Certified Mail Receipt O% Mss T (7004 2890 0000 5527 3286 STATE OF FLORIDA BD tf AGENCY FOR HEALTH CARE ADMINISTRATION. STATE OF FLORIDA, AGENCY FOR EME HEALTH CARE ADMINISTRATION, %p Petitioner, - AHCA NO: 2008001181 ~ ve JACKSON COUNTY HOSPITAL DISTRICT d/b/a JACKSON HOSPITAL, Respondent. a | ADMINISTRATIVE COMPLAINT The Agency for Care Administration (“AHCA”), by and through undersigned counsel, hereby files this Administrative Complaint against Jackson County Hospital District d/b/a Jackson Hospital (“Respondent” or “Jackson Hospital”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2007) and alleges: NATURE OF THE ACTION 1. This is an action to impose two (2) administrative fine in the amount of Two Thousand ($2,000.00), based upon two deficiency pursuant to §395.1065(2){a), Fla. Stat. (2007), and Rule 59A-3, Fla. Admin. Code (2007). §395.1065(2)(a) The agency may deny, revoke, or suspend a license or impose an administrative fine, not to exceed $1,000 per violation, per day, for the violation of any provision of this part or rules adopted under this part. Each day of violation constitutes a separate violation and is subject to a separate fine. §59A-3.255(1)(a-c) Emergency Care Each hospital offering emergency services and care shall post, in a conspicuous place in the emergency _ service area, a sign clearly stating a patient’s tight to emergency services and cate as set forth in Section 395.1041, F.S. The sign shall be posted in both English and in Spanish. (b) Each hospital offering emergency services and care shall post a sign identifying the service capability of the hospital. The categories of services listed on. the sign may be general in nature if the sign refers patients to another location within that facility where a list of the subspecialties is available. The sign identifying the service capability of the hospital and the additional listing of subspecialties, if a separate subspecialty list is maintained, shall be in both English and in Spanish. (c) The signs required by this rule section shall be posted in a location where individuals not yet admitted to the hospital would reasonably be expected to present themselves for emergency services and care. §59A-3.255(2)(a) Emergency Care Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, E.S., relating to emergency services. The policies and procedures shall incorporate at a minimum: (a) Decision protocols identifying the emergency services personnel within the hospital responsible for the arrangement of outgoing and incoming transfers DATES [ SEE | * | “G07 SURVEY OR ORDER COUNT(| FOR 8): 1 | bor" Li d Validati Lu Fi 2007 licensure an alidation. , ine JURISDICTION AND VENUE 2. This agency has jurisdiction pursuant to Chapter 395, Part 1 and Sections 120.569 and 120.57, Fla. Stat. (2007). | 3. Venue lies in Jackson County, Marianna, Florida, pursuant to Section 120.57, Fla. Stat. (2007); Chapter 594-3, Fla. Admin. Code (2007), and Rule 28.106.207, Fla. Admin. Code (2007). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing hospitals pursuant to Chapter 395, Part I, Fla. Stat. (2007), and Chapter 59A-3 Fla. Admin. Code (2007). 5. Jackson Hospital is a for-profit corporation, whose 100-bed hospital is located at 4250 Hospital Drive, Marianna, Florida 32446. Jackson Hospital is licensed as a hospital, license #3999; certificate number 3535, effective date July 1, 2007 through June 30, 2009. Jackson Hospital was at all times material hereto, a licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT 1 FOR IMPOSITION OF $1,000 FINE Jackson Hospital failed to post conspicuously the required signage in places likely to be noticed by patients entering into the emergency room ambulance entrance and treatment rooms. State Tag-H030 Section 395.1065(2)(a), Fla. Stat. (2007) (Criminal and administrative penalties; injunctions; emergency orders; moratorium) “Rule 59A-3.255(1)(ac), Fla. Admin. Code (2007) 6. AHCA re-alleges and incorporates paragraphs 1 through 5. 7. On or about July 27, 2007, AHCA conducted a complaint investigation survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a. On or about July 27, 2007, Jackson Hospital failed to post conspicuously the required signage in places likely to be noticed by patients entering into the emergency room ambulance entrance and treatment rooms. The findings are: An observation of the waiting room on 7/26/07 at approximately 10:05 a.m. revealed the sign in English only. Further observation of the Emergency Room (ER) revealed no other conspicuously place to be noticed by individuals entering the treatment area, and ambulance entrance. An interview was conducted with the ER Unit Manager and the Risk Manager on 7/26/07 at approximately 10:05 am. The ER Unit Manager and Risk Manager acknowledged the required signage was not posted in all places to be notified by patients entering the emergency and acknowledged the one sign was only in English. Correct by: 8/26/2007 8. The regulatory provisions of the Fla. Stat. (2007), that is pertinent to this alleged violation read as follows: §395.1065 Criminal and administrative penalties; injunctions; emergency orders; moratorium. (2)(a) The agency may deny, revoke, or suspend a license or impose an administrative fine, not to exceed $1,000 per violation, per day, for the violation of any provision of this part or rules adopted under this part. Each day of violation constitutes a separate violation and is subject to a separate fine. §59A-3.255 Emergency Care. (1)(a) Each hospital offering emergency services and care shall post, in a conspicuous place in the emergency service area, a sign clearly stating a patient’s right to emergency services and care as set forth in Section 395.1041, F.S. The sign shall be posted in both English and in Spanish. (b) Each hospital offering emergency services and care shall post a sign identifying the service capability of the hospital. The categories of services listed on the sign may be general in nature if the sign refers patients to another location within that facility where a list of the subspecialties is available. The sign identifying the service capability of the hospital and the additional listing of subspecialties, if a separate subspecialty list is maintained, shall be in both English and in Spanish. (c) The signs required by this rule section shall be posted in a location where individuals not yet admitted to the hospital would reasonably be expected to present themselves for emergency services and care. 9. The violation alleged herein constitutes a deficiency and warrants a fine of $1,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $1,000. COUNT II FOR IMPOSITION OF $1,000 FINE Jackson Hospital failed to follow their policy and procedure related to discharging a patient whose medical condition was not stable for one (1) of twenty-two (22) sampled patients (#10). State Tag-H031 Section 395.1065(2)(a), Fla. Stat. (2007) (Criminal and administrative penalties; injunctions; emergency orders; moratorium) Rule 59A-3.255(2)(a), Fla. Admin. Code (2007) 10... AHCA realleges and incorporates paragraphs 1 through 5. 11. On or about July 27, 2007, AHCA conducted a complaint investigation survey at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a. On or about July 27, 2007, Jackson Hospital failed to follow their policy and procedure related to discharging a patient whose medical condition was not stable for one (1) of twenty-two (22) sampled patients (#10). The findings are: Review of the clinical record for patient # 10 revealed patient #10 was admitted to Jackson County Hospital on 6/30/07 at approximately 2:56 a.m. via ambulance after a motor vehicle accident. The Patient Progress Note dated 6/30/07 at 2:56 a.m. stated, "Presents to ER involved in Motor Vehicle Crash (MVC). Unsure if was ejected. Complain of arm pain, obvious deformity noted to right arm. Chief complaint: MVC with possible fractures to upper extremities. Pain to upper arms recorded as 10 (scale of 1 to with 1 as least and 10 maximum pain). Pain describes as acute and throbbing. Review of the Discharge Instruction on 6/30/07 at 9:45 a.m. stated: (1) Wear arm sling until follow up with Ortho. (2) Take Lortab 5 m.g. one or two tablets every 4-6 hours as needed for pain (3) Return as needed. Discharge diagnosis # 1: right elbow dislocation. Discharge diagnosis # 2: Sprains At 11:50 a.m. Physician Progress note dated 6/30/07 stated, the ER Medical Director advised by the Radiologist patient # 10 may have fracture of the pelvis and needs follow up (2 hours after discharge at 9:45 a.m.) At 11:55 a.m. Patient # 10's mother was called by the ER Unit Manager to asked if she would bring patient # 10 back for some follow up pelvic X-rays". At 12:10 p.m. Patient # 10's mother called and advised she was taking patient # 10 to a hospital in Alabama (SEAMC). At 1:00 p.m. the ER physician at SEAMC called Jackson County Hospital and spoke to the Medical Director to question why a CT scan of the abdomen and spleen was not performed and why routine labs were not drawn. The SEAMC ER physician reported to the ER Medical Director patient # 10 had Bibasilar Atelectasis in both lungs, fractured ribs, lacerated spleen and fractured kidney. An interview was conducted with patient # 10 on 7/26/07 at approximately 2:20 p.m. Patient # 10 stated that she did not remember anything from the night of the acciderit. Patient # 10 stated that she was in the hospital in SEAMC for 9 day. Patient # 10 stated that she had a ruptured spleen, busted left kidney, right dislocated and fractured elbow, fractured pelvis in 3 places. And one rib was fractured. Review of the SEAMC emergency record revealed patient # 10 was admitted to the ER on 6/30/07 at 1:20 p.m. with vital signs as: BP 112/70, heart rate 91, respirations 20, temperature 98.8, oxygen saturation 100%, and pain 10 on the scale of 10. Chief complaint MVA injury to abdomen, back pain, pelvis pain, left arm pain, and right arm pain due to overturned vehicle Patient # 10 was admitted to SEAMC. Review of the Discharge Summary from SEAMC dated 7/9/07 stated, " Diagnosis: 1. Motor vehicle accident 2. Splenic laceration 3. Left kidney laceration 4. Rib fracture 5. Right elbow fracture/dislocation 6. Pelvic fracture Review of the Policy, "COBRA GUIDELINES" from Jackson Hospital revealed, "4. Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during, or after said transfer or discharge. If the patient is a reasonable tisk to deteriorate due to the natural process of their medical condition, they are legally unstable according to COBRA standard". Correction date: 8/26/07 12. The regulatory provisions of the Fla. Stat. (2007), that is pertinent to this alleged violation read as follows: §395.1065 Criminal and administrative penalties; injunctions; emergency orders; moratorium. (2)(a) The agency may deny, revoke, or suspend a license or impose an administrative fine, not to exceed $1,000 per violation, per day, for the violation of any provision of this part or rules adopted under this part. Each day of violation constitutes a separate violation and is subject to a separate fine. 59A-3.255 Emergency Care. Each hospital providing emergency services and care shall establish policies and procedures which incorporate the requirements of Chapter 395, F.S., relating to emergency services. The policies and procedures shall incorporate at a minimum: (a) Decision protocols identifying the emergency services personnel within the hospital responsible for the arrangement of outgoing and incoming transfers. * ek 13. The violation alleged herein constitutes a deficiency and warrants a fine of $1,000. WHEREFORE, AHCA demands the following relief: L. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I & II. 2. Jackson Hospital an administrative fine in the amount of $2,000.00 for the violation cited above. 3. Grant such other relief as the court deems is just and proper. Respectfully submitted this 3! Say of /4. earch 2008, Leon County, Tallahassee, Florida. \QyPuiches! O. Mathis la. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office) (850).921-0158 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Fla. Stat. (2007). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney, Telephone (850) 922- 5873. RESPONDENT 18 FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY thay true jerue and correct copy of the foregoing has been served by certified mail on BI day of , 2008 to Jackson Hospital, 4250 Hospital Drive, Marianna, Florida 32446. Michael oO. Mathis, Esq. eb0e SUBr ORE tIOy (pounbey yuewesiopuy) Say Aleaqeq panieos (peynbey wewassopt 8a, Idjsosy Winey “=) 313 TVIdisso/u CWOS SASH MAM 7B S}EGSM ITO YSIA UONEUIOJUT AIdAI|Sp 104 (papinoig abeian09g.aauemsuy ON TAU He 3NSatiOg) idid3day “VW GalsiLyad "ODINIES |EISOd “S'N. qe@ce 2259 Oooo "7 COMPLETE THIS SECTION ON DELIVERY SENDER: COMPLETE THIS SECTION @ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse so that we can return the card to you. ™@ Attach this card to the back of the mailpiece, or on the front if space permits: D Agent Ol Addressee C, Date of Delivey . Is delivery address different from item 47 [1 Yes If YES, enter delivery address below: [1 No 1. Article Addressed to: Jackson eho ase euRrL | Macianna, FL ZQyyc. 5. Sanja ‘Type ertified Mait 1] Express Mail (I Registered C Return Receipt for Merchandise 0 insured Mail Oc.00. | 4. Restricted Delivery? (Extra Fee) O Yes 2. Article Number ‘ (Transfer from service label) * 7004 2@890 OO00 5527 324b PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 ;

Docket for Case No: 08-002587