Pam 5. STATE OF FLORIDA VO ah ED | AGENCY FOR HEALTH CARE ADMINISTRATION & STATE OF FLORIDA, OOMAY 26 AM 10: 46 AGENCY FOR HEALTH CARE OMISION OF ADMINISTRATION, ADH AIS TRATIVE HEARINGS Petitioner v. . CASENO.: (O~ gaa! SEBASTIAN RIVER MEDICAL CENTER, Responcient. ADMINISTRATIVE COMPLAINT Petitioner, STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (“Agency”) by and through the undersigned hereby issues this Administrative Complaint against Respondent, SEBASTIAN RIVER MEDICAL CENTER (“SRMC’), for violation of state hospital licensure law, and imposes administrative fines in the amount of $50,000. As grounds for the imposition of such administrative fines, the Agency states: . 1. The Agency has jurisdiction over SRMC and the enforcement of hospital licensure law and risk management law pursuant to Chapter 395, Florida Statutes, and Rules 59A-3 and 59A-10, Florida Administrative Code. 2. SRMC is a hospital within the meaning of Section 395.002(11), Florida Statutes, and Rule 59A-10.002(2), Florida Administrative Code. 3. The Agency conducted a site survey of SRMC on or about December 6, 1999, pursuant to Sections 395.0161 and 395.0197(15), Florida Statutes, and hereby determines that SRMC is in violation of numerous risk management, Exhibit A requirements andi ubject to fines, pursuant to Section’e5.0197(12), Florida Statutes, as follows: a.) Hospital risk management violations 4.: Hospitals are required to report specified adverse incidents to the Agency within fifteen (15) days (“Code 15 Report”) of occurrence. Section 395.0197(8), Fla.Stat. (1999); Rule 59A-10.0065, Fla.Admin.Code (1999). 5. The Agency finds that a death occurring on or about 10/24/99 at SRMG - which meets the criteria of a Code 15 Report, has not been reported. Patient V.H. was admitted to SRMC on 10/21/99 and treated with IV potassium which was not properly monitored causing critical levels of potassium in the patient's blood stream resulting in cardiac arrest and death on 10/24/99. Therefore, SRNC has violated Section 395.0197(8), Florida Statutes, and Rule 59A- 10.0065, Florida Administrative Code. . 6. Hospitals are required to submit a written plan of correction to the Agency addressing deficiencies determined during the course of any risk management survey. Section 395.0197(12), Fla.Stat. (1999). 7. The Agency finds that SRMC'‘s written plan of correction received 1/4/00 for the 12/6/99 survey required correction of the aforementioned deficiency by filing a Code 15 Report by 12/22/99. As of 3/31/00, SRMC has failed to file the Code 15 Report required to be filed for the incident occurring on or about 10/24/99. Therefore, SRMC remains in violation of Section 395.0197(8), Florida Statutes and its own plan of correction. Wh 1 H epmevaae: ww) . Ne b.) Fines for violation of hospital risk management law 8. The Agency hereby assesses an administrative fine against SRMC for an Intentional and willful failure to submit a Code 15 Report regarding an adverse incident occurring on or about 10/24/99 in violation of Section. 395.0197(8), Florida Statutes, and Rule 59A-10.0065, Florida Administrative Code, of $25,000, pursuant to Section 395.0197(12), Florida Statutes. 9. The Agency hereby assesses an administrative fine against SRMC for the continued intentional and willful failure to submit a Code 15 Report as required by the plan of correction submitted 1/4/00 regarding an adverse incident occurring on or about 10/24/99 in violation of Section 395.0197(8), Florida Statutes, and Rule 59A-10.0065, Florida Administrative Cade, of $25,000, pursuant to Section 395.0197(12), Fiorida Statutes. 10. Therefore, the total of administrative fines from the above specified violations of hospital risk management law assessed against SRMC amounts to $50,000. c.) Rights to a hearing 11. SFIMC has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel, to take. testimony, to call or cross-examine witnesses, and to have argument if a hearing is requested. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, SRMC’s request for a formal hearing must set forth with . specificity disputed issues of material fact. Failure to so set forth such disputed issues of material fact may be treated by the Agency as an election of an ha informal proceeding pursuant to Section 120.57(2), ride Statutes. SRMC has a right to request mediation pursuant to Section 120.573, Florida Statutes. Choosing mediation will not affect SRMC’s right to an administrative hearing. A request for hearing shail be filed with: Agency for tiealth Care Administration, 2727 Mahan Drive, Building #3, Tallahassee, Florida 32308-5403, Attention: Sam Powers, Agency Clerk, General Counsel's Office, with a copy to Anna Polk, Agency for Health Care Administration, 2727 Mahan Drive, Building #1,. Tallahassee, Florida 32308-5403. SRMC should include a copy of this administrative complaint with any request for hearing. 42. \f SRMC does not contest the matters asserted in this administrative complaint, the amount of the total fine should be remitted by check or money order payable to: Agency for Health Care Administration, 2727 Mahan Drive, Building #1, Tallahassee, Florida 32308-5403, Attention: Anna Polk. 13. Failure to pay the fine or request an informal or formal hearing within twenty one (21) days of receipt of this complaint will result in an admission of the facts alleged herein and an entry of a final order based upon such facts by the Agency. i i t i 13 ‘ mmm be Cs Ce | ISSUED this_/44_ day of April, 2000. AGENCY FOR HEALTH CARE oy Deputy Director State of Florida : Agency for Health Care Administration : 2727 Mahan Drive . an Ft. Knox Executive Center Ill Tallahassee, Florida 32308-5403 ad Lae a} | hereby certify that this Administrative Complaint was sent by U.S. ! Certified Mail Return Receipt’ Requested to: Baye Ms. Diane D. Torres Executive Director Sebastian River Medical Center 13695 U.S. Highway 1 Sebastian, Florida 32978-0838 this /7__ day of April, 2000. Mark S. Thomas, Esquire

Docket for Case No: 00-002221