Petitioner: AGENCY FOR HEALTH CARE ADMINISTRATION
Respondent: LIBERTY BEHAVIORAL MANAGEMENT OF FLORIDA, INC., D/B/A SAVANNAS HOSPITAL
Judges: CLAUDE B. ARRINGTON
Agency: Agency for Health Care Administration
Locations: Fort Pierce, Florida
Filed: Feb. 15, 2002
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Thursday, May 16, 2002.
Latest Update: Dec. 24, 2024
Ly vision of Administrative -
STATE OF FLORIDA | c E | | r
AGENCY FOR HEALTH CARE ADMINISTRATI eos
AGENCY FOR HEALTH CARE DAS
ADMINISTRATION, Cate —
Petitioner, AHCA No.: 09-01-0108H
2001075351
v. ; 7000-1670-0011-4845-7205
7000-1670-0011-4845-7229
LIBERTY BEHAVIORAL 7000-1670-0011-4845-7212
MANAGEMENT OF FLORIDA, d/b/a/
SAVANNAS HOSPTIAL,
Respondent.
/
ADMINISTRATIVE COMPLAINT
COME NOW, the Agency for Health Care Administration (hereinafter “AHCA”),
and files this Administrative Complaint against Liberty Behavioral Management of
Florida, Inc., d/b/a Savannas (hereinafter “Savannas Hospital”, “Hospital” or “Facility”), .
pursuant to Chapter 395, Part I, Florida Statutes (“Fla. Stat.”) and Chapter 59A-3, Florida
Administrative Code (“Fla. Admin. Code”). As grounds for this administrative complaint
AHCA alleges as follows:
NATURE OF THE ACTION
1. This is an action to impose an administrative fine in the amount of one
thousand six hundred dollars ($1,600.00) pursuant to § 395. 1065(2)(a), Fla. Stat.
JURISDICTION AND VENUE
2. This court has jurisdiction pursuant to §§ 120.569 and 120.57 Fla. Stat. and
Chapter 28-106 Fla. Admin. Code.
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3. Venue lies in St. Lucie County pursuant to § 120.57 Fla. Stat. and Chapter 28
Fla. Admin. Code.
PARTIES
4. AHCA is the enforcing authority with regard to hospital licensure pursuant
to Chapter 395, Fla. Stat. and Chapter 59A-3, Fla. Admin. Code.
5. Savannas Hospital is licensed to operate as a hospital at 2550 SE Walton
Road, Port Saint Lucie, Florida 34952.
COUNTI
_ SAVANNAS HOSPITAL STAFF FAILED TO FOLLOW POLICIES AND |
PROCEDURES THAT WERE WRITTEN TO ENHANCE THE SAFETY OF THE
HOSPITAL, ITS PERSONNEL AND PATIENTS.
§§ 394.458(1)(a) and 395.003(5), Fla. Stat.
6. AHCA realleges and incorporates paragraphs 1 through 5 as if fully set
forth herein.
7. Based on record review during the survey conducted on 05/21/01 through
5/25/01, it was determined that the facility did not ensure that illegal substances were not
introduced into the facility.
8. Review of facility records revealed that on 05/14/01, a patient was
admitted under a Marchman Act to the Chemical Dependency Unit (CD Unit). On
05/15/01, it was documented in the hospital records that this patient was observed
“smoking crack” on the patio of the CD unit. The documentation of the follow-up to this
incident stated: “ explored pressing charges with the treatment team, but
recommendation was made to flush the drug. Two witnesses flushed the powder/rocks”.
The documentation also stated that this patient brought the illegal substance into the
SURPRISE ORE PRE RE eRRETSE ne
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facility under an electrode used for electrocardiography, which according to staff,
occurred at the transferring facility. The facility failed to conduct a thorough body search
on admission and failed to notify the appropriate legal authorities that an illegal substance
was brought into the facility and used by their patient(s).
9. Review of other facility records for the year 2000 revealed that there were
_ at least two other incidents where patients were found to have brought contraband or
illegal substances into this facility despite the fact that the body search had allegedly been
completed.
10. During the survey of 8/23/01, based on record review for one of eighteen
records, AHCA determined that the hospital staff did not follow policies and procedures
that were written to enhance the safety of the hospital, its personnel and patients. During
one admission, staff on the unit discovered a patient had a pocketknife.
11. Record review during the survey for patient #17, a voluntary patient who
was admitted to the dual unit on 7/6/01, revealed the patient was admitted with a
pocketknife. This was taken into staff custody. Procedure for admission is that the
patient be searched and a metal detector wand is to be used prior to admission to prevent
weapons from being brought onto the unit. This is an uncorrected deficiency from the
survey of 5/25/01.
12. Based on the foregoing, Savannas Hospital violated § 394.458(1)(a) Fla.
Stat., carrying in this instance a fine of $800. § 394.458, Fla. Stat., is made applicable by
§ 395.003(5)(a)(b), Fla. Stat.
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SRE RE CRE ME TR IT
COUNT If
SAVANNAS STAFF DID NOT FOLLOW AND IMPLEMENT THEIR POLICIES
AND PROCEDURES THAT WERE WRITTEN TO ENHANCE THE SAFETY OF
THE HOSPITAL, ITS PERSONNEL AND PATIENTS.
FLA. ADMIN. CODE R. 59A-3.223(1)(a)-(d)
13. AHCA realleges and incorporates paragraphs 1 through 5 as if fully set
forth herein.
14. During the survey of 5/25/01, based on observation, staff interview, and
review of hospital incident reports AHCA determined that the hospital did not implement
and monitor a hospital wide safety program. The findings were as follows:
15. Medications ordered by the physician were omitted due to pharmacy
procurement problems. No incident reports were being made out by the nurses.
16. Patients were not being identified for history of violence. Patients who
were verbally assaultive and volatile were not supervised adequately. There was no
_control of staff sharps. Nursing staff acuity policy for staffing units did not make a full
assessment of patient’s needs,
17. The Intensive Treatment Services unit was left without a licensed nurse
present. The licensed nurse did not know the staffing procedure and neglected to carry a
walkie-talkie. | — .
18. — Incident reports for restraints were not always made out and restraint ~
policy was not followed.
19. During the survey of 8/23/01, based on observation and record review for
2 of 18 records the hospital staff did not follow and implement their policies and
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procedures that were written to enhance the safety of the hospital, its personnel and
patients.
20. During tour on the Adult Chemical Dependency Unit on 8/20/01, between
9 am and 10 am, a cabinet below the counter at the entrance to the nurses’ station was
observed by the surveyor and Nursing Clinical Director to be unlocked and to contain
razors. The policy of the facility is that razors are to be kept in a locked sharps room.
21. Record review during the survey for patient #17, revealed that a voluntary
patient was admitted to the dual unit without being checked with the metal detector. The
patient revealed to staff on the unit when asked that he/she had a pocketknife. This knife
was given to staff. Staff had not used the metal detector prior to the patient being
admitted to the unit, as policy requires. |
. 22. Record review for patient #18 who was admitted under a Baker Act on
7/27/01 revealed that the patient eloped from the facility " bubble " intake room during
the assessment referral process. Investigation revealed the patient had been left alone by
the assessment referral staff who stepped out of the intake room to make copies of forms.
The staff member who left the patient stated when interviewed on 8/23/01 he/she was
aware of the facility policy never to leave a patient alone. This is an uncorrected
deficiency from 5/25/01.
23. Based on the foregoing, Savannas Hospital violated Fla. Admin, Code R.
59A-3.223(1)(a)-(d), carrying in this instance a fine of $800.
PRAYER FOR RELIEF
WHEREFORE, AHCA requests this Court to order the following relief:
A. Make Factual and legal findings in favor of the Agency on Counts I and Il.
CRN ERE TOT aR OSE ERERET RIB TAT SeR AT RE ee or =
ee ed
B. Assess costs related to the prosecution of this case, if applicable.
Respondent is notified that it has a right to request an administrative hearing
pursuant to § 120.569, Fla. Stat., 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 Fla. Admin. Code R. 28-106.201, 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 § 120.57(2), Fla. Stat.
ELECTION AND EXPLANATION OF RIGHTS FORMS ATTACHED
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.
Issued this 28" day of January, 2002.
I HEREBY CERTIFY that a true and correct copy hereof has been furnished by
U.S. Certified Mail, Return Receipt Requested to Robert Cobiella, MLD., Executive
Director, Savannas Hospital, 2550 SE Walton Road, Port Saint Lucie, Florida 34952,
Liberty Behavioral Management of Florida, Inc., 57 River Street, Suite 301, Wellesley,
MA 02481, to CT Corporation System, 1200 South Pine Island Road, Plantation, Florida
roe
TC ET ee NE RE I ll a a
33324 and to Michael Bittman Esq., 301 E. Pine Street, Suite 1400, Orlando Florida
32801 on January 28, 2002.
ORIGINAL TO:
Agency Clerk
Agency for Health Care
Administration
2727 Mahan Drive
Tallahassee, Florida 32308
COPIES TO:
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, Mail Stop #14
Tallahassee, Florida 32308
Diane Reiland
Field Office Manager
Agency for Health Care
Administration
1710 E. Tiffany Drive
Suite 100
W. Palm Beach, FL 33407
Alba M. Rod heat ; o i
Assistant General Counsel
Agency for Health Care Administration
8355 NW 53™ Street
Miami, Florida 33166
FL Bar No. 0880175
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Docket for Case No: 02-000679
Issue Date |
Proceedings |
May 21, 2002 |
Final Order filed.
|
May 16, 2002 |
Order Closing File issued. CASE CLOSED.
|
May 16, 2002 |
Respondent`s Notice of Withdrawal of Petition for Evidentiary Hearing filed.
|
Mar. 18, 2002 |
Letter to Judge Arrington from M. Bittman regarding request for subpoenas (filed via facsimile).
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Mar. 15, 2002 |
Respondent`s First Request for Production of Documents (filed via facsimile).
|
Mar. 15, 2002 |
Respondent`s First Request for Interrogatories to Petitioner (filed via facsimile).
|
Mar. 15, 2002 |
Notice of Service of Respondent`s First Request for Interrogatories to Petitioner (filed via facsimile).
|
Mar. 01, 2002 |
Order of Pre-hearing Instructions issued.
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Mar. 01, 2002 |
Notice of Hearing issued (hearing set for May 28 through 30, 2002; 9:00 a.m.; Fort Pierce, FL).
|
Feb. 28, 2002 |
Order Granting Consolidation issued. (consolidated cases are: 02-000677, 02-000679)
|
Feb. 27, 2002 |
Motion to Consolidate (Cases requested to be consolidated: 02-0677, 02-0679) filed by Respondent via facsimile.
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Feb. 27, 2002 |
Joint Response to Initial Order (filed via facsimile).
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Feb. 27, 2002 |
Notice of Unavailability (filed by A. Rodriquez via facsimile).
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Feb. 21, 2002 |
Initial Order issued.
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Feb. 15, 2002 |
Election of Rights for Administrative Complaint filed.
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Feb. 15, 2002 |
Administrative Complaint filed.
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Feb. 15, 2002 |
Petition for Evidentiary Hearing filed.
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Feb. 15, 2002 |
Notice (of Agency referral) filed.
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