STATE OF FLORIDA Hi, BoP) AGENCY FOR HEALTH CARE ADMINISTRATION 07 Hygy 2, PH STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA No.: 2007000651 Petitioner, Return Receipt Requested: 7002 2410 0001 4235 0791 Vv. 7002 2410 0001 4235 0807 7002 2410 0001 4235 0814 LIFEMARK HOSPITALS OF FLORIDA, INC. d/b/a PALMETTO GENERAL HOSPITAL OT ; a) () y Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the State of Florida, Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, files this administrative complaint against Lifemark Hospitals of Florida, Inc. d/b/a Palmetto General Hospital (hereinafter “Palmetto General Hospital”) pursuant to 28-106.111 Florida Administrative Code (2006), and Chapter 120, Florida Statutes (2006), hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $500.00 pursuant to Section 395.1065(2) (a) Florida Statutes (2005). JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes (2006), and Chapter 28-106 Florida Administrative Code (2006). 3. Venue lies in Miami-Dade County, pursuant to 120.57 Florida Statutes (2006), and Chapter 28, Florida Administrative Code (2006). PARTIES 4. AHCA is the enforcing authority with regard to hospital licensure law pursuant to Chapter 395, Part I, Florida Statutes (2006), and Chapter 59A-3 Florida Administrative Code (2006). 5. Palmetto General Hospital is a hospital facility located at 2001 W. 68 Street, Hialeah, Florida 33016. Palmetto General Hospital is licensed as a hospital under license number 4313. Palmetto General Hospital was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I PALMETTO GENERAL HOSPITAL FAILED TO PROVIDE NURSING INTERVENTION. RULE 59A-3.2085(5) (e), FLORIDA ADMINISTRATIVE CODE (NURSING SERVICE) 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Palmetto General Hospital was cited with one (1) deficiency due to complaint investigation surveys that were conducted on August 8, 2006 and November 30, 2006. 8. A complaint investigation conducted was conducted on August 8, 2006. Based on interview, observation, facility policy and procedure review, and clinical record review, it was determined that the facility failed to provide nursing intervention after dietary recommendations were made for 1 of 5 (#1) sampled patients. The findings include the following. 9. An observation was conducted of sampled patient #1 on 8-8-06 at 11:45 am. The patient was observed in bed at a 45 degree angle, on a feeding tube, the nasal cannula was not in place and the patient was with dry cracked lips and sunken eyes. 10. Interview with the family member for sampled patient #1 on 8-8-06 at 11:50 am revealed the family member is at. the facility from 7:00 am until 11:00 pm every night. When the medications are given by the PEG the registered nurse flushes the tube with water. The family member notices that there have ‘been several feeding rate changes without explanation. 11. Interview with the Registered Nurse #1 on 8-8-06 at 12:05 pm for sampled patient #1 revealed that the patient was receiving 275 cc of water divided throughout the shift. The RN apologized because this was the first day that the nurse was treating the patient. The rate had been increased by the physician on 8-4-06 to 300 cc. 12. Further interview with the Charge Nurse on 8-8-06 at 12:20 pm for sampled patient #1 revealed that if there were changes made in the rate of feeding and the nurse changed it, it is because the nutritionist made a recommendation and is considered an order. 13. Interview with the Director of Nutrition on 8-8-06 at 1:09 pm revealed a diet order for tube feeding would be in place upon admission. An initial assessment would be conducted within 24 hours of admission. Starting rate would be recommended to physician. Enteral nutrition recommendations are made to the physician and documented in the patient's record. The dieticians can only make recommendations not orders. The orders are only made by the physician attending the patient. 14. Review of the current policy and procedure for "Enteral Nutrition" revealed that the physician orders enteral tube feedings for patients who have a functional gastrointestinal tract but are unable to orally meet their nutritional needs. The physician specifies in the patient's medical record the name of the tube feeding formula, initial dilution or strength, rate of feeding and route. Nursing will assess patients on admission and throughout hospital staff for nutritional deficit/needs and process physician's orders for enteral feeding to Pharmacy. The dietician is to assess nutritional needs of the patient; monitor tolerance and efficacy of feeding; and document in the medical record. The dietician also assists with transitional feedings to an oral diet; or parenteral feedings if enteral feedings is not tolerated, selection/transition to alternative enteral formula, and progression of enteral formula feeding. 15. Review of the physician's orders for sampled patient #1 revealed that on 7-24-06 at 1900 there was an order for the PEG tube feeding at 25 cc an hour and increased to 35 cc an hour as tolerated. The patient was receiving the medications via the PEG tube. 16. Review of the nurses' notes for sampled patient #1 on 7-26-06 at 0900 revealed that the PEG tube feeding was at 45 cc an hour. There was no physician order for the increase. 17. On 7-27-06 at 1015 the dietician's note for sampled patient #1 revealed that the current feeding rate was at 45 cc an hour and recommended an increase to 72 cc an hour. There was no documentation that the nurse notified the physician about the increase and there was no physician’s order. 18. On 7-30-06 at 1130 there was a nurse’s note for sampled patient #1 that revealed the feeding rate was at 45 cc ‘an hour. There was no documentation about the recommendation of the dietician and no physician order for the increase from 25/35 to 45 cc an hour. 19. On 8-1-06 at 1400 there was. a dietician's follow up note for sampled patient #1 which revealed the rate was at 45 cc an hour and a recommendation was made to increase the rate to 58 cc an hour and water flush 200 cc three times a day. There was no documentation that the physician was notified about the recommendation or that an order was placed for the recent increase on the feeding rate. 20. On 8-2-06 at 1005 there was a dietician's follow up note for sampled patient #1 which revealed the nurse stated that the patient was having several diarrhea episodes. The current feeding rate was at 48 cc and hour and a recommendation was made to change the feeding and reduce the rate to 40 cc an hour. There was no physician order for the change of 23/35 to 45 cc an hour, or the change from 45 cc an hour to 48 cc an hour. There was no documentation that the physician was notified about the recommendations of the dietician. 21. On 8-4-06 at 1800 the feeding rate for sampled patient #1 was changed to 300 cc every eight hours. There was an arrow pointing up explaining the fluids were to be increased. On 8-4-06 at 6:16 pm the order was scanned and verified. The nurse's notes revealed that the patient received the 300 cc throughout the hospitalization. 22. On 8-7-06 at. 930 there was a dietician's follow up note for sampled patient #1 which revealed the patient was receiving 30 cc an hour feeding rate and a third recommendation was made to increase the feeding rate to 58 cc an hour. On 8-7- 06 at. 2330 there was a nurses' note which revealed there was an alteration in nutrition, the pump was currently infusing at 30 cc an hour. There was no physician order for the alteration in nutrition and no documentation that the physician was notified about the recommendation of the dietician. 23.. A complaint investigation survey was conducted on November 30, 2006. Based on observation, record review, and interview, it was determined that the facility failed to implement their own policy and procedure for patient that are at. risk for fall in 2 of 5 (#5, #6) sampled patients. The findings include the following. 24. Clinical record review of sample patient #5 revealed that he/she was admitted to the facility on 11/29/2006 due to Pneumonia to Left Lobe. Review of the shift to shift Registered Nurse Assessment revealed that the patient was not classified as at risk for falls. 25. Interview with the Nurse Manager of the Unit on 11/30/2006 at 410PM revealed that sampled patient #5 was at risk for falls. 26. Observation of room 506 door revealed that sampled patient #4 was in bed and awake. Behind the bed headboard on the wall there waS an orange piece of paper taped to it that documented patient at risk for falls. Observation of the patient's wrists revealed that he/she was not wearing an orange wristband as required. Observation of the patient's feet revealed that he/she was wearing red slippers as required for patient that are at risk for falls. 27. Clinical record review of sampled patient #6 revealed that. he/she was admitted to the facility on 8/28/2006 due to Asp. Pneumonia, Sepsis and seizures. Review of the shift to shift Registered Nurse Assessment revealed that the patient was classified as at risk for falls. 28. Observation of room 507 revealed that sampled patient #5 was in bed and sleeping. Behind the bed headboard on the wall there was sign posted as required. Observation of the patient's wrists revealed that he/she was not wearing an orange wristband as required. The surveyor did not observe’ the patient's feet because he/she was sleeping and surveyor did not want to bother the patient. 29. Review of the facility policy and procedure for fall prevention and resources revealed that patient's that are at risk for falls will have a reference Orange colored armband placed on the wrist and red no slip/skid socks applies to serve as identifiers/preventative measures for the entire health care team. The patient risk status will be reported during change of shift report. 30. Interview with the Risk Manager on 11/30/2006 at 5PM the process for occurrence reporting is via computer on line which is located from every terminal therefore it is accessible to everybody to report. The report. automatically is submitted to risk management. After it is submitted, interview and analysis is conducted. Based on outcome or based need follow-up may be referred to the appropriate manager or director for intervention.. Then after appropriate intervention and outcome the issue will closed. This is an uncorrected deficiency from the survey of August 8, 2006. 31. Based on the foregoing, Palmetto General Hospital violated 59A-3.2085(5) (e), Florida Administrative Code (2006), which warrants an assessed fine of $500.00. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Assess against Palmetto General Hospital an administrative fine of $500.00 for the violation cited above. 3. Assess costs related to the investigation and prosecution of this matter, if applicable. 4. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2006). Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. 10 IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER he, Uilearney, urdes A. Naranjo, Esq. la. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Harold Williams Field Office Manager Agency for Health Care Administration 8355 N. W. 534 Street Miami, Florida 33166 (U.S. Mail) Jean Lombardi Agency for Health Care Administration Finance and Accounting 2727 Mahan Drive,. Mail Stop #14 Tallahassee, Florida 32308 (Interoffice mail) Hospital Program Office Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #31 Tallahassee, Florida 32308 (Interoffice mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof was sent by U.S. Mail, Return Receipt Requested to Ana Mederos, CEO, Palmetto General. Hospital, 2001 W. 68t* Street, Hialeah, Florida 33016; Lifemark Hospitals of Florida, Inc., 13737 Noel Road, Suite 100, Dallas, Texas; CT Corporation System, 1200 South Pine Be Island Road, Plantation, Florida 33324 on this VA day of raw 12 U.S. Postal Service. CERTIFIED MAIL... RECEIPT (Domestic Mail Only; No Insurance Coverage Provided) For delivery information visit our website at www.usps.com: OFFICIAL USE ce] red) | sd , J D insured Mal 16.0.0. She me jed Delivery? xtra Fee) <1 Yes’ 7002 2410 0001 4235 0793 PS Form 3800. Ju U.S. Postal Service..; CERTIFIED MAIL,. RECEIPT (Domestic Mail Only; No Insurance Cover. 46 For delivery information visit our website at Restricted Delivery Fee (Endorsement Required) 7002 2410 0001 4235 o807

Docket for Case No: 07-002302