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. ad ik ad r i i ae RAM AE A ei A a i Si A i ee | ae 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 SRI com eo Si A A A eed Me 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. i a mr pre 7 at pre er 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 ii i a a reer oe cece Cite i acca were me © Si a de ee 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 OP i tO ose ee cape me “9p i ae oe

Docket for Case No: 02-000679