STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION n wv AGENCY FOR HEALTH CARE - ADMINISTRATION, Petitioner, AHCA No.: 09-01-0053 H . 2001036811 v. : Return Receipt Requested 7000-1670-0011-4845-7243 LIBERTY BEHAVIORAL 7000-1670-001 1-4845-7236 MANAGEMENT OF FLORIDA, INC., 7000-1670-001 1-4845-7311 d/b/a SAVANNAS HOSPITAL, 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 fine AHCA alleges as follows: NATURE OF THE ACTION 1. This is action to impose an administrative fine in the amount of One Hundred Eight Thousand Dollars ($108,000.00) pursuant to § 395.1065(2)(a), Fla. Stat. JURISDICTION AND VENUE 2. This agency has jurisdiction pursuant to §§ 120.569 and 120.57, Fla, Stat., and Chapter 28-106, Fla. Admin. Code. 3. Venue lies in St. Lucie County pursuant to § 120.57, Fla. Stat., and Chapter 28, Fla. Admin. Code. oe a nee ee we resi coo geen meyers on ae ac ee a b E F i E E & ke f E iz E i 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, FL 34952. COUNT I SAVANNAS HOSPITAL FAILED TO ENSURE THAT ADEQUATE NURSING CARE WAS PROVIDED TO MAINTAIN A SAFE CLINICAL ENVIRONMENT. FLA. ADMIN. CODE R. 59A-3.2085(5) 6. AHCA realleges and incorporates paragraphs 1 through 5 as if fully set forth herein. 7. During the complaint investigation conducted on 4/13/01 through 4/19/01 and the revisit survey of 5/21/01 through 5/25/01, based on observation, interview and clinical record review, it was determined that Savannas Hospital did not provide quality nursing care and did not maintain a safe clinical environment for all patients. This finding is for patients #2, #5, #23 and #24. The findings include: (a) The Plan of Correction for the 4/19/01 complaint investigation “documented that “Staff education occurred 4/11/01 and 4/13/01 - staff were to be trained to screen patients for suicidal/homicidal intent and indication plus any history of violence”. A violence precaution policy was developed to help staff identify and intervene appropriately when a patient has a history of violence. This policy documented: “It is the policy of Savannas Hospital to identify patients who are high risk for violence in order to protect staff and other patients”. “During Phase I Assessment patients with a high risk for violence will be identified”. This Plan of Correction and policy and procedure were not followed. Staff did not screen and identify the history of violence and homicidal threats for Patient #5. Staff did not adequately supervise Patient #2. Staff did not adequately supervise Patient #5 and Patient #2 while smoking on the eee cee — CORRE Re eRe gem RINNE RCI OT mM oper eR ET REN Ee eRe SOME TE ge eR EE eS Ta Ma cs hae lh ae A A patio the evening of 5/20/01 as evidenced by the following: On 5/21/0 1 a Registered Nurse surveyor toured the Intensive Treatment Services Unit at 9:30 a.m. and found a male patient (45) sleeping on a mat in the Quiet/Seclusion Room. The RN in charge of the Intensive Treatment Services Unit on the day shift informed the surveyor that the evening before the male patient in the Quiet Room had been in a fistfight with another male patient (#2). It had been determined that patient #2 had hit Patient #5 with a plastic chair. Both patients were on eye-contact observation (Close Observation) only after the fight took place. The records of both male patients were reviewed. (i) Patient #2 was admitted the afternoon of 5/15/01 under Baker Act having been agitated and threatening toward staff at a local hospital . emergency room prior to admission at Savannas. The nurse’s notes between 5/15/01 and 5/20/01 documented the patient was easily agitated, angry, argumentative, slamming doors, verbally abusive using profanity toward the staff such as “New York ___hole and Black Bitch”. Nurse’s notes further documented this patient had a labile mood and potential for violence. On 5/19/01 the staff documented in this patient’s record that other patients stated that the patient was “mean”, “scary”, and “that something will happen”. On 5/19/01 the staff documented the patient was “volatile”. The treatment plan approaches for treating behavior dated 5/16/01 documented nursing will monitor level of agitation/anxiety to deescalate verbally and give medication as needed. The treatment plan documented activity therapy will encourage creative activities, increase positive coping skills, increase relaxation skills, and increase behavioral skills. There were no approaches for the Physician or Social Work. On 5/20/01 at 10:00 p.m., the nurse’s notes documented that Patient #2 was on the patio with two female patients. The patients were smoking and there were no staff present. Patient #2 engaged in a verbal argument with Patient #5 that escalated to a fistfight. Patient #2 hit Patient #5 with a plastic chair. The nurse’s notes documented that Patient #2 suffered injuries in the form of abrasions to the ST ETE ORM Tree | i i E F r face, knuckles and hands. Patient #2 was not placed on Close Observation (eye contact) until after the fight of 5/20/01. (ii) The intake assessment of Patient #5, who had been admitted on 5/1 7/01, did not document a history of violence. The treatment plan had no violence precaution for this patient. However, the nurse on the Intensive Treatment Services unit told the surveyor this patient had a history of violence and a history of being on the Intensive Treatment Services Unit in 4-point restraints. The surveyor reviewed this patient’s closed records and found the following for admission 3/8/01 to 3/23/01: On 3/18/01, Patient #5 had been admitted under a Marchman Act which was converted to a Baker Act status on 3/20/01 for threatening to kill a staff member. The patient was placed in a 4-point (limb restraints) at this time. The patient clearly had a history of violence and homicidal threats. Upon record review for admission of 5/15/01, it was determined that the nurse’s notes documented that on 5/20/01 at 10:00 p.m., while this patient was smoking on the patio with Patient #2, a verbal argument ensued which . escalated to a physical fight. Patient #5 was hit with a plastic chair and suffered cuts on the knuckles. This patient was placed on constant observation on 5/20/01. On 5/20/01, _ one of the two patients, an elderly female who was also on the patio smoking, stated to survey staff that she was scared when this incident took place. (b) _—_ Record review of the staffing and sheets for the Adolescent Unit revealed that on 5/20/01, 5/21/01, and 5/22/01, there were two staff members assigned to the Adolescent Unit on all three shifts. Record review and interview with staff on this unit, revealed that three of the three patients on 5/20/01 and 5/21/01, had a recent history of suicidal and/or assaultive behavior (Patient # 38, #39 and #40). (c) On 5/22/01 and 5/23/01, three of the four patients on this unit were assessed as having a recent history of suicidal and/or assaultive behaviors. The acuity system in place during this period of time used to determine staffing needs did not consider these behaviors in their “definition of acuity and numerical value”, therefore y ; 4 a A i he i a ean ae So cocldihacncataituaneateeee ae staffing for that unit did not change. On all three shifts for these two days, there were only two staff members per shift. Also on this unit, staff did not maintain a safe environment. In support of this, on 5/23/01 it was observed that scissors were left in unlocked drawers. . (d) Record review of the staffing on the Dual Diagnosis Unit revealed that on 5/20/01, 5/21/01 and 5/22/01, there were two staff members assigned to the unit on the 11:00 p.m. to 7:00 a.m. shift. The census on this shift for these three days was as follows: 5/20/01 = 13 patients 5/21/01 = 14 patients 5/22/01 = 13 patients During this period of time, interview with staff and record review revealed the following: Two patients with assaultive potential, two patients with suicidal risk, two patients on detox precautions and one patient with a diabetic protocol. The acuity system in place during this period of time did not consider these behaviors in their “definition of acuity and numerical value”; therefore, the staffing for that unit did not _ change on the 11:00 p.m. to 7:00 a.m. shift. (i) Interview with the Executive Director and Director of Clinical Services, on 5/22/01 revealed that there had been an additional staff person assigned as a “float” on this shift. Interview with the unit staff revealed that this hospital “float”, a mental health technician, primarily relieved staff for breaks. This accounts for at least six hours of the “float’s” eight hour shift. The Executive Director and Director of Clinical Services agreed that this was the responsibility of the “float”. (ii) Record review and staff interview revealed that the night shift Nursing Supervisor continued to be the House Supervisor and the screener for admission this night shift. Review of the Admission/Screening log revealed that since the last survey ending 4/19/01, there were seven patients screened on one night shift. Staff 5 re pene PR RIT corey “4 a TT " oer sie 7 ROC UTE TERRE RN ARE TERE OO TRI ERR REET TORE RR I °F TRE interviews and record reviews further revealed that since this is a Baker Act Receiving facility, there are numerous screenings done on all three shifts. Due to the limited number of staff members working on \ the 11:00 p.m. to 7:00 a.m. shift, the Nursing ae Supervisor/Screener has a limited amount of time to fulfill the Nursing Supervisory . responsibilities and/or to be available to assist the unit staff. (e) . Observations on the Adolescent Unit, Chemical Dependency Unit, and Dual Diagnosis Units on 5/21/01 and 5/22/01 revealed that there were various projectile type objects (tape dispensers, stapler, hole-puncher) out on the nurses station ‘within reach of patients. , () On 5/23/01 between 12:00 noon and 1:00 p.m., Patient #24 was , observed in the patient lounge area outside the nurse’s station on the Intensive Service Unit. The patient was loudly shouting to the mental health technician “you’re f__king with the wrong person.” The patient continued to loudly verbalize negative comments about the care provided in the facility for another five minutes. The mental health technician did not report the patient’s remarks to a nurse. (g) | During the annual survey on 5/21/01 through 5/25/01 the acuity level of the Adult Unit was reviewed by the surveyor. On 5/21/01 at 9:45 a.m. there was a census of twelve patients in the Unit, which has the capacity to hold sixteen patients. There were two newly admitted patients who by hospital policy should have been on close observation for the first twenty-four hours. This was not done. (h) —_‘ During the annual survey of 5/21/01 through 5/25/01 the acuity level of the Adult Unit was ascertained by the surveyor. On 5/21/01 at 9:25 a.m. there was a census of twelve patients in the Unit, which has the capacity to hold sixteen patients. There were two newly admitted patients who by hospital policy should be on close observation for twenty-four hours. Two patients were suicidal. One was severely depressed needing assistance with daily hygiene, eating, and frequent redirection. One patient on the unit was in a wheel chair and needed assistance with ambulation. On the 6 SPREE PRE RT Tere ESTERS SRE AE EERE ER FE-PE RE RR RTS dh ii a morning of 5/21/01 the surveyor obtained the following care needs of patients from the Charge Nurse and Program Director. The Patients’ care needs given by staff were as follows: 5 patients= Self care independent functioning 2 patients = Minimal care 3 patients= Moderate care; 2 patients= High level of care. @ The surveyor reviewed the patient acuity system the Adult Unit used to determine staffing needs. The acuity system did not assess or consider under staffing needs, the patient at risk for elopement, the two suicidal patients or the patient at risk for falls. After the surveyor questioned the acuity points, the nurse who was assigning the patients changed the acuity points to a higher level. The staff on 5/21/01 consisted of the following: two registered nurses, one mental health technician and aunit secretary on day shift. On 5/20/01 the Unit census was eleven. Interview on 5/20/01 with one of the nurses revealed that one of the registered nurses (RN) was sent home leaving only one RN and a mental health technician in the unit. The acuity level was the . same on 5/20/01 as on the day shift on5/21/01. On both night shifts there was one RN and one mental health technician who “floats” relieving staff for meals or for transportation duties. On 5/21/01 based on interview, it was found that one of the staff became upset because he/she was told he/she might be working only four hours instead of eight hours. This staff person felt he/she was needed on the unit at the time. The acuity level was as stated above for 5/20/01 and 5/21/01 in the previous paragraph. A nurse on the unit stated that it was a common occurrence that if the census dropped staff would be sent home despite acuity level. Interview with the staff and Program Director revealed that the Executive Director made all staffing decisions. They stated they did not have the authority to increase staff if the acuity increased without consulting the Executive Director. TOES PRT RT RTE ERE SCRE TT FORE TI IRR PRE ETRE AY ERS TERN RT ERR SR ROR ree ee eT Si aed Aaah i die caeeceeaaae (i) This citation also addressed a complaint that alleged that young violent male patients ‘were being commingled on the Intensive Treatment Services unit with vulnerable elderly patients. During a tour of the Unit on 5/24/01 at 1:30 p.m., an interview with staff regarding acuity levels of the patients, revealed the following: At 5:15 p.m, a young male patient (#P 37), suddenly flipped over a desk because an elderly patient tried to take his cake. He used verbal threats as follows: “If that old lady doesn’t stop bugging me I will blow/snap.” This patient was counseled by staff on a one-to-one basis and given medication to calm him. He was also placed on constant observation (eye contact). The elderly patient and the young male patient remained on the Intensive Treatment Services Unit, which is where violent patients are placed. The Intensive Treatment Services Unit Program outline in clinical manual #4 documents that the Intensive Treatment Services Unit has “maintenance of a highly structured low stimuli small and stable milieu with a high staff patient ratio that provides a safe and supportive environment that encourages control of disruptive behavior”. The clinical milieu was not being maintained as described in the program plan. The hospital admitted elderly patients to the Intensive Treatment Services Unit with patients having labile, volatile, and -assaultive behaviors. The staff stated that this patient had been admitted on the Dual Diagnosis Unit on previous hospitalizations. On the last admission, this patient had attacked the Medical Director on the Dual Diagnosis unit causing the physician to refuse admission of the resident to that unit. The staff person stated the patient was now placed on the Intensive Treatment Services Unit because he/she could no longer return to the Dual Diagnosis Unit. @) On 5/21/01 additional review of the Intensive Treatment Services Unit revealed the commingling of violent assaultive patients with vulnerable elderly patients who had no history of violence as follows: four of 12 patients were elderly. The unit had a staffing acuity system in place but the definition of “Acuity” and “Numerical Value” did not include violent, assaultive or suicidal patients. On the evening of 5/20/01 8 Te wwe rep ree om SPRERRRC SEIRETIT Tr* e PE TENT CRTRRREETT SCE RT TORRE REE Ee ER ORM RNR RE ORR ere ee ET Te RE Re at 10:00 p.m. as documented above there was a violent episode on the Intensive Treatment Services Unit between two male patients. On 5/20/01, the night shift had only two staff and a “float”. On 5/21/01 the Surveyor toured the unit. On staff were two female RN’s and one female mental health technician. Nursing staff stated they were very uncomfortable and that another mental health technician was coming in at 10 a.m. The acuity-based system of the hospital did not include a full assessment of each patient’s needs. The average acuity for the ITS unit assigned was 2.7. The acuity had to be doubled in order for more staff to be requested. Even when acuity doubled and unit staff requested more staff, management had the authority to deny any increased staffing request. (k) Additional review of the Intensive Treatment Services Unit revealed that Patient #23 was Eighty-Four years old with medical diagnosis of Obstructive Pulmonary Disease and Congestive Heart Failure. Psychiatric diagnosis was depression with suicide attempt. Problems noted on the nursing assessment on admission were a) shortness of breath on exertion, b) back pain/back injury, c) superficial abrasion left wrist and chest, d) needs help with ambulation. The Intensive Treatment Services . Unit has no handicapped shower or bathroom. On 5/23/01 the showers were observed to be small stall-type showers with a tile edge requiring a patient to step over. On admission, there was no care plan to assist the patient with activities of daily living, dressing and bathing. On 3/20/01 there was a problem noted on the treatment plan of fragile skin but no approaches or care plan was documented. A care plan was documented starting on 4/01/01 to assess skin daily, apply lotion to dry skin, and do dressings as ordered. This patient had the following doctor’s orders for wound dressings: On 3/21/01, left forearm sterile saline/Neosporin to site after wash with Hibiclens, cover with gauze; On 3/31/01, consult M.D., right forearm lesion; On 4/01/01, wash skin tears, Hibiclens, cover with Neosporin and Tegaderm every 2 days, no tape on skin, just gauze wrap. There was no documentation in the nurse’s notes of skin condition or when/how 9 meme OR ne CREE ope “OORT RTE OE To RET Eo RE CER RE RE skin problems occurred. The only documented injury to the patient in the nurse’s notes was 3/23/01 right wrist injury from slipping to the floor. This patient was assisted with a shower only once on 3/28/01. There was no documentation of skin condition when shower _ given. The nurses’ notes for this patient contained no documentation of daily skin ‘assessments being completed on 4/02/01, 4/03/01 or 4/04/01. During the entire admission, there was no treatment plan for the resident’s Chronic Obstructive Pulmonary Disease. (6) On 5/23/01 from 6:30 a.m. to 7:30 a.m. the RN Surveyor Team Leader toured Savannas Hospital’s units with the night supervisor. The following observations were made on the Intensive Treatment Services Unit: Two psychiatric technicians were alone at the unit while the RN was off the unit typing a report. The surveyor asked the mental health technicians to call the RN with their Walkie-talkie. The mental health technicians stated the nurse did not have a Walkie-talkie with him. The night supervisor stated that the nurse was a “float” and did not know she should not leave the unit. The typing of the report should have been done in the medication room of the unit, Savannas Hospita!’s Plan of Correction of 4/19/01 reflects under Staff . Communication and Emergency Response that night staff is to carry a Walkie-talkie to increase immediate communication. (m) On 5/23/01 during tour of Savannas Hospital’s units with the Night supervisor from 6:30 a.m. to 7:30 a.m., scissors and screwdrivers were found on the units in unlocked drawers on 3 clinical units. Staff stated there was a policy for control of patients’ sharps but no policy or inventory of sharps brought onto the units or used by staff. The Risk Manager confirmed this on 5/23/01. Surveyor found 2 large sharp scissors and 1 screwdriver in the unlocked drawers of the nurse’s station on the Dual Unit. The RN in charge knew of no policy for inventory or control of these sharps. Surveyor found on the Adolescent Unit 5 pairs of scissors in the unlocked drawers of the nurse’s station. Two pairs were large sharp scissors, two pairs were medium sharp, and 10 CEST PORTE TRE oe RE TPE RR RRR ST RTE TEPC CNR PREFS E CF RETR RRE RMI T i eR So rm ae eC SRE or ee one was used for paper cutting. There was a locked drawer in the nurse’s station marked pencils, staples, rubber bands, and highlight. Staff was questioned and stated there was no policy for inventory or control of sharps belonging to staff. Surveyors found two large scissors in unlocked drawers at nurse’s station on the Adult Unit. Staff knew of no policy for inventory or control of staff’s sharps. On the Intensive Treatment Services Unit, the scissors were kept locked in the medication room according to the mental health technician who stated the scissors were there so that no patient could get them. There was no inventory of the number of scissors. (n) Nursing policy required the nurse to complete an incident report/medication variance report for omitted doses of medication. Based on review of incident reports and interview with staff nurses, Savannas Hospital staff were not completing incident reports when a physician-ordered medication could not be given due to the unavailability of the medication from the hospital pharmacy or from another alternate source. On 5/24/01 the Program Director of the Intensive Treatment Services Unit was interviewed and asked why the nurses did not complete an incident report. The Director stated that medication not being available is such a common occurrence nursing _ does not make incident reports because they would do nothing else. This is in violation of Fla. Admin. Code R. 59A-3.2085(5), carrying in this instance a $36,000 fine ($1,000.00 per day from day of initial survey to date of follow-up survey). COUNT I SAVANNAS HOSPITAL FAILED TO PROVIDE ADEQUATE EDUCATION AND TRAINING TO ITS STAFF FLA. ADMIN. CODE R. 59A-3.2085(5)(c) 8. AHCA re-alleges and incorporates paragraphs 1 through 5 as if fully set forth herein. 11 ee One Ree Tere gee i ee ee re 9. Based on review of personnel files during the survey conducted on 4/13 through 4/19/01, it was determined that one employee was not trained in Cardiopulmonary Resuscitation (“CPR”). Additional findings include: . (a) During the follow-up survey that took place from 5/21/01 through 5/25/01, AHCA determined that the education and training provided to nursing personnel did not adequately augment staff knowledge in patient care. This is based on identification of staf? s lack of implementation of the Plan of Correction from the 4/19/01 survey and the deficient practices noted curing this survey. (b) Staff was not identifying patients with history of violence as new policy required, Registered Nurse left the unit without her Walkie-talkie leaving only the mental health technician on the Intensive Treatment Services Unit. Staff did not make out incident reports for omitted medications and restraint episodes as required by policy. Nursing staff did not maintain staffs sharps inventory or control. Staff did not follow restraint policies. . This is in violation of Fla. Admin. Code R. 59A-3.2085(5)(c), carrying in this instance a $36,000 fine ($1,000.00 per day from time of initial survey to time of - revisit). . COUNT IL SAVANNAS HOSPITAL DID NOT PROVIDE QUALITY OF CARE AND A SAFE ENVIRONMENT FOR ITS RESIDENTS §§ 394,459(4), (4)(c), 394.453, Fla. Stat., incorporated by reference of § 395.003(5)(a), Fla. Stat. 10. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 11. During the revisit of 5/22/01 and based on observation, interview, review of facility documentation, and review of clinical records, the facility did not maintain patient privacy, did not provide a safe environment, did not provide quality of care and 12 ee St ddiineecadake NEES RR OTR RRR ROO ETRE ETE IRR OTR RT HREM PERT RTT failed to ensure that the rights of the patients residing in the hospital were respected as specified in the Florida Statutes for Baker Act. Findings include: (a) | Baker Act Regulations require that each unit maintain a logbook for determination of sequential episodes of restraint. Upon initiation of restraints, the logbook shall sequentially record all uses of restraints, and for each resident use the date and time of initiation, release, and elapsed time should be recorded. Based on interviews with staff and management at the hospital during this survey, the hospital did not maintain restraint logs. (b) On 5/22/01 on the Intensive Treatment Services Unit, when the surveyor asked for the restraint log the surveyor was given an admission log. One column of the admission log documented if a restraint was used during admission. The admission log was the only documentation maintained by Intensive Treatment Services Unit. Upon inquiry to other units and staff regarding documentation of restraints staff stated that no logs related to restraints were kept. The only documentation for restraint was kept on the individual patient’s clinical records. (c) On3/20/01 Patient #5 was placed in 4-point restraints on the ITS . Unit. The reason for the restraint was that the patient threatened to kill a staff member. There was no “Documentation for Seclusion Restraint Sheet” completed for this episode of restraint. Nursing management staff searched in medical records and other places and could not find documentation. (d) Patient #27 was an elderly female who was Baker Acted to the hospital for “labile mood and crying spells”. From admission on 5/03/00 until discharge on 6/02/00, review of restraint tracking revealed this patient had 12 episodes of restraint during the admission. Actual review of the doctor’s orders and Documentation for Seclusion Restraint revealed the patient had 66 episodes of restraint. The documented reason for restraint was unsteady gait and unable to contract for safety. The patient was kept restrained to the Geri-Chair with a Posey Vest or to bed with side rails and a Posey 13 CORSE ORR RETRO SERRE EE ERE RRR = OREN = RENE NE = = TREE SRN EET eR re RoE Ro cypress crept Bid oe ae Vest even when the documentation noted she was asleep. No less restrictive measures were documented prior to the use of the Posey Vest. 12. During the Survey of 5/22/01 through 5/25/01, based on patient record review and interview with staff, AHCA determined that drugs listed in the hospital formulary were not available when ordered by the physician. This was an ongoing problem. The findings include: (a) The practice on the Intensive Treatment Service Unit was that patients were told they had to supply their own medications. These were to be brought in with them or brought in by the family. This was confirmed on 5/22/01 with the Risk Manager and Director of Admissions. Patient #3 was admitted 5/01/01 to the Intensive _ Treatment Service Unit. On 5/01/01, the patient had a physician’s order for Synthroid .112 meg, daily. Review of the medication administration record revealed that this hormone medication was not administered to the patient on May 2, 2001 or on May 3, 2001. Below where the nurse had initialed and circled the initial were the letters “NF”. The nurse surveyor asked the unit nurse what “NF” meant. The reply was that this meant this was a non-formulary drug. Review of the hospital formulary revealed that the - medication in question, Levothyroxine Sodium (Synthroid) was on the formulary and should have been available. (b) On 3/18/01 Patient #5 was admitted under a Marchman Act. On 3/20/01 the patient was placed in 4-point restraints (limb restraints) due to verbal threat to kill a staff member. The physician’s order for medication to be given at the time of restraint (2:40p.m.) was for Prolixin 5 mg., IM and Ativan Img. There was no documentation in the clinical record of this emergency medication being given to the patient. This medication is on the hospital formulary and should have been available. Interview with nursing staff revealed the medication was not given because it was not available in the hospital on 3/20/01. 14 1 TERRE EEE TERR TERR RS PR RE RRR EE RR SRR TS ORR ORE “ERROR RE oro RRR CR I orem an er eee (c). The Director of Nursing instructed the nurses on the Intensive Treatment Service Unit to begin a log, which listed pharmacy problems. This log was started in April 2001. The following were documented in the log on the Intensive Treatment Service Unit: , (i) Keflex (Cephalexin) antibiotic. Not available 4/15/01. This is a hospital formulary drug. Gi) On 4/16/01 numerous nonformulary medications ordered. It took 12 hours to obtain the medication. (iii) On 4/28/01 Tigan not available. This is a hospital formulary drug. (iv) On 4/29/01 at 6:30 p.m., a patient was admitted with physician’s orders for numerous non-formulary medications. The drugs were not obtained or given until 4/30/01 on the evening shift. (v) On 4/30/01 a STAT (give now) dose of Imodium (Loperamide) tablets II was ordered. Only 1 tablet was available in the pharmacy. This medication is for diarrhea, A note in the Intensive Treatment Service Unit log stated .“medication/pharmacy issues”. Next to the entry for this nursing action a notation read _. “Director of Nursing (named) referring to Executive Director (named)”. (vi) On 4/30/01 Lipitor not available for the second day. This drug is on the hospital formulary and should have been available. The problem identified by nursing was that the family had not brought in the drug. (d) Hospital policy was for nurses to make out a Medication Variance/Incident Report for omitted doses. Interview with the Program Manager for the Intensive Treatment Services Unit of the hospital revealed nurses did not make out incident reports when there were omitted doses of medications when the drug was not available. The Manager stated it is such a common occurrence that the nurses would 15 ORC ROE RTS RE ET RRR FR Ts SEL RE CREE TR TR Re rp have no time to do anything else. Staff on other units also stated incident reports were not made out when medications were not available as the problem is too pervasive. (e) On 5/22/01 the physician wrote an order for patient #24 to receive Lotrisone cream to be applied to his/her rash twice daily for five days. On 5/23/01 between 12:00 noon and 1:00 p.m. in the Intensive Treatment Unit, this patient was observed becoming agitated and complaining loudly that he/she had not yet received this medication. Review of the facility drug formulary dated 4/02/01 revealed that this medication is a formulary medication. On 5/22/01 interview with staff nurse on the Intensive Treatment Services Unit revealed that this medication was still not available for use. (69) There was a physician order for Zyprexa 10 mg by mouth, three times daily for patient #P25. On 5/21/01, during the medication pass observation between 12:00 noon and 1:00 p.m., the dosage of Zyprexa ordered was unavailable. The medication nurse had to borrow medication from another patient to administer to this patient. (g) On 5/ 18/01 the physician ordered Lac Hydrin 12% ointment to be -applied to bladder three times daily. On 519/01 the physician documented in this patient’s clinical record “no substitute for Lac Hydrin 2% ointment.” Review of the facility drug formulary dated 4/01/01 revealed that his medication was non-formulary. Review of the Medication Administration Record for this patient revealed that this medication had never been administered to this patient and was documented as “unavailable”. This patient was discharged on 5/22/01. (h) Family interview of sampled resident’s family revealed that the patient’s family was instructed to bring in patient’s medication on admission. The second day of this hospital stay the physician wrote an order for the patient’s family to bring in any medications from home. The family member complied. On 3/06/01 this physician wrote a new order for medication, which was non-formulary. The family member was 16 OTT RE REPT REE oO TERETE PE TT S ciialintaaadiiinaamitiie: se: ae ks A ied telephoned and instructed to obtain this medication as soon as possible. The family member told the facility that he/she would have to drive 25 miles to obtain this medication. The facility instructed the family to do so. . @ Review of the Medication/Pharmacy issues log on the Adolescent Unit revealed that a patient with a history of Cardiogenic Syncope had two episodes of fainting on 4/17/01. There was no ammonia spirits in the entire facility. Q@ Review of the logs of pharmacy issues on the Adolescent Unit, Dual Diagnosis Unit and Chemical Dependence Units, revealed the following medications were unavailable at various times during the months of April 2001 and May 2001: a) Droperidol (Formulary); b) Benadryl (Formulary); c) Ammonia Spirits (Formulary); d) Decadron (Formulary); e) Dilantin (Formulary); £) Prolixin (Formulary); g) Zovirax (Formulary); h) Tessalon Perles (Formulary), i) Lopressor (Formulary). (k) Interview with the Director of Nursing on 5/22/01 and 5/23/01 revealed that in April 2001 the Director of Nursing (“DON”) asked the nurses on the unit to keep a log of all medications that were not available for patients to use. This log was for documentation of pharmacy problems. qd) Random Patient #30 with a diagnosis of bipolar disorder in a manic phase was ordered Neurontin 300 mg on 3/27/01. On 3/29/01 the patient had not received his/her medication, as it was not available. This patient was still in an acute phase of his/her illness. This medication was not in the hospital formulary and was not obtained. (m) Random patient #31 was admitted on 4/28/01 with diagnosis of drug dependency to narcotics. Medical diagnosis: Recent fall with left vertex contusion, ataxia, Crohn disease, Periferal vascular disease, coronary artery disease, hypertension, rhinitis, polysubstance abuse. Patient’s drug orders were Plavix 75 mg., Prednisone 2.5 mg., Premarin 1.25 mg., Slow Mag. 64 mg., 2 tabs bid, Tranxene 7.5 mg bid, Tricor 200 mg daily, Effexor 37.5 mg. daily, Cozaar 50 mg. daily, Nitrodur patch 0/4 daily, Pentasa 17 Se RTE ror or eg rere nn se oe SNE Peper epee ope CURR ARET METER orn 1 mg. twice daily, Inderal 20 mg three times daily, Vioxx 50 mg daily, Valium 5mg twice daily. On 4/30/01 Inderal, Slow Mag and Plavix, were not given to patient because family had not brought in the above medications and pharmacy was unable to supply them. Patient did not receive the Slow Mag until after 5/02/01 when family contact was made. Patient’s family member stated he/she would get the medication. Inderal is a drug that should never be stopped abruptly. Based on drug manual this can cause or precipitate hypertension, myocardial ischemia, or cardiac arrhythmias. Maximum effect of this drug is (3-5) three to five hours (8-11) hours for long acting types. This drug was on hospital formulary. (n) Random Patient #29 diagnosed with organic mood disorder, secondary to metastatic carcinoma R/O dementia, diabetes, and back pain was ordered Decadron 4 mg orally twice daily on the 4/02/01. Tenormin 25 mg was also ordered on 4/02/01. Patient had severe pain due to his/her cancer. According to the staff, the Decadron was used to help control the pain. Patient did not get Decadron until 4/04/01. This is a drug that can cause physical harm if stopped suddenly. It is also on hospital formulary. Monopril, an anti hypertensive, was also ordered on 4/02/01, but it too was -not available to the patient. One of the nurse managers stated patient was very upset at not having had his/her medication as he/she stated it helped his/her pain. (0) The list of drugs that were not available between April and May 2001: Risperdal 1 mg. orally; Decadron; Zoloft 50 mg; Klonopin: Trazodone; Fleet Enema; Remeron: Zyprexa; Ativan 1 mg.; Wellbutrin SR 100 mg. (needed for three patients); Zestril 10 mg.; Tegretol; Restoril; Colace. (p) Closed record review of patient #16, a Seventy Four year old, revealed that this patient was admitted on 3/30/01 as a voluntary patient with a diagnosis of depression. This patient was discharged on 4/19/01. During the initial psychosocial assessment and throughout this patient’s hospitalization on the Adult Unit, he/she reported being unhappy about this hospitalization, and stated, “I don’t want to be here.” 18 Ce RT rr IR EER OR Ree a Seem * “ee feo eRe SORE EE RES O CRRE ROET T RORRRE SIEPWEREET FOP T RR ERE EO SR EERE RTE TERETE ERT = This patient filed a Request for Discharge on 4/04/01, but retracted it on 4/05/01. Approximately 4% hours later, the patient stated to the social worker that he/she resented retracting this Request for Discharge. Review of the clinical record revealed that throughout this patient’s hospitalization, the patient was refusing to take medications, refusing to attend groups and activities, and at times refusing food and fluids. On 4/16/01 a second opinion was requested for another psychiatrist, which was completed on 4/17/01. Recommendations included “court ordered medications.” This patient remained a voluntary patient throughout this stay and was discharged on 4/19/01. 13. The above referenced violations constitute grounds to levy this administrative fine pursuant to § 395.1065(2)(a), Fla. Stat., in that the above-referenced conduct of Respondent constitutes a violation of the minimum standards rules and regulations for the operation of a hospital. The violation of § 394.459(4), Fla. Stat., is incorporated by § 395.003(5)(a)(b), Fla. Stat. This violation carries in this instance a $36,000 fine ($1,000 per day from date of initial survey to date of the revisit), pursuant to the provisions of § 395.1065(2)(a), Fla. Stat. PRAYER FOR RELIEF Wherefore, AHCA requests this Court to order the flowing relief: A. Make factual and legal findings in favor of the Agency on the Counts 1 through 3. B. Assess costs related to the investigation and prosecution of this matter, 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 19 rong eee I fogeme e ee amee e a a RT ER oe RTT Se REPT TE CR ET RD RE peepee STE REET EORTC ETE” CR PEC a eR SRT RR MR 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, MD, Executive Director, Savannas Hospital, 2550 SE Walton Road, Port Saint Lucie, FL 34952; Liberty Behavioral Management of Florida, Inc., 97 Lowell Road, 2" Floor, Millbrook Tarry, Concord, MA 01742; CT Corporation System, 1200 South Pine Island Road, Plantation, FL 33324 and Michael Bittman, Esq., 301 E. Pine Street, Suite 1400, Orlando, FL 32801 on the 28" day of January, 2002 Alba M. Rodriguez ; g 4, Assistant General Counsel Agency for Health Care Administration 8355 NW 53" Street Miami, FL 33166 20 rene © dae eeee eee a dee atte Sein aati shia. cadeesautidtami teem S aeaitetameee aiecaacaae Gi i ee ee ORIGINAL TO: Diane Grubbs Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 COPIES TO: Hospital Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Mail Stop #14 Tallahassee, FL 32308 Diane Reiland Field Office Manager Agency for Health Care Administration 1710 E. Tiffany Drive Suite 100 W. Palm Beach, FL 33407 21 TRE meme? mE oe Sat Me netted ae PRE RIE OT RTI RR i ik A A OR Re RRR tS or Te

Docket for Case No: 02-000677