m, STATE OF FLORIDA o3 de y)) AGENCY FOR HEALTH CARE ADMINISTRATION Cy i; one 40K, le “4 » STATE OF FLORIDA Ko soy "Os AGENCY FOR HEALTH CARE CAS) Rg. ADMINISTRATION, ae “om 2. ? Petitioner, O4 c} (004 vs. AHCA NO.2003006330 Return Receipt Requested PAN AMERICAN HOSPITAL CORP., 7002 2410 0001 4236 9151 d/b/a PAN AMERICAN HOSPITAL, 7002 2410 0001 4236 9168 Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, files this Administrative Complaint against Pan American Hospital Corp., d/b/a Pan American Hospital (hereinafter “Pan American Hospital”) pursuant to 28-106.111 Florida Administrative Code (2001) (F.A.C.) and Chapter 120, Florida Statutes ("Fla. Stat.") hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of twenty thousand ($20,000.00) dollars pursuant to Section 395.1065(2) (a) Fla. Stat. JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to Section 120.569 and 120.57 Fla. Stat. and Chapter 28-106 F.A.C. 3. Venue lies in Dade County, pursuant to 120.57 Fla. Stat. and Chapter 28, F.A.C. PARTIES 4. AHCA is the enforcing authority with regard to Hospital licensure law pursuant to Chapter 395, Part I, Fla. Stat. and Rules 59A-3 F.A.C. 5. Pan American Hospital is a hospital facility located at 5959 N.W. 7° Street, Miami, Florida 33126 and is licensed under Chapter 395, Part I, Fla. Stat. and Chapter 59A-3. F.A.C. COUNT I PAN AMERICAN HOSPITAL FAILED TO PROVIDE A METHOD FOR ASSURING THAT A REVIEW OF EMERGENCY PATIENT CARE AND SERVICES IS PERFORMED AND DOCUMENTED AT LEAST MONTHLY 59A-3.255(6) (f), F.A.C. (EMERGENCY CARE) 6. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 7. During the State Validation survey conducted on 2/10-12/2003 and based on review of the performance improvement program and interview the facility failed to provide a method for assuring that a review of emergency patient care and services is performed and documented at least monthly, using the medical record and pre-established criteria. 8. Review of the performance improvement program records and interview with the Performance Improvement Coordinator on 2-11-03 revealed that the system has predetermined processes that are monitored. The system does not allow for unexpected or unusual occurrences that may impact the health and safety of patients. There was no evidence of information being gathered to monitor the Emergency Room psychiatric transfer process in the performance program. 9. Interview with the Director of Social Work on 2-11- 03 revealed that the problem with patient transfer to psychiatric facilities was reported to the Director of Performance Improvement as required by department policy. Interview with the Director of Performance Improvement on 2- 11-03 revealed that he/she was aware of the problems that the social workers were having with the transfers from the Emergency Room to psychiatric receiving facilities. Further interview with the Director of Performance Improvement revealed that the problems with the transfer process were not reported the Chief Operating Officer, as required by department policy. There was no evidence of tracking and/or trending the Baker Act and/or transfer process to the psychiatric receiving facilities in the performance improvement records reviewed. Time given for correction: 3/13/2003. 10. During a complaint investigation conducted on 8/21/2003 and based on record review and interview the facility did not review the Emergency Room (ER) records monthly to insure that the appropriate care is being provided and documented in the medical record for 20 of 20 sample records reviewed. The findings include: 11. Review of the Performance Improvement Program revealed no evidence that the ER records were being reviewed for completeness of the medical record. Review of the 20 ER records revealed that 10 of the patients were admitted to the hospital for further treatment and 10 were discharged home. of the 10 patients who were treated in the ER and discharged; there was no evidence of physicians discharge order from the ER for patients #5, #7, #14, #16, and #17; there was no evidence of discharge instructions for patients # 4 and #5; there was no evidence that physicians documented progress notes throughout the ER stay to indicate that the patient was medically clear for discharge or their initial impressions and differential diagnoses, additional assessments of the patient or the final diagnosis upon discharge of the patient from the ER for patients #4, #7, #11, #15 and #17. Review of the 20 records of patients seen in the ER revealed that there was evidence that the physicians failed to date and time the medical screening documentation for patients # 1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #18. For sample patient # 19 the record revealed that the patient was admitted to the ER at 6 pm and admitted as an inpatient at 10:20 pm, but the medical screen was documented as 8 am. There was no evidence of a date on the form. Interview with the Director of the ER confirmed that a monthly audit of the medical records had not been completed. 12. Based on the foregoing, Pan American Hospital violated 59A-3.255(6) (f), F.A.C., carrying in this case, an assessed fine of $1,000.00 x 20 patients’ records = $20,000.00. PRAYER FOR RELIEF WHEREFORE, AHCA intends to: A. Assess against Pan American Hospital an administrative fine of $20,000.00 for the violations described in Count I in accordance with Section 395.1065(2) (a) Fla. Stat. B. Award the Agency for Health Care Administration reasonable attorney’s fees, expenses, and costs. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statues (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency for Health Care Administration, Lealand McCharen, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted. \ so - Rodney Assistant General Counsel Agency for Health Care Administration 8355 NW 53°* Street Miami, Florida 33166 (305) 499-2165 Copies furnished to: Diane Lopez-Castillo Field Office Manager Agency for Health Care Administration 8355 NW 534 Street Miami, Florida 33166 Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing complaint and election of rights was sent by U.S. Certified Mail, Return Receipt Requested to the Administrator, Pan American Hospital, 5959 N.w, 7th Street, Miami, Florida 33126 and to Robert E. Venney, Registered Agent, 901 Ponce de Leon Blvd., Coral Gables, Florida 33134 on Sat Loe , 2003. Nelson FE. Rodney

Docket for Case No: 03-004684