tour of the facility on April 10-11, 2000, between 8 a.m. and 4 p.m., it was observed that there were several areas of concern involving electrical safety. The findings were as follows: (1) It was observed in the laboratory area that there were many electrical | outlets on many ¥ workstations, where there was a need for a GFI (ground fault interrupter) device. Tt was observed that there was limited protection i in areas where there were wet surfaces, or a close proximity to a sink. In addition, there were several areas throughout the hospital where there was also a need for GFI’s. The facility should conduct a full survey to look at this concern, and address their policy for the use of electrical devices in wet locations. (2) Jt was observed in many areas of the facility that it had been allowed to use surge suppressors for other than their designed uses. It was observed throughout the hospital that staff had made daisy chain electrical extension devices out of the surge suppressors by ganging them together, thus overloading the circuits and voiding the use of the device for a listed device for light weight electrical devices. IT was observed that the facility had allowed the staff to use these electrical devices for extension devices for large current drawing machinery. An example of a large electrical current drawing device is a toaster, iron, coffee pot, air conditioner, and microwave oven. It was observed that many of these devices were being plugged into these surge devices in violation of hospital policy, and the electrical code. A general survey of the hospital is needed to insure that all staff has the proper electrical device for use in their workspace. Surge suppressors were designed for use on office equipment, which draws low current and amperage. The use of these approved devices for other than their designed usage, can place a strain on the main wiring in the hospital, could cause shorts in the system, or could severely injure a patient or staff member if the device should become overloaded. (3) In addition, on all states letter from “HCFA”, in the summer of 1999 stated that these devices (surge suppressors) were to be used for their intended use, which i is for use on office equipment and other light amperage drawing equipment. In addition, the letter states that if a facility cannot meet their electrical needs without the excessive use of this equipment, than a full electrical survey by licensed electrical engineer should be undertaken to ~ establish a facility’s electrical needs, and address same. This is in violation of Rule 59A4-3.077, F.AC., and NFPA 70, 99, carrying in this instance a $2,000 fine. This deficiency incorporates Tag K-049. (C) The facility did not meet the minimum requirements for the maintenance and testing of the Sprinkler System. The findings include: (1) | While conducting a document review of the facility’s records with the Maintenance Engineer, on 4/26-27/99, between 7:30 a.m. and 4:00 p.m., it was revealed that the facility had not tested the fire sprinkler system as required by the NFPA 25 Code for testing of Fire Systems, or per the Florida State Fore Marshall’s Standard 4A-48. It is required that the Fire Sprinkler be tested to a specific standard (NFPA 25) which requires that quarterly inspections of the system be conducted in house, with all documented test being reviewed by a certified fire sprinkler company ANNUALLY. In addition, an annual test of the system must be conducted by a certified Fire Sprinkler Contractor, with all records maintained on site. (2) The facility had not conducted a yearly certification of the fire sprinkler system in the pavilion. (3) There was storage in the kitchen located within 18-inch space, which impacts the activation and flow of the sprinklers. Storage is not permitted within 18in space. (2C) During the survey of 7/02/99 it was determined that the facility did not meet the minimum requirements. The findings include: qd) During the document review on July 1, 1999, it was discovered that the facility’s contractor has found that there were deficiencies in the Fire Sprinkler System, which had not been corrected at the time of the revisit survey. This is in violation of Rule 59A-3.077, F.A.C., and NFPA 13, NFPA 25, carrying in this instance a $2,000 fine. This deficiency incorporates Tag K- 062 — (D) The facility did not meet the requirements for cubicle curtains. The findings include: (1) While on tour of the facility with the Engineering Staff of the facility on , April 26-27, 1999, between 7:30 a.m. and 4:00 p.m., it was observed that the facility had not maintained its’ cubicle curtains within the facility to the NFPA Standard for the requirements of the mesh. All cubicle curtains must have the proper size mesh to insure that in the event of a fire, the fire sprinkler system will be able to penetrate the top of the curtain to adequately penetrate a fire, and protect the patient. Areas include: Kidney Dialysis room, OR suite recovery room (8) cubicle curtains with wrong mesh central core of holding area OR wrong curtains. (2D) The facility had not met the minimum requirements for cubicle curtains at the time of the REVISIT survey of July 1, 1999. Findings include: (1) —- During the tour of the facility, and during an interview with the Hospital Engineer, it was discovered that there were areas of the facility in which the hospital had not yet installed the required cubicle curtains. This is in violation of Rule 59A-3.077, F.A.C., and NFPA 99, 101-1994, carrying in this instance a $2,000 fine. This deficiency incorporates Tag K-074. (E) The facility had not met the minimum requirements for the safe operation and ; maintenance of all equipment. The findings include: zc) - Ie on on tou of the facility with the engineering staff, on 4/26-27199, a between 7: 7:30 am. and “& 00 p.m., it was observed that the visitor’s elevator equipment room had al control panels and 1 equipment panels open. These panels must be secure at all it's electri times to i sure ‘that ni staff 0 or emergency personnel member gets injured if responding toa situation n requiring , entry t to ; these rooms. in addition, ANSI 17A (National levator Code) “requires that all elevator equipment be secure at all times that service work is not being conducted. The maintenance staff had been using the mechanical equipment room to store paints. (2E) At the time of the revisit conducted on July 1, 1999 it was determined that the hospital did not met the minimum requirements for the safety of all associated equipment. The findings include: (1) The elevator equipment, including the main electrical boxes were not cover or sealed as required. This is in violation of Rule 59A-3.077, F.A.C and ANSI 17A (National Elevator Code), carrying in this instance a $2,000 fine. This deficiency incorporates Tag K-079. (EF) _ The facility did not meet the minimum requirements for the location of and testing of the smoke fire dampers. Findings include: (1) While conducting document reviews of the facility’s engineering staff, it was revealed that the facility had not documented that all of the smoke and fire dampers hade been located and tested as per the requirements of the life Safety Code, the NFPA 90A. (2) During interviews, it was revealed that the facility had not tested any dampers located on the first floor. (3) The facility could not produce a list of all of the dampers located within the facility. ; @) The facility had not tested the dampers located within the Pavilion. (QF) At the time of the resurvey of July 1, 1999 it was determined that the facility did not meet the requirements for Fire and Smoke Damper testing as required. Findings include. ra defiance (1) During the tour of the facility and during an interview with the Hospital Engineer, it was discovered that the facility had not met the minimum requirements of having all of t he smoke and fire dampers located within the facility tested as required. This is in violation of Rule 59A-3.077, F.A.C., and NFPA 101-1994, 90A and 90B, carrying in this instance a $2,000 fine. This deficiency incorporates Tag K-104. 4. The Respondent has violated the provisions 395.018(2)(a), (F.S.), in that the Respondent has violated the minimum standards, rules and regulations promulgated by the Department under Chapter 395, Part I, (E.S.) 5. The above referenced violations constitute grounds to levy this administrative fine pursuant to Section 395.1041(5), (F.S.), in that the above-referenced conduct of Respondent constitutes a violation of the minimum standards rules and regulations for the operation of a hospital. 6. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, (F.S.); to be represented by counsel (at its expense); to take testimony, to call and 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, your request for an administrative hearing must conform to the requirements in Rule 28-106.201, (F.A.C.), and must state which issues of material fact you dispute. Failure to dispute material issues of fact in your request for a hearing may be treated by the Agency as an election by you of an informal proceeding under Section 120.57(2), (E.S.) ELECTION AND EXPLANATION OF RIGHTS FORMS ATTACHED 7. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY ONE (21) DAYS FROM THE 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. E | I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by US. Certified Mail, Return Receipt Requested to Mr. Thomas Pentz, Administrator, Lawnwood Regional Medical Center, 1700 S. 23" Street, Fort Pierce, Florida 34950-0188 (#70.0 1670 C1 ‘£8439652 Lawnwood Medical Center, Inc., One Park Plaza, Nashville, TN 37203 (#7000 1670 001148439645), and to The Prentice-Hall Corporation System, Inc., 1201 Hays Street, Suite 105, Tallahassee, Florida 32301 (#700016 70001148439621 .) on this _/ 7H day of Mi “¢ , 2001. PATRICIA FEENEY, Field Office Man Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, Florida 33407 Copy sent to: Alba M. Rodriguez, Assistant General Counsel Agency for Health Care Administration 8355 N.W. 53rd Street Miami, Florida 33166 Hospital Program Office Agency for Health Care Administration 2727 Mahan Drive ~ Tallahassee, Florida 32308 Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 recep iep om

Docket for Case No: 01-002773