STATE OF FLORIDA 2 AGENCY FOR HEALTH CARE ADMINISTRATION ‘ STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2008007913 v. FLORIDA HOSPITAL-ORMOND MEMORIAL, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through undersigned counsel, and files this Administrative Complaint against FLORIDA HOSPITAL-ORMOND MEMORIAL, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of two thousand ($2,000) dollars, based upon the Respondent being cited for two (2) confirmed violations of Rule 59A-3.255(6) (c), Florida Administrative Code (2007). JURISDICTION AND VENUE 2. The Agency has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and Chapter 395, Part I, Florida Statutes (2007). 3. Venue lies in Volusia County, Division of Administrative Hearings, pursuant to Rule 28-106.207, Florida Administrative Code (2006) . PARTIES 4. “The agency is the regulatory body responsible for the. licensure of hospital registries and the enforcement of all applicable federal and state regulations, statutes and rules, governing nurse registries pursuant to § 400, Part III, Florida Statutes (2007), and Fla. Admin. Code R. 59A- 18. The Agency is authorized to deny, revoke or suspend the license of, or impose an administrative fine against, a nurse registry, for violations of the applicable federal and state regulations, statutes and rules, pursuant to §§ 400.506, and 408.815(1)(c), Fla. Stat. (2007). 5. The State of Florida, Agency for Health Care Administration (“AHCA”) is the enforcing authority with regard to hospital licensure pursuant to Chapter 395, Part I, Florida Statutes (2007), and Chapter 59A-3, Florida Administrative Code (2007). 6. Respondent is a Florida non profit hospital located at 875 Sterhaus Avenue, Ormond Beach, Florida 32174. Respondent was, at all times material hereto, a licensed hospital, License number 4201, under Chapter 395, Part I, Florida Statutes (2007), and Chapter 59A-3, Florida Administrative Code (2007). COUNT I RESPONDENT FAILED TO ENSURE THAT ALL PATIENTS LEAVING THE -- FACILITY -AND HAVING TRANSFER PAPERS ARE -LOGGED.INTO--THE- TRANSFER LOG, IN CONTRAVENTION OF RULE 59A-3.255(6) (c), FLORIDA ADMINISTRATIVE CODE (2007) AN ADMINISTRATIVE FINE OF $1,000 IS WARRANTED. PURSUANT TO SECTION 395.1065(2) (a), FLORIDA STATUTES / (2007) 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully. set forth herein. 8. On April 22, 2008, AHCA conducted an unannounced complaint investigation. 9. Based on review of the facility transfer log, and staff interview, the facility failed to ensure that all patients leaving the facility and having transfer papers are logged into the transfer log. The surveyor’s findings were as follows: Review of the medical record for Patient #26 revealed that the patient was "transferred" to another facility for out-patient testing. The medical record did contain part’ ” of the transfer form indicating that the emergency department of the other facility had been notified of the patient's arrival for x-ray testing. Review of the transfer log revealed that Patient #26 was not listed. Interview with the Director of Risk Management, Director of the Emergency Department and the Executive Director of Nursing on 4/23/08 at llam, revealed that all patients leaving the facility either for transfer to another facility for specialized care, or out-patient testing per their procedure are to have transfer forms - filled.out.and the facility where the-patient-is going is to be notified. They stated that transfer of patients sent for out-patient testing who will come back to the facility are not listed in the transfer log, even though transfer forms have been completed on the patients. 10. The findings listed above constitute a violation of Rule 59A-3.255(6) (a), Florida Administrative Code (2007) . Respondent did not have appropriate policies and procedures in place and implemented, which resulted in patients leaving the facility and having transfer papers not logged into the transfer log. 11. A fine of one thousand ($1,000) dollars for this violation is statutorily authorized pursuant to Section 395.1065(2), Florida Statutes (2007). COUNT II RESPONDENT FAILED TO ENSURE THAT A CENTRAL LOG IN THE EMERGENCY DEPARTMENT FOR EACH PERSON SEEKING ASSISTANCE WAS COMPLETE INCLUDING CONTAINING INFORMATION REGARDING THE PHYSICIAN, ARRIVAL MODE, IN CONTRAVENTION OF RULE 59A- 3.255(6) (e), FLORIDA ADMINISTRATIVE CODE (2007) AN ADMINISTRATIVE FINE OF $1,000 IS WARRANTED. PURSUANT TO SECTION 395.1065(2) (a), FLORIDA STATUTES (2007) 12. AHCA re-alleges and incorporates paragraphs (1) “through (6) as if fully set forth herein. OB 13. On April 22, 2008, AHCA conducted an unannounced complaint investigation. 14. Based on a review of the facility central log and staff interview, the facility failed to ensure that a central log in the emergency department for each person seeking assistance was complete including containing information regarding the physician, arrival mode. The surveyor’s findings were as follows: Review of the facility documentation on the central log revealed that all information was not provided for each person presenting to the emergency department seeking assistance. Examples include: . 01/01/08 - 2 of 40 patients listed did not include the name of the physician 1 of 40 patients listed did not include the disposition of the patient 01/05/08 - 5 of 40 patients listed did not include the name of the physician 01/08/08 - 3 of 20 patients listed did not include the name of the physician — 01/09/08 - 8 of 40 patients listed did not include the name of the physician 2 of 40 patients listed did not include the mode of arrival 01/10/08 - 4 of 20 patients listed did not include the name ef the physician : 2 of 20 patients listed did not include the mode of arrival 4 of 20 patients-listed did not include-the discharge - disposition 02/06/08 - 2 of 17 patients listed did not include the name of the physician 2 of 17 patients listed did not include the arrival mode 03/07/08 - 10 of 35 patients listed did not include the -name of the physician 4 of 35 patients listed did not include the arrival mode 03/17/08 - 3 of 21 patients listed did not include the name of the physician 03/18/08 - 3 of 20 patients listed did not include the name of the physician 03/19/08 - 8 of 35 patients listed did not include the name of the physician 1 of 35 patients listed did not include the mode of arrival Interview on 4/22/08 atl0am with the Director of the Emergency Department confirmed that this information had not been included in the emergency department central log. 15. The findings listed above constitute a violation of Rule 59A-3.255(6) (e), Florida Administrative Code (2007). Respondent did not have appropriate policies and procedures in place and implemented, which resulted in the central log lacking required information. 16. A fine of one thousand ($1, 000)dollars for this violation is statutorily authorized pursuant to.Section 395.1065(2), Florida Statutes (2007). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency .for Health Care Administration, respectfully requests that the Court order the following relief against Respondent : (A) Make factual and legal findings in favor of the Agency on Count I and II; (B) Recommend an administrative fine against Respondent in the amount of two thousand ($2,000) dollars for Count I and II, pursuant to Section 395, Part I, Florida Statutes (2007); (C) Assess attorney's fees and costs; and (D) Grant all other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests’ for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST 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. Réspectfully submitted, yl Fe oe Moore, Esq. pyida Bar # 768715 _ Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) -922-5873 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof has been sent | by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8374, to Registered Agent, T.L Trimble, 111 North Orlando Avenue, Winter Park, FL 32789, on this the “¢l_ day. of July, 2008, and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8381, to Owner, Memorial Health Systems Inc, 701 -W.- Plymouth Avenue, -Deland, FL 32724, on _this the 4\_ day of July, 2008 and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8398, to Administrator, Daniel Andrew Wolcott, 675 Sterhaus Avenue, Ormond Beach, FL 32174, on this the WA day of July, 2008. O. Moore, Esquire Copies furnished to: Patricia Caufman Field Office Manager Agency for Health Care Administration (Interoffice Mail) COMPLETE THIS SECTION ON DELIVERY Null FF reer C Addressee B. Recel ed by (Printed Name) C. Date of Delivery pycé. Hu lip pe 50-09 D. Is delivery address different from item 12 [J Yes if YES, enter delivery address below: [g-No BENDER: COMPLETE THIS SECTION A. Signature § Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. & Print your name and address on the reverse so that we can return the card'to you. Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: Daniel Prnavow Wy\cet WIS Gerhnaus Fuenve, Ormond Beach EL 2217p 3, Service Type NG certified Mail. © Express Mall D Registered’ 1 Return Receipt for Merchandise. D1 insured Mail 1 C.0,. 4, Restricted Delivery? (Extra Fee) O Yes 3 2° Article Number (Transfer from service label) ° >§ Form 3811, February 2004, Domestic Return Receipt . 102595-02-M-1540__ creamer come Dl ddetdddldilbollndildhie SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY @ Complete items 1, 2, and 3. Also complete ces < ature item 4 if Restricted Delivery is desired. L\ 1H b fi 1 Agent @ Print your name and address on the reverse | X/ WD Wl CLV Ai 0 Addressee so that we can return the card to you.. i Re betvd fg; odhyaine C. Date of Delivery ™ Attach this card to the back of the mailpiece, y ZB / y or on the front if space permits. Nt AA L744 AE: D. IS delivery address fiffferent from item? (1 Ye 1, Article Addressed to: It YES, enter delivery addréss below: C1.No T.-L Ty mb, Wi North Ovando Ave \ Ww WAL Paw, F L 3. Service Type . 1% tft Certified Mail ’ C1 Express Mail OL 4 C Registered CO Retum Receipt for Merchandise CD insured Mail O co. 4. Restricted Delivery? (Extra Fee) Yes 2, Article Number (Transfer from service label) ; : PS Form 3811, February 2004 Domestié Return Receipt 102595-02-M-1540 SENDER: COMPLETE THIS SECTION A, Sjonature ™ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ™ Print your name and address ‘on the reverse = «6o-that We can returri the card to you. ™ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: Daniel Prdvew Wolcottr 2b Qoutmh Manne Ave : Umma earn FL 321147 D. Is a address differei eis if YES, enter delivery addre eas be Certified Mail. © Express Mail J Registered ' CO Retum Receipt for Merchandise. C2 insured Mail O cop. 4, Restricted Delivery? (Extra Fee) ave Rvtonceteoy YOO LEGO 0000.SS2u E330 : PS Form 3811, February 2004. Domestic Retum Receipt 102595-02-M-1540 :

Docket for Case No: 08-004270