(wo a 86;10:(86-Und) NOLLWN s:CIS® » S069:SINC » DGS TL-UAS » [ML UGlMeg Weysea] ad 2494) Suvi AY OADY O07 aoee STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, wenn, (ly DUIS vB. AHCA NO.2006004265 Return Receipt Requested OAKRIDGE AMBULATORY SURGERY LLC, 7002 2410 0001 4234 8989 d/b/a OAKRIDGE AMBULATORY 7002 2410 0001 4234 8996 SURGERY, LLC, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, files this Administrative Complaint against Oakridge Ambulatory Surgery, LLC, d/b/a Oakridge Ambulatory Surgery, LLC (hereinafter “Oakridge Ambulatory Surgery, LLC’) pursavant to 28-106.111 Florida Administrative Code (2005) and Chapter 120, Florida Statutes (2005) hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $274,000.00 pursuant to Section 95.1065(2) (a) Florida Statutes and Rule 59A-10, Plorida Administrative Code. EXHIBIT Wa ShT AML 9000/62/90 A 080/208 tabbles* neo/eog Ry 85-20:(85-WUL) NOLAN» \0I80 « S0G9:SINCLs ADEM Ta-HAS ew uOleg wiyses] med ZecGhs] g0nz/ez/G LW QADH Ose aD Yd JURISDICTION AND VENUE 2. ° This court. has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Plorida Administrative Code. , 3. Venue lies in Broward County, pursuant to 120.57 Florida Statutes and Chapter 28, Florida Administrative Code. , , PARTIES 4. AHCA is the enforcing authority with regard to ambulatory surgical centers licensure law pursuant to Chapter 395, Part I, Florida Statutes and Rules 59-10, Florida Administrative Code. 5. Oakridge Ambulatory Surgery, LLC is a 4 bed capacity ambulatory surgical center facility located at 1000 N.E. 56 Streat, Fort Lauderdale, Florida 433334, and is licensed under Chapter 395, Part I, Plorida Statutes’ and ' Chapter 59A-5, Florida Administrative Code, " couNT r OAKRIDGE AMBULATORY SURGERY, LLC FAILED TO PROVIDE APPROPRIATE PROTECTIVE SERVICES REGARDING SUPERVISION TO PREVENT ACCIDENTS FOR {WO RESIDENTS Sections 395.0197(1) (a) and 395.1055, Florida Statutes, and Rule 59A-10/002(10), Florida Administrative Code (PROGRAM REQUIREMENTS) :6. AHCA reralleges and incorporates paragraphs (1) through (5) as if fully set forth herein. Ya Qh T AML 9000/82/90 aea/baa ih 84-20-(6S-Uu) NOUN s C189 069:SING s UPGRMTLA-UAS FL. 4Eeg wayses] Hd ZS) 9O0ZICIS LY GASH sOGiP BOW 7. During a complaint investigation conducted on 4/26/06 and based on interview and record review the facility Risk Manager Designee, who. ig a licensed Risk Manager and/ Risk Manager failed to implement the internal Risk Management program requiring the documentation, investigation, analysis, and corrective actions to be taken relating to several staff reported incidents of alleged sexual misconduct by a specific employee. The sexual misconduct/assault by the staff affected 1 of 5 sampled Patients (#4). , 8. During the investigation of CCR #2006003748 on 4/26/06 a Registered Nursé (RN) stated in an interview at approximately 2:00 PM, in May, a Surgical Technician was observed with his/her hand on the pubic area of a sedated female patient. The patient .was in the Recovery Room after conscious sedation, asleep on a bed with a curtain almost fully closed. There was a slight opening between the curtaina where the RN was able to observe the Surgical Technician's action. The RN, who observed this action, grabbed another nurse working in the Recover Room to witness what he/she saw. Roth nurses observed the Surgical Technician touching the sedated patient's pubid area. oO. The RN further stated, in the interview on 4/26/06, he/she went to the Risk Manager Designee and reported what the RN had observed. The RN stated the Risk Yd OPT ANT 9007/67/c0 oco/sooR) 8Q-0{66-Uu) NOLLWUNG s C180 5 S069:SINO s UFAEMTLA‘UAS seu jbiMec waqsesl we 296°) goOzICzG LY QADY 08/6 Bove Manager Designee told him/her, that the RN was harassing the Surgical Technician, and berated the RN. The RN went back to the Recovery Room in tears and told the other RN what had happened after his/her reporting of the witnessed incident to the Risk Manager, The second RN became fearful and refused to tell the Risk Manager what he/she also observed, after learning what had transpired with the first RN. 10. Subsequent to the above incident the said Surgical Technician, observed to have indulged in non-consensual sexual misconduct, was observed by the same two RN's assisting the said patient te the restroom to dress the patient ‘prior to the patient being discharged. The male Surgical Technician was observed going into the bathroom with the female patient unaccompanied by a female staff and to close the door. The first RN (initial witness and the reporter of the incident) wanted to stop the Surgical Technician from being alone with the patient, and knocked on the door telling the patient her spouse was there to pick her up. The patient was then discharged. 11. During an interview with the second RN witness on 4/26/06, at 2:15 PM, the nurse stated, the first RN had grabhed him/her to witness the situation in the Recovery Room. This RN saw the Surgical Technician with his hand on the patient's pubic area. Per this nurse, the first RN interrupted the Surgical Technician. The second RN confirmed Yd QF: HAL 9007/87 /e0 AG-0{65- Ud) NOLLVWNG 0180 SOG9'SINO UPESTLZUAS «lew WEieg arses] we ZK: QoOzICzI LY QAOU 06/9 BO¥e the Surgical Technician took the patient to the restroom and Closed the door; the first RN knocked on the door and removed the patient; the first RN reported the incident to the Risk Manager Designee, and the first RN came back erying, and stated the Risk Manager Designee had said he/she did not want to hear anymore, and was sick of the RN harassing the Surgical Technician. The second RN further stated, - he/she did not call the police because the RN thought it was to be handled with the management. 12. It 4g to be noted the regulation at a, 395.0197(10) (a), Florida Statutes, requires "any witness who witnessed or who ‘possesses actual knowledge of the act" ‘(sexual misconduct (9) (c) that ia the basis of an allegation neo/900 Fy shall: (a) notify the local police. 13. During an interview with the Risk Manager Designee on 4/26/06, at approximately 2:30 PM, he/she stated that no one reported any incident in May. The Risk Manager Designee further stated, he/she only learned of the incident from the Newspaper article published April 23, 2006. In addition, the Risk Manager Designee stated there was a 51 year old patient involved in an incident with the Surgical Technician. Per the Risk Manager Desiqnee he/she had been reviewing all of the patient records from May, and still is unsure which patient it could be, and what could have happened. * Ya BbST ANT onnz 77 /en 4¢-20(86 Mu) NOLLYUNG 520189 SO69:SING JFEMTLACUAS x oULL yByMeg weyses] id 24:9) 9O02IZIS AW CINDY OSI BOW 14. Review of the clinical record for patient #4, vevealed a legal letter dated April 10, 2006 requesting the entire chart of the- patient for services dated May 3, 2005. Enclosed/attached to the letter is a Health Insurance Portability and Accountability Act (HIPAA) complaint medical authorization form executed by the patient.. the facility was again made aware of a complaint/allegation of sexual misconduct. by a staff against the patient at the time of receipt of the mentioned letter, but still failed to. implement the internal risk management program to include the documentation of an alleged oveurrence of and incident on their incident report form, the investigation of the gccurrence and determination of the cause(s), and the reporting of such an incident to the State Adult Protective Service: (APS) . ) ) . 1S. Review of the personnel file of the ‘identified ' Surgical Technician revealed the employee was terminated by the facility on 8/15/05. The reason documented for the texmination is, the Surgical Technician did not complete the probation period for that position and another position was not available. Attached is a typed letter from the Riak den /igala Manager: Designee documenting’ what he/she had heard in a prior conversation with an RN who complained about the Surgical Technician. The documentation by the Risk Manager. Designee includes, the RN felt the Surgical Technician Yd RPT ANT onn7/e7 en 4$-20(65- Ul) NOLL C180 S069:SINC s ZVGSMTL‘UAS FIL Blog wayses) wid Ze) guozCzG LY OAOY 06/8 BOY "stared" at female patients and on one occasion, when the RN was preparing a female patient for surgery, the RN asked the Surgical Technician to leave the room, and the Surgical Technician refused. 16. During an interview with the Risk Manager Designee on 4/26/06, at approximately 2:30 PM, he/she stated that the Surgical Technician was terminated because of the inability nen enn to grasp the position of a Surgical Technician. When the Surveyor showed the Risk Manager Designee the statement he/she documented in the employees file, the Risk Manager Designee stated, "oh I did not remember that being there", 17. During an interview on 4/26/06 at approximately 12:30 PM with the RN who made the complaint acknowledged in the Risk Manager Designee's documentation in the Surgical Technician the RN specified the staff perform atanding preps (preparation of the surgical site) on female patients prior to surgery. The RN gave the following deseription: the patient stands up naked with arms above the head and legs spread open; the staff swab Betadine solution all over the patient's body, including the breast and between the legs. In addition the RN aaid, several nurses observed the specific Surgical Technician would stop doing work and would turn facing the back of the patient, and watch the procedure. In this position the patient would not be able to see the Surgical Technician, The patient would be Ys Ref) ANT annzse7/en Non Ban TH 84-0(6s-) NOLLVENG s C189 $06SIN s UPAMTLATUAS slot julien wayses] We 24:9) SOOCIIG LY CADY O66 BOW unaware because they would be faced the other way. The nurses requested the Surgical Technician leave the Room on these occasions. This happened a couple of times. The Ri indicated he/she told the Risk Manager Designee about the behavior of the Surgical Technician at least a few months prior to the Surgical Technician being transferred to Endoscopy in September 2004. 18. Upon inquiry, the surveyor learned, the RN did not fill out/complete an incident report, or sign one, The RN further stated when any nurse complained about the Surgical Technician, the Administration stated they were harassing him. The RN said, he/she didn't report the behavior or incidents anymore because other staff did and got “in trouble" for harassment; they transferred him to a surgical unit to be a Surgical Technician; It is like a promotion; a Physician, complained about the Surgical Technician staring at the patients breasts, and then the Surgical ‘Technician was terminated. 19. All the nurses’ complaints prior to the Physician's complaints: were not investigated. The Physician's complaints were not documented or placed on an incident report form as-required by the regulations and the facility policy. 20., Review of the incident reporting policy and procedure reveal it mandates: Wi ge’) BNT annz/e7 en nea avait 84-20-(8-U) NOLLWUNG ‘0180 s $060'SINO s UF BAMTLA-UAS sew yubKeg wojsea] We Zac 9OURIEZS LY CAOY CHO Bove A. To document all unusual circumstances which, may affect, patients or employee’s safety or patient care. B. To document all inquiries, so that preventive action can be initiated to avoid recurrences. c. To provide a mechanism for reporting ail circumstances, recommending action and monitoring action taken and the effectiveness of the action. 21, Patient #4 was not informed of the incident which occurred to the patient's person while she was sedated. There was no incident report generated or investigation conducted regarding the incidents. 22. The police was not informed of ‘the incident for patient #4 as required at Section 395.0197(10(a), Florida Statutes. The Surgical Technician continued to work/function as an employee at the facility for at least one year after the first RN complained. The staff, as reported, became afraid to make any complaints to the facility based on the Risk Manager Designee's reaction to the reports they made, Staff who complained about the Surgical Technician behavior and the inappropriate behavior he was observed performing were reprimanded. The facility Risk Manager Designee did not investigate and document any and all complaints and implement the risk management mechanisms The said Risk Manager Designee failure to investigate reported incidents was cited in an appraisal visit conducted 4/29/02 by the Yd 09:7 BOL 9006/82/90 oco/TIO 84; 20-66) HOLLY CISD + SO69:SINC ZPESNTLA'UAS «et UflMeg Wasea] We Zb:QP:} QOOZIUIS LY CASH Oil 30¥d Agency for Health Care Administration. The Risk Manager Designee/Risk Manager/ facility failed to follow their policy ‘and procedure as well as State regulatory requirements. As of 4/26/06, during the process of the investigation, when the Risk Manager Designee, the staff and the Administrator were asked during an interview, are you knowledgeable of the requirements to notify the police department upon receipt of a complaint of witnessed sexual misconduct and Adult Protective Services of the allegation of sexual misconduct from a'patient against a staff. The replies were as follows: A. The nurses replied, "no, I didn't knew." B. The Risk Manager Designee replied, "I didn't know’ until it was in the news." The Risk Manager Designee also stated on 4/26/06 she still felt it wasn't witnessed and did not have to he reported. c. The Administrator stated, “if it waan't witnessed it doesn't have to be reported." As found and documented in this report at item #1, sexual misconduct relating to patient #4 was observed/witnessed. It was determined at the time of the 4/26/06 investigation that the managerial staff continues to: fail the severity of the facility's failure to, 10 Yd 09:7 AL 9000/82/80 nen/7T0 95-20:(S5-W.) NOLLYUN + -CISO » S060:SING » ZUGANTLSUAS , SUL Tulkeq weyseS] We ZP:Ob QO0EICZIG LW QAOH s 0CrZb Ove document /record "all" incidents and to investigate all reported incidents, Furthermore the staff failed to honor the affirmative duty of all health care providers and all agents and employees of the healthcare facility to report incidents of patient abuse to the State of Florida Adult Protective Service. : 26. The failure to implement the risk management program requirements and continued failure to comprehend and implement the State regulatory requirements placed the safety ‘and welfare of the patient as well as all current patients at risk to be subjected to sexual abuse by staff and or others on the facility grounds. The high potential for placing patients at the risk for abuse with continued failure to document knowledge of an incident and to investigate its occurrence, as demonstrated in the continued failure to document the incident which occurred to patient #4 again after receiving written notification dated April 10, 2006 and after learning, of it in the newspapers April 23, 2006, place the patients safety at risk and constitutes immediate jeopardy. Based on the foregoing, Oakridge Ambulatory .LLC violated Section 395.0197(1) (a), Florida Statutes, and Rule 59A-10.002(10), Florida Administrative Code and the fine assessed is $136,000.00 ($1,000.00 per day x 136 days from 2/04/05 through 8/15/05). This deficiency i Yi = OS:7 Sy 9007/87/80 46-0(6S-Wul HOLLY «C180 SOBQ:SING s ZNGAMTLEUAS sew, Blog wayses] We Z¥:9K:) 9OOZICZG LY QAOW ONC) 30¥a also. was ‘ground for the Immediate Moratorium imposed on 05/01/06. , COUNT IT OAKRIDGE AMBULATORY SURGERY, LLC FAILED TO SUBSTANTIATE THE FACILITY IMPLEMENTED THE POLICY FOR NOTIFICATION OF THE “%ZOCAL POLICE BY WITNESSES WHO POSSESS ACTUAL KNOWLEDGE OF SEXUAL MISCONDUCT Sections 395.0197(9), Florida Statutes (SEXUAL MISCONDUCT) 28. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29. During the complaint investigation ‘conducted on 4/26/06 and Based on review of facility records and staff interview conducted on 4/26/06 the facility failed to substantiate the. facility implemented. the policy for notification of the local police by witnesses who possess actual knowledge of sexual misconduct and to adhere to the regulatory requirement at Section 395.0197(10) (a), Florida Statutes for notification of the local police by witnesses who possess actual knowledge of sexual misconduct by personnel. Furthermore the facility Risk’ Manager Designee (a licensed Risk Manager) failed to investigate every allegation of sexual misconduct made against, a personnel who has direct patient contact. This. failure affected at the least two patients (#4 & #2) who received care and services at the facility between February 2005 and August 15, 2005. 12 Non /e TAT Ya TS:T AML 9000/82/90 Aen /PTOlR B0-20-(6S-uuu] NOLLYEING C189 « $0GOSSIN« FGSATLA-UAS «atu, ubiKeg weseal We Z9:9'4 900CICzIG L¥ QAOY ONL BOW During the investigation of CCR #2006003748 on 4/26/06 a Registered Nurse (RN) stated in an interview at approximately 2:00 PM, in May a Surgical Technician (staff was observed with his/her hand on the pubic area of a sedated female patient. The patient was in the Recovery Room after conscious sedation, asleep on a bed with a curtain almost fully closed. There was a slight opening between the curtains where the RN was able to observe the Surgical Technician's action. fhe RN who observed this action, grabbed another nurse working in the Recover Room to witness what he/she saw. Both nurses observed the Surgical Technician touching the sedated patient's pubic area. The RN further stated, in the interview on he/she went to the Risk Manager Designee and reported what the RN had observed. The RN stated the Risk Manager Designee told the RN, the RN was harassing the Surgical Technician, and berated the RN. The RN went back to the Recovery Room in tears and told the other RN what had happened after his/her reporting of the witnessed incident to the Risk Manager. The second RN became fearful and refused to tell the Risk Manager what he/she also observed, after learning what had transpired with the first RN. Subsequent to the above incident the said Surgical Technician, observed to have indulged in non-conseneual sexual misconduct, was observed by the same two RN's 13 YA TST AML 9000/02 /S0 BS-Z0:(S5-UU) NOLLYUN CISD + S069:SING s LDGAMTLaanS . [auuL yyGiveg ways) me 2F:9b:} 900zIG2/S LW GADH - 00/6) Bove assisting the said patient to the restroom to dress the patient prior to the patient being discharged. The male Surgical Technician was observed going into the bathroom with the female patient unaccompanied by a female ataff and ‘to close the door. The first RN (initial witness and the ocd /STOR) reporter. of the incident) wanted to stop the Surgical Technician from being alone with the patient, and knocked on ‘the door telling the patient her spouse was there to pick her up. The Patient was then discharged. 33. During an interview with the second RN witness on 4/26/06, at 2:15 PM, the nurse stated, the first RN had grabbed him/her to witness the situation in the Recovery Room. This RN saw the Surgical Technician with his hand on the patient's pubic area. Per this nurse, the first RN interrupted the Surgical Technician, The second RN confirmed the Surgical Technician took the patient to the restroom and closed the door; the first RN knocked on the door and removed the patient; the first RN reported the incident to the Risk Manager Designee, and the first RN came back crying, and stated the Risk Manager Designee had said he/she did not want to hear anymore, and was sick of the RN harassing the Surgical Technician. The second RN further stated, he/she did not call the police because the RN thought it was to be handled with the management. 14 Yd TST AML 9002/82/80 . 84-20(88-UU) NOLLVNG «N89 SO68'S Is YESMITLA-UAS a uEAeg wyses] wach) gouztels AW CAOY 06/9) 30M During an interview with the Risk Manager Designee on 4/26/06,: at approximately 2:30 PM, he/she stated that no one reported any incident in May. The Risk Manager Designee , further stated, he/she only learned of the incident from the oro/9TOA Newspaper article published April 23-30. In addition the Risk Manager Designee stated there was a 51 year old patient involved in an incident with the Surgical Technician. Per the Risk Manager Dasignee he/she had been reviewing all of the patient records from May, and still is unsure which patient it could be, and what could have happened. At the time of the investigation on -4/26/06, Patient #4's clinical record contained a letter dated April 2006 requesting the entire chart of the patient for services dated May 3, 2005, Upon the receipt of this the facility was again made aware of a complaint/allegation of sexual misconduct by a staff against a patient, however failed to implement the internal risk management program to include the documentation of an alleged occurrence of an incident on their incident report form, the investigation of the occurrence and determination of the cause(s), and the reporting of such an incident. to the State Adult Protective Service (APS). During an interview on 4/26/06 at approximately 12:30 PM with the RN who made the complaint acknowledged in the Risk Manager Designee's documentation in the Surgical 15 YOY TGs] ANT onn7/e7 en OSO/L TOR 8G-20-(6S-WH) NOLLYANG s C189 s $060‘SIN LPEEMMTLACHAS soul, yyEideg weysea] Wd Zr) QOOTIRIG LW CAD s OIL) BOM Technician's personnel File, the RN specified the staff perform standing preps (preparation of the surgical site) on. female patients prior to surgery. The RN gave the following description: the patient stands up naked with arms above the head and legs spread open; the staff swab Betadine solution all over the patient's body, including the breast and between the legs. In addition the RN said, several nurses observed the specific Surgical Technician would stop doing work and would turn facing the back of the and watch the procedure. In this position the patient would not be able to see the Surgical Technician. The patient would be unaware because they would be faced the other way. The nurses requested the Surgical Technician leave the Room on these occasions. This happened a couple The RN indicated he/she told the Risk Manager Designee about the behavior of the Surgical Technician at least a few months prior to the Surgical Technician being transferred to Endoscopy in September 2004. Upon inquiry, the surveyor learned, the RN did not fill out/complete an incident report, or sign one. Neither did the Risk Manager complete an incident report upon notification of the Surgical Technician's inappropriate The RN further stated when any nurse complained about the Surgical Technician, the Administration stated 16 Wa 2S:T FL 9007/87 /e0 Bi-20(ss-u) NOLLYENG 189 SO60'SINO JNG3M TLS HAs ous Glog wiayseg] Wd CPGh:) 9002ICzIs LY OAOU, OGRE 3D¥d they were harassing him. The rn said, he/she didn’t report the behavior or incidents anymore because other stafF did, and got “in trouble" for harassment; they. transferred him to & surgical unit‘to be a Surgical Technician; It ig like a Promotion; a Physician complained about the Surgical Technician ataring atthe patients breasts, and then the Surgical Technician was terminated. 39. All the nurses’ complaints prior to the Physiciants | complaints were not investigated. The facility police, neither was there evidence found to substantiate the physician's complaints were investigated, 40. Review of the incident reporting policy and procedure reveal it mandates; A. To document all unusual circumstances, which, may affect Patient or employee's Safety or Patient's care. B. To document all inquiries so that preventive .action can be initiated £0 avoid recurrences, 080/9T0R Cc. To provide a mechanism for reporting all circumstances, recommending action and monitoring action taken and the effectiveness of the action. 42. It was’ learned .£rom the review of facility documents and staff interviews, Patient #2 complained to nursing personnel on 2/4/05 that male staff #1 (said Staff . 17 3G; 10:{98-UNL) NOLAN +0180 s S080:SINOs 1M TAs UAS «fowy, ube waseal Wel ZP94°) 9OOZICRIS LY ADU: OCi6) 30d involved in the incident above in example #1.) touched her breast and placed his finger into the subject's sexual organ. Interview on 4/2 personnel reported pat 6/06 with staff revealed nursing ient #2's complaint to the administrator/Risk Manager Designee who documented an incident report: 42. Review of the incident report dated 02/04/05 on 4/26/06 revealed it specifies, staff #1 touched the subjeat's preasts and placed his hand down the subject's pants and touched the “belly button". The documented information differs with the actual reported patient's ‘complaint. The incident report completed by the Risk Manager Designee documents, & patient. had made a complaint against a "male staft member"; the staff member touched the patient inappropriately; the patient stated the sta£E member touched her breast ‘and put his hand down the patient's pants and ‘ touched the patient's belly button; the patient appeared 0¢0/sTOR quite upset although still quite sedated. The Risk Manger Designee as per the report assured the patient it would be ‘investigated. 43. The results of the investigation document, the staff member stated he/she had removed Flectrocardiogram (EKG) leads from the patient's chest area and checked the abdomen a8 indicated. 18 Yd 29:7 AML 9002/£¢/80 gg: zo:les ul) WoLLYUNG 180 S06'SINO SENT AAS am weg wwejsea] Wa ZH°90L QOOEICIS LW CADU : OC102 30¥e 44. Review of the personnel file of the individual/personnel alleged to have behaved inappropriately revealed there was no evidence of the complaints against him. As it relates to the 2/04/05 inceident/occurrence the staff member wae coungeled to be conscious of his activities with patients and to explain the procedures to them prior to touching them. 45, It was learned during stati interview on 4/26/06 that staff #1 isolated female patients, by taking them into the bathroom while he was supposedly assisting them to change/drese . 46. After the 2/04/05 incident a charge nurse instructed staff #1 to stop the practice. StafE #1 stopped it for a few weeks and then resumed the behavior of isolating female patients in the bathroom. During ataft interview on 4/26/06 staff further stated, a Plastic Surgeon made complaints about staff #1 staring at female patients; the plastic surgeon wrote a letter about the behavior of the staff. Several staff members corroborated on 4/26/06 that the Plastic Surgeon had made the complaints, and subsequently etaff, #1 waa terminated three days after the facility received the Plastic Surgeons letter, on Bugust 15, 2005. a7. It is to be noted there was no indication the staff complaints of observed sexual misconduct by staff #1 19 020/020 Yd 29:7 WML 9002/8%/80 84-20(80W) HOLLY sO1S9 sSO69‘SINO ZUGRNTLAcUAS UL USieg Ue} Wed 290.) QOORIIG LY CAO O/H BOY or his inappropriate behavior were ever investigated. - In addition there was no information regarding the staff complaints found in staff #1 personnel file, or any written evidence (incident reports) to substantiate an acknowledge of the repeated allegations of sexual misconduct involving staff #1, or the investigation of the allegations made staff #1. The only allegation documented and investigated was that made by patient #2. The police was not notified of the ineident to patient #4 as required at Section 395.0297(10) (a), Florida Statutes. The Surgical Technician continued to work/function as an employee at the facility for at least 6 months after the first RN complaint was made of witnessed sexual misconduct by staff #1 against patient Personnel who complained about staff #1 behavior and the. inappropriate behavior he was observed performing, were reprimanded. The facility Risk Manager Designee did not investigate and document any and all complaints and 080/120 implement the risk management mechanisms, The said Risk Manager Designee failure to investigate reported incidents was cited in an appraisal visit conducted 4/29/02 by the Agency for Health Care Administration, . The Risk “Manager Designee/Risk Manager/facility failed to follow their policy and procedure as well as State regulatory requirements. 20 Yd €S:7 ML 9007/87 /¢e9 26-20(S-4U) NOLL YNd 0159 SO68'SIN ZGEMTLAZUAS UNL UBKeg UWayseal We ZHU) QOUICRIG LY QAOY 06M 3Ove As of the 4/26/06 investigation, when the Risk Manager Designee, the staff and the Administrator were asked an interview, are you knowledgeable of the requirements to notify the police upon receipt of a report of a witnessed sexual act / misconduct, and to report information regarding abuse to Adult Protective Services. The replies were as follows: A. ‘The nurses replied, "no T didn't know," B. The Risk Manager Designee replied, "I didn't know until it wags in the news." The Risk Manager Designee also stated on 4/26/06, who still felt it wasn't witnessed and did not have to be reported. A reasonable explanation was never provided regarding why all incidents reported were not documented and investigated, The administrator stated, "if it wasn't witnessed it doesn't have to be reported." As of 4/26/06 it was determined the Managerial _ personnel and staff ‘continue to be ignorant/lack the 060/200) appropriate knowledge regarding the facility policy requirements as well as the regulatory requirements. The failure to implement the policies/risk management program/ and the regulatory requirements and the Continued ignorance of these requirements place the safety and welfare of all patients receiving care at the facility at visk(s).— Such risks constitute an immediate jeopardy to all patients, 21 Wi CC°T ONT annzsossnn 060/820 53. Surgery, 84°20:(SS-UL) NOLLYUNG s CISD » SO6S:SING . AUBIATTLALYAS «own, uCikeg weysea] wa zp:96:] 9o0ziezls AW ADH sOR/ez Bove Based on the foregoing, Oakridge Ambulatory ULC violated Section 395.0197(1)2, Florida Statutes, and the fine assessed is $2,000.00 ($1,000.00 per sexual abuse incident). This deficiency also was ground for the Immediate Moratorium imposed on 05/01/06. COUNT ITT OAKRIDGE AMBULATORY SURGERY, LLC FAILED TO ENSURE THERE ARE 54. TWO PEOPLE IN THE RECOVERY ROOM AT ALL TIMES Sections 395.0197(1)2, Florida statutes (RECOVERY ROOM TWO (2) PERSON REQUIREMENT) AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 55. 4/26/06 During a complaint investigation conducted on and based on interview and record review, the facility failed to ensure there are two ‘people in the Recovery Room at all times, This affected 1 of 5 sampled patients (#2). 56. Review of an incident report dated 2/04/05 documented a patient had made a complaint against a "male staff member". The staff member touched the patient inappropriately. Per the report, the Patient specified the staff member touched his/her breast and put his/her hand down the patienta pants and touched the patient's "belly button". The patient appeared quite upset although still quite sedated. The Risk Manager assured the patient it would be investigated. 22 Yd 9:1 AML 9000/82/s0 060/920 0G-20(S-Uu} NOLAN s C180 »S069°SINOs JVGBATTLAWAS Ful yhog weysesl wa zp9 QOOZIEZIS LY CADH sOG/#2 39d 57. The facility investigation documented the alleged staff member said he/she had removed Blectrocardiogram (EKG) leads from the patient's chest area, and checked the abdomen as indicated. The employees file was reviewed and there were no other complaint 's found (See ROOl in this report for other reports against said employee) . Per the facility investigative report into this incident, the staff member was counseled to be conscious of his/her activities with patients and to explain the procedures to them prior to touching them. — , 58. Review of the Risk Manager Designee (licensed Risk Manager) evaluation revealed documented, the Nurse Administrator spoke with the patient and, employee, and it was understood that while the patient ‘was recovering £rom anesthesia, the medical assistant/surgical technician and the Registered Nurse (RN) were recovering ‘ the’ patient (attending the patient in the Recovery Room). The medical assistant/surgical technician was removing the EKG leadg from the patient's chest. The RN stepped away from the patient for less than two minutes to get a package. There were two other patients in the area. This weport failed to meet the requirement at §9~a-10.0055(2) Florida Administrative Code,’ which specifies the report must be a clear and concise description of the incident including exact elements as needed. Yd §9:T NL 9002/¢2/80 0¢0/S209 80-20-(9S4UU) NOLLWRING + “0180 » $060:SINO s HGRA TLA-AAS [etm yUEKeg wose We Ze96:F SOUZIEZS Ly QAOY Ulse 3O¥d 59. During an interview on 4/26/06 at approximately 12:00 PM with the RN who was present as per above deseribed occurrences, he/she specified he/she (the RN) was at lunch when the incident occurred. Based on the above, the medical assistant/surgical technician was left by himself with the’ patient in the Recovery Room. As per the RN, when he/she returned from lunch he/she gaw there were two Patients. He/she went to evaluate patient #2, and found the patient laying on the left side. The patient confided in the RN that a male staff member had touched the patient's breasts and had inserted a finger into the patient's vaginal area. The RN took the patient to the Nurse Manager's office. The patient relayed the same information to the Nurse Manager. The patient was lucid at the time, and was sure of what took place. The RN stated there may have been another employee from Admissions who went to the Recovery Room at the time of the incident, but he/she was not sure. This other employee. would not have been a clinical personal. Furthermore, the State requlations at 59A-5.0085(3) (a), Florida Administrative Code specifies; a registered professional nurse shall be present in ‘the - recovery area at all times when a patient is present. Tt is to be noted, the description of what occurred per the patient and nurse is documented otherwise than what the patient reported, 24 We PST AML 9000/80/50 64. The failure to ensure two personnel are always in 85-20:(85-UL} NOLLYUN + CISD sS089:SINC » ZPGANTLa- HAS 5 Lows Jutikeq waysea] md 2h:9¥:} 90OZIEZIG LW OAOY = 06/02 3Ovd During a tour of the facility on 4/26/06, there were three employees observed in the Recovery Room. The staffing was reviewed, and there were three to five employees scheduled per documentation provided to cover the Recovery Rooms at all times. The staff was unable to provide, for review upon request, the previous schedules for the Recovery Room. The facility was unable to substantiate the two person rule which requires two persons be in attendance in Recovery Room except when emergency circumstances require otherwise, was in place on the day of the above incident and consistently implemented. the Recovery Room, one of which shall be present in the 060/920 9 Recovery Room "at all times" shall be a professional nurse leave the safety and healthcare of the patients at risk. The risk constitutes an immediate threat to the health welfare and safety of the patients and thereby ‘conatitutes an immediate jeopardy to all patiénts’ safety. Based on the foregoing, Oakridge Ambulatory LLC violated Section 395.0197(1)2, Florida and the fine assessed is $136,000.00 ($1,000.00 per day x 136 days from 2/04/05 through 8/15/05). ‘Thia deficiency also was ground for the Immediate Moratorium imposed on 05/01/06. 25 Wa oT aM 9000/82/90 46-2065) NOLLYUN «C180 S060'SNC ZF ATLA WAS. Tew yuteg Uwayse3] Wel Z:9P:1 QOOZIERIG LY GAOY s OCI 20¥d CLAIM 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, II and IIt. B. Assess a fine against the facility in the amount of ($274,000.00). The Respondent igs notified that it has a right to request an administrative hearing pursuant to ‘Section 120.563, Florida Statutes, Specific options for administrative action are set out in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, attention Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, Velephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF 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 . ehson E. Rodney, Esquire AHCA — Senior Attorney Spokane Bldg., Suite #103 8350 NW 52™ Terrace | Miami, Florida 33166 (305) 470-6802 26 060/120) Wa PST ahh 9000/80/90 6-20-(-UU) NOLLWUNG s 0189 + $069:SINO s ERM TLA-HAS s[ouy ybiyleg weyseal Wal 269%) SOOZICCS LY ADU + 08/82 39¥d Copies furnished 'to:, : 4 Diane Reiland Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (U.8. Mail) Hospital Program Office Ageney for Health Care Administration 2727 Mahan Drive, Mail Stop #31 Tallahassee, Florida 32308 (Interoffice mail) Jean Lombardi Agency for Health Care Administration Finance and Accounting 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof was sent by U.Ss. Mail, Return Receipt Requested to Diana Albert, administrator, Oakridge Ambulatory, LLC, 1000 N.E. 56e Street, Fort Lauderdale, Plorida 33334, and to c. fT, Corporation System, Registered Agent, 1200 South Pine Island Road, Plantation, Florida 33324 on Wass Li, 2006. E. Rodney, Esq. 27 00/920 Wa PST AML 9000/62 /S0

Docket for Case No: 06-002115