The Issue The central issue in this case is whether the Respondent is guilty of the violations alleged in the administrative complaint; and, if so, what penalty should be imposed.
Findings Of Fact Based upon the testimony of the witnesses and the documentary evidence received at the hearing, I make the following findings of fact: The Department is the state agency charged with the responsibility of regulating the profession of nursing pursuant to Chapters 455 and 464, Florida Statutes. At all times material to this case, Respondent has been licensed by the Department, license nos. RN 1672492 and 167249A. Respondent holds dual licensure since he is listed as a registered nurse (RN) and an advanced practice RN with specialty (ARNP). In Respondent's case, the advanced specialty practice is in the area of anesthesia. To become licensed as an ARNP, Respondent submitted an application, a fee, and copies of a certification from the Council on Recertification of Nurse Anesthetists (CRNA) which included an identification card specifying Respondent's CRNA number to be 24936. Respondent represented, under oath, that the copies were true and correct duplicates of the originals. Based upon this documentation, the Department issued the ARNP license. On or about March 25, 1986, Respondent was employed by the Hialeah Anesthesia Group (HAG). Respondent's supervisor was Manuel B. Torres, M. D., president of HAG. On or about November 30, 1987, Dr. Torres notified Respondent that his employment and privileges at Hialeah Hospital were being suspended. According to Dr. Torres, this suspension was to continue until confirmation was given by the Impaired Nurse Program at South Miami Hospital that Respondent's problem had been corrected. At the same time, Dr. Torres notified the CRNA that Respondent had voluntarily entered an impaired nurse program. Subsequently, Dr. Torres received a letter from Susan Caulk, staff secretary for CRNA, which notified him that, according to CRNA files, Respondent had not passed the certification examination, was not a member of the American Association of Nurse Anesthetists, and that Respondent's CRNA recertification number was not valid. Dr. Torres then notified the Department regarding the certification issue. Later, after Respondent had completed a controlled substance addiction program at Mount Sinai Medical Center, Dr. Torres advised him that, if he could prove his CRNA certification, he could be rehired at Hialeah Hospital. Respondent never returned to demonstrate his certification. An individual who represents himself to be certified as an ARNP when he has not qualified to be so certified has exhibited conduct which falls below the standard of care of the nursing practice. Further, such an individual, by practicing as an advanced practitioner without the educational background, compromises the safety of patient care.
Findings Of Fact In March 1975, Respondent was employed as a registered nurse at the Sarasota Memorial Hospital, Sarasota, Florida. On March 26, 1975, he was performing duties as "charge" nurse on the 3 P.M. to 11 P.M. shift in the Orthopedic Clinic. At approximately 4 P.M., Muriel Johnson, R.N., Clinical Supervisor, while making her initial rounds for the shift, talked to two of the patients who indicated they felt no need for medication and had not received any. She then observed that the patients' medication and treatment sheets indicated that Respondent had given them Percodan, a narcotic drug, that afternoon. She then checked Respondent's nurses notes and the federal narcotic control sheet used to keep track of narcotics on the floor, and found no entries for the patients in question on either document. Both of these documents should have reflected the administration of medication to the patients at the time it was given. She proceeded to report the apparent discrepancy to her supervisor. (Testimony of Johnson) The Sarasota police was notified and two police officers arrived at the hospital about 11:15 P.M.. They were informed by a nurse that Respondent was suspected of checking out narcotics, but not issuing them to patients. Based on the foregoing information, they followed Respondent's automobile as he left the hospital that evening and stopped it about a quarter of a mile south of the hospital on US highway 41. Respondent's wife was driving the automobile at the time. Respondent was placed under arrest and, upon a search of his person, various drugs in hospital containers or packages were discovered, including seven Percodan tablets, six Synalgos DC capsules, and two Empirin with Codeine tablets. Percodan is a controlled Schedule 1 drug used to relieve pain and Synalgos DC is a Schedule 3 drug. Respondent was cooperative at the time of his arrest. He was charged with three counts of illegal possession of drugs and, on September 12, 1975, in the Sarasota County Circuit Court, Case No. 75-229-CF-A- 01, upon a plea of Nolo Contendere, adjudication of guilt was withheld and Respondent was placed on probation for two years, fined $1,000.00, and ordered to undergo psychiatric counselling. (Testimony of Hogle, Peterson, Perry, Petitioner's Exhibit 1,2, Composite Exhibit 3). On March 12, 1975, at the Sarasota Memorial Hospital, Respondent signed for 1 capsule of Chloral Hydrate, 300 mg. for a patient named Lena J. Herman. He indicated on the narcotic and barbituate administration record number 126951 that the medication was refused and destroyed. Hospital policy as set forth in written procedures provides that destruction of narcotics or barbituates must be witnessed and countersigned on the narcotics and barbituate administration record by another nurse. No such witnessing signature was shown on number 126951. (Testimony of Kuebler, Petitioner's Composite Exhibit 5). On March 13, 1975, at 8:00 P.M., at the Sarasota Memorial Hospital, Respondent signed out 1 tab of Demerol, 50 mg. for a patient named Herman on narcotic and barbituate administration record number 128232, and on the same date and the same hour for the same patient signed out for another tab of Demerol, 50 mg. on narcotic and barbituate administration record number 128097. The medication record and nursing notes for that patient on the date in question show that only one of the tablets was administered by Respondent to the patient subsequent to signing it out. (Testimony of Kuebler, Petitioner's Composite Exhibits 4 & 5). Respondent was an excellent nurse who had been employed at the Sarasota Memorial Hospital for over one year. He was dependable and took good care of his patients. (Testimony of Johnson, Kuebler, Bowden, Respondent's Composite Exhibit 1). Respondent has received comprehensive alcoholism counseling and treatment in state facilities and at the First Step of Sarasota, a counseling and treatment center. He recognizes his problem with alcohol and has managed to keep it under control while living at First Step with the assistance of the drug Antabuse. He has helped at First Step with other patients and the Executive Director there would like to hire him as a nurse when an opening occurs. He has been a cooperative and cheerful probationer in the opinion of his probation officer. (Testimony of Bowden, Ves'sells, Clark).
Recommendation That the license of Faris E. Moyer to practice as a registered professional nurse be revoked for unprofessional conduct, in violation of Section 464.21(1)(b), Florida Statutes. DONE and ENTERED this 12th day of August, 1976, in Tallahassee, Florida. THOMAS C. OLDHAM Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Julius Finegold, Esquire 1330 American Heritage Building Jacksonville, Florida 32202 Robert J. Elkins, Esquire 2187 Siesta Drive Post Office Box 15425 Sarasota, Florida 33579
The Issue Whether the Respondent committed the violations alleged in the Administrative Complaint dated August 1, 2002, and, if so, the penalty that should be imposed.
Findings Of Fact Based on the oral and documentary evidence presented at the final hearing and on the entire record of this proceeding, the following findings of fact are made: AHCA is the state agency responsible for licensing and regulating the operation of nursing home facilities, including ensuring that nursing homes are in compliance with criteria established by Florida statute. Chapter 400, Part II, Florida Statutes (2002). AHCA is authorized in Section 400.23(7), Florida Statutes (2002), to assign a licensure status to a nursing home and in Section 400.23(8), Florida Statutes (2002) to impose administrative fines on nursing homes that fail to meet the applicable criteria. The Nursing Center is a skilled nursing home located in Homestead, Florida. At the times material to this proceeding, the Nursing Center was licensed by AHCA and was required to comply with all rules, regulations, and statutes applicable to skilled nursing homes. On May 16 and 17, 2002, AHCA conducted an investigation at the Nursing Center in response to a complaint regarding an incident involving a resident named J.D. Helen Ahmed was the principal investigator; Christina Garcia participated in the complaint investigation on May 17, 2002, only. The results of the complaint investigation were set forth in a Statement of Deficiencies and Plan of Correction, which is a form prescribed by the federal Department of Health and Human Services, Health Care Financing Administration, and is commonly referred to as a "Form 2567." The Form 2567 completed by the AHCA investigators as a result of the May 16 and 17, 2002, complaint investigation identified three deficiencies, only one of which is at issue herein. The deficiency at issue herein was identified in the Form 2567 with the federal tag number "F 309," which is associated with a violation of the quality of care requirements set forth in Title 42, Section 483.25, Code of Federal Regulations; F 309 is the tag number assigned to a deficiency that is not covered by Section 483.25(a) through (m).1 The deficiency was classified in the Form 2567 at a federal scope and severity level of G, on a scale of A to L, with A being the most severe.. The deficiency was also identified as a violation of Rule 59A-4.106(aa), Florida Administrative Code, and as a Class II deficiency under Florida law. The AHCA investigators supported the citation for a Class II deficiency under F 309 with the assertion in the Form 2567 that, "[b]ased on interview, record review and review of policies and procedures, the facility staff failed to prevent hypoglycemia as a result of inappropriate insulin use and failed to adequately treat a severe hypoglycemic incident in one of four sampled residents, resident #1 [J.D.]." J.D. was admitted to the Nursing Center with the diagnoses of pneumonia; congestive heart failure; left hydronephrosis; hypertrophy (benign) of the prostate; atrial fibrillation; Type II [diabetes] (non-insulin dependent type); status post myocardial infarction; old cerebrovascular disease; dementia; depression; cardiac pacemaker; and aortocoronary by-pass status. At the time material to this proceeding, J.D. was a "brittle" diabetic whose blood sugar levels were difficult to control. The Care Plan developed for J.D. on April 18, 2002, identified as a priority problem his potential for abnormal blood sugar related to diabetes mellitus. The goal developed for this problem stated: "Resident will not exhibit s/s [signs/symptoms] of hypo/hyperglycemia thru 7/18/02." This goal was to be met by administering medications as ordered by J.D.'s physician and by providing J.D.'s diet as ordered. In accordance with the recommendation dated April 24, 2002, of an endocrinologist who examined J.D. on April 3, 2002, J.D.'s treating physician wrote a medication order dated April 24, 2002, for Humalog insulin, which was to be administered by injection, in an amount to be determined on a sliding scale depending on his blood sugar levels. The order specified that the Humalog insulin was to be administered "A/C", or before meals. "A/C" is commonly understood in nursing practice to mean that a meal should be given within 30 minutes after medication is administered. Humalog is a very fast-acting type of insulin, with a therapeutic onset time of six to 15 minutes and a peak of 45 minutes to one hour. The therapeutic effect of Humalog insulin on blood sugar levels lasts from four to six hours. It is optimum to provide a meal within 15 minutes after the administration of Humalog insulin, and a delay in the ingestion of food after Humalog insulin is administered can result in the onset of severe hypoglycemia, or insulin shock. At the time material to this proceeding, the early morning medication pass at the Nursing Center routinely began at 6:00 a.m. and was completed at about 7:00 a.m. A medication pass is the discrete period of time during which prescription medications are administered to the nursing home residents. The practice of the nurse who administered the Humalog insulin injection to J.D. on the morning of April 26, 2002, was to give insulin injections at the end of the medication pass. When checked during the 6:00 a.m. medication pass on April 26, 2002, J.D.'s blood glucose was 84. In accordance with the sliding scale included in the physician's orders for J.D., six units of Humalog insulin were administered to J.D. by injection. J.D. was the last resident on his wing to receive an insulin injection on the morning of April 26, 2002, which would have placed the time of the injection at approximately 7:00 a.m., a time that was within acceptable nursing standards for administration of medication during a medication pass. At the time of the injection, the nurse observed that J.D. opened his eyes and shook his head in response to her calling his name. The usual practice at the Nursing Center was to deliver breakfast to the wing on which J.D. resided at 7:15 a.m. Pursuant to the policy at the Nursing Center, meals were to be served first to diabetic residents. In the normal course of business at the Nursing Center, delays in delivery of meals are reported to the administrator. The administrator received no report indicating that breakfast was delivered late to J.D.'s wing on April 26, 2002. The nurse who administered the insulin injection to J.D. on the morning of April 26, 2002, checked on him between 7:15 a.m. and 7:30 a.m., and his status did not appear to have changed since she administered the injection. J.D.'s breakfast tray was being delivered at the time of the nurse's visit, but she did not return to see if J.D. had eaten the breakfast; rather, she gave her report at 7:30 a.m. and left the facility. J.D. was unresponsive and could not eat his breakfast by the time it was delivered to his room.2 It is the normal practice at the Nursing Center for staff to check to make sure a resident has eaten; the staff will feed a resident if the resident cannot feed himself or herself and if a family member has not fed the resident. Normally, J.D.'s wife was with J.D. and fed him his meals. On the morning of April 26, 2002, J.D.'s wife was unable to go to the Nursing Center, and, at a time that is unspecified in the record, J.D.'s daughter arrived to feed J.D. his breakfast. The Nursing Center's nursing notes reveal that, at 8:30 a.m. on April 26, 2002, J.D. was unresponsive; his pupils were symmetrical and reactive to light; his blood pressure was 110/70, his pulse was 88, and his respiration was 24; his breathing pattern was even, unlabored and non-diaphoretic; and there was no cyanosis. In addition, J.D. had no detectable blood sugar. The Nursing Center's written policy and procedure for the treatment of insulin shock, or severe hypoglycemia, in effect at the time material to this proceeding required that a physician be notified immediately; that sugar be administered orally or through a glucose IV as ordered by the physician; that the resident be transported to the hospital if ordered by a physician; and that a responsible party be notified. These procedures were consistent with the practices generally found in skilled nursing homes at the time, although the policies and procedures would ideally have included more creative and proactive treatment options. The Nursing Center's procedures for the treatment of insulin shock were followed: A nurse placed a call to J.D.'s treating physician. Emergency response personnel were called; they arrived before the doctor and administered a dextrose solution intravenously. The doctor was located in the facility and arrived at J.D.'s room at approximately 8:40 a.m. J.D. was transferred to the Mercy Hospital Emergency Room at approximately 8:45 a.m., with a transfer diagnosis of "altered mental status." The nurse's notes reflect that he was unresponsive at the time of his transfer.3 J.D.'s daughter, who had been present throughout the emergency, accompanied him to Mercy Hospital. At the time of the incident on April 26, 2002, there was no glucose gel at the Nursing Center to administer to patients who became hypoglycemic, nor was there a standing physician order for glucagon injections for patients who became hypoglycemic. In the opinion of one of the AHCA investigators, these changes in the Nursing Center's procedures for treating hypoglycemic residents would improve its procedures for the treatment of insulin shock: Glucose gel is a better option than glucose tablets because there is no need for the gel to dissolve before becoming effective, and glucagon injections avoid the need for administering glucose intravenously, which may sometimes be difficult in a person experiencing insulin shock. These treatments for severe hypoglycemia are not, however, standard in nursing homes. Summary The evidence presented by AHCA, together with facts not in dispute herein, are sufficient to establish clearly and convincingly that the Nursing Center staff failed to provide the care necessary to prevent J.D. from becoming severely hypoglycemic after he received six units of Humalog insulin at or about 7:00 a.m. on April 26, 2002. It is uncontroverted that, because Humalog is a very fast-acting type of insulin, it is necessary that the injection precede a meal by no more than 15 to 30 minutes. In addition, the April 24, 2002, order of J.D.'s physician specified that Humalog insulin was to be administered to him before a meal, and it is understood in the nursing profession that a physician's order requiring that a medication be administered before a meal means that the meal should be provided no more than 30 minutes after the medication is administered. Although the evidence establishes that J.D.'s breakfast was delivered between 7:15 a.m. and 7:30 a.m., the Nursing Center admitted that J.D. was unable to eat his breakfast at the time it was delivered. The Nursing Center's practice is to check on a resident to make sure meals are eaten and to feed a resident if a family member is not present to do so, but there was no evidence presented to establish that any member of the Nursing Center's staff checked at or about 7:30 a.m. to see if J.D. had eaten his breakfast. The only member of the Nursing Center's staff who checked on J.D. within 30 minutes of the time the Humalog insulin injection was administered was the nurse who had administered the injection, and J.D.'s breakfast was just being delivered when she looked in on him. Although the evidence reflects that J.D.'s daughter arrived the morning of April 26, 2002, to feed J.D. his breakfast, there is no evidence establishing the time of her arrival. The failure of the Nursing Center's staff to ensure that J.D. ate his breakfast within 15 to 30 minutes after receiving the Humalog insulin injection was a material omission in his care; a violation of the physician's order that the Humalog insulin be given before meals; and inconsistent with the goal set forth in J.D.'s care plan to prevent J.D. from exhibiting signs and symptoms of hypoglycemia. No evidence was presented to establish an alternative cause for J.D.'s severe hypoglycemia on the morning of April 26, 2002, and the credible evidence is sufficient to prove clearly and convincingly that the failure of the Nursing Center to ensure that J.D. actually ate his breakfast caused him to become severely hypoglycemic.4 As a result his severe hypoglycemic condition, J.D. was unresponsive for an unspecified period of time and required intravenous administration of a dextrose solution by emergency response personnel and transfer to a hospital emergency room. Although there was no evidence presented to establish that J.D. failed to recover fully from the hypoglycemic incident, the facts that he went into insulin shock and was unresponsive for more than 15 minutes are sufficient to support the inference that, until he was fully alert and responsive, he was unable to maintain his optimal physical condition during the hypoglycemic incident. The greater weight of the credible and persuasive evidence presented by AHCA is not sufficient to establish that the staff of the Nursing Center failed to adequately treat J.D. during the hypoglycemic incident. The uncontroverted evidence establishes that the staff of the Nursing Center followed the facility's insulin shock policy and procedures in treating J.D. and that the policy and procedures prescribed treatment of hypoglycemia that was the standard among skilled nursing homes.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order Sustaining the reduction in the licensure status of Egremont Health Care Associates, d/b/a Nursing Center at Mercy, to conditional for the period extending from May 17, 2002, to October 31, 2002; and Imposing an administrative fine in the amount of $2,500.00. DONE AND ENTERED this 31st day of January, 2003, in Tallahassee, Leon County, Florida. PATRICIA HART MALONO Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 31st day of January, 2003.
Conclusions Competent substantial evidence supports the conclusion that Adrian Fuentes disabilities are the result of the failure to deliver him before his mother loss amniotic fluid, or up to an estimated 12 hours earlier. An earlier delivery was the standard of care expected in a case of IUGR. His permanent and severe disabilities were directly and proximately caused by the failure of SBHD employees to handle an ultrasound report expeditiously as directed and as their policy provided. ATTORNEYS’ FEES AND LOBBYISTS’ FEES: In compliance with s. 768.28(8), F.S., but not with Section 3 of this claim bill, Claimant's attorneys' fees are set at 25 percent. There is no lobbyist for the bill at this time. As of October 9, 2007, the attorneys reported having incurred costs of $115,246.02 for representing the Claimant. The Claimants entered into an agreement to pay attorneys’ fees and costs. RECOMMENDATIONS: For the reasons set forth in this report, I recommend that Senate Bill 60 (2008) be reported FAVORABLY. Respectfully submitted, Eleanor M. Hunter Senate Special Master cc: Senator Jeremy Ring Representative Evan Jenne Faye Blanton, Secretary of the Senate House Committee on Constitution and Civil Law Tom Thomas, House Special Master Counsel of Record
The Issue The issue is whether Respondent committed the offenses set forth in the Administrative Complaint and, if so, what disciplinary action should be taken against her license to practice nursing in the state of Florida.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of facts are made: At all times material to this proceeding, Respondent was licensed by the State of Florida as a practical nurse, holding license number PN0876551. At all times material to this proceeding, Respondent was employed by Arch Creek Nursing Home (Arch Creek) where she worked as a practical nurse on the 11 p.m. to 7 a.m. shift. Her direct supervisor, Ms. McDonald, R.N., worked the 7 a.m. to 3 p.m. shift. The Arch Creek Director of Nursing, Jeanette Jaffe, R.N., also worked the day shift. At all times material to this proceeding, Respondent was assigned to provide nursing care to patient E. R., a seventy-seven (77) year old female. After suffering a stroke, E. R. was admitted to North Shore Medical Center (NSMC) on November 16, 1990. She was transferred from NSMC to Arch Creek on December 7, 1990. At that time, E. R. suffered hypertension and was partially paralyzed and aphasic. Because she was incontinent of bowel and bladder, a foley catheter was used for urine drainage. A gastrostomy tube was required for nutritional feeding. At the time of admission to Arch Creek, E. R. also had a stage II sacral decubitus ulcer on her buttocks which was one and one half (1 1/2) inches by one half (1/2) inches. The decubitus ulcer was not infected at that time. On December 7, 1990, Dr. Cottler, E. R.'s physician at Arch Creek, ordered that the decubitus ulcer be treated with a DuoDerm dressing, an occlusive "sealed" treatment, which was to be changed every three (3) days. He also ordered that E. R. be turned every two (2) hours to alleviate pressure in the sacral area. On December 9, 1990, a 3:00 p.m. nurse's note reflects that E. R. had two (2) open sores with a small necrotic area on her buttocks. Dr. Cottler examined E. R. on December 11, 1990. He did not describe the ulcer in his notes or change the orders for treatment. At that time, the wound was approximately 4" by 6" inches. On December 17, 1990, a 2:45 p.m. nurse's note reflects that E. R.'s decubitus ulcer was getting worse and needed to be evaluated. Nurses' notes are inherently reliable. The presence of these notes in E. R.'s chart should have alerted Respondent to the changes in E. R.'s condition. Respondent had the opportunity to observe whether the DuoDerm dressing was intact and clean when she performed her rounds on the night shift. This was especially important after a bowel movement to ensure that fecal matter did not contaminate the wound. On December 20 and 21 at 6:00 a.m., Respondent noted on E. R.'s chart that a treatment was done to the buttocks. On neither occasion did Respondent chart information relating to the size, color, odor, or drainage of the decubitus ulcer. All of these factors needed to be documented so that a record could be developed as to any changes in the patient's condition and to facilitate an ongoing assessment of the treatment. Respondent did not contact Dr. Cottler during the night shift of December 20-21. There is no persuasive record evidence that Respondent verbally reported E. R.'s condition to the registered nurse in charge on the mornings of December 20 and December 21. On December 21 at 4:00 p.m., a nurse noted in the chart that the skin around E. R.'s sacral area was black with a fowl odor and appeared not to be responding to treatment. This same nurse noted that Dr. Cottler's new orders required E. R.'s wound to be treated with twenty-five percent (25 percent) acetic acid and wet to dry dressings every eight (8) hours. A decubitus ulcer does not change to a fowl smelling necrotic ulcer in ten (10) hours. Therefore, it is likely that the signs of decay were present when the Respondent treated E. R.'s buttocks on the night shifts of December 19- 20 and 20-21. Around noon on December 23, E. R.'s temperature was 100.8 degrees. Respondent again provided nursing care to E. R. on the night shift of December 23-24. At 3:00 a.m., she observed that E. R. was slower to respond and short of breath. However, this assessment of E. R.'s condition was incomplete. Respondent did not record the patient's vital signs or note the condition of the decubitus ulcer. She also failed to alert Dr. Cottler of the change in E. R.'s condition. Evidence that Respondent made a verbal report regarding E. R.'s condition to the registered nurse at 7:00 a.m. on the morning of December 24 is not persuasive. Because E. R. was slower to respond and short of breath at 3:00 a.m. on December 24, Respondent should have recorded the patient's vital signs and documented other relevant information, including the condition of the decubitus ulcer. Armed with all the information for a total assessment, Respondent should have immediately alerted the doctor about E. R.'s condition. At 2:00 p.m. on December 24, a nurse's note reflects that E. R. was unresponsive and short of breath. The nurse informed Dr. Cottler, who ordered a chest x-ray and oxygen for E. R. Dr. Cottler subsequently authorized transfer of E. R. to NSMC. At the time of transfer, Dr. Cottler was under the impression that E. R. had aspirated. On admission to NSMC's emergency room, E. R. was unresponsive and acutely short of breath. Her vital signs were extremely beyond her normal range: temperature, 102.8; pulse, 130; respirations, 40; and blood pressure, Additionally, E. R.'s white blood cell count of 31,000 indicated the presence of infection. Dr. Kann took care of E. R. upon her admission to NSMC on December 24. Within twenty-four (24) hours, he observed that E. R.'s wound was roughly nine (9) inches by six (6) inches by three (3) inches deep; it had greatly increased in size and had deteriorated in condition during the seventeen (17) days that E. R. had been a resident at Arch Creek. On January 8, 1991, fifteen (15) days after E. R. was discharged from Arch Creek, Respondent charted a late entry on E. R.'s Weekly Decubitus or Treatment Sheet. This entry was dated December 13, 1990, and states: I, Catherine Evanoff, L.P.N., reviewed this patient on 12/13/90. Superficial decubitus area extends 6"-7" across both left & right buttocks (Coccycx area, necrotic tissue, is deeper in depth and surrounded by red soft, tender tissue. All decubitus area is soft, mushy w/strong foul odor & drainage present.) Respondent made this late entry at the request of Jeanette Jaffe, R.N., the Director of Nursing at Arch Creek. Ms. Jaffe asked Respondent to make the record because Ms. McDonald, the registered nurse in charge of the day shift and Respondent direct supervisor, no longer worked at Arch Creek. Respondent should not have made the late entry fifteen days after the care was provided. A late entry should be made only where such information continues to be relevant and pertinent to the care being provided to a patient. After emergency room treatment, E. R. was admitted to NSMC's intensive care unit.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore recommended that the Board of Nursing enter a Final Order finding that Respondent violated Section 464.018(h), Florida Statutes (1989). Additionally, the Board of Nursing should: (1) reprimand Respondent's license; (2) place Respondent on probation for two (2) years with direct supervision; (3) require Respondent to take continuing education courses in decubitus care and charting in addition to her required continuing education credits; (4) require Respondent to pay an administrative fine in the amount of $1,000. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 28th day of November 1994. SUZANNE F. HOOD, Hearing Officer Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 28th day of November 1994.
Conclusions THIS CAUSE comes before the AGENCY FOR HEALTH CARE ADMINISTRATION (the "Agency”) concerning the Certificate of Need (“CON”) 10111 Application which was filed by BAY HOSPITAL, INC. d/b/a GULF COAST MEDICAL CENTER (hereinafter “Gulf Coast”) to establish a 6- bed Level III NICU in Bay County, Florida. The Agency preliminarily approved Gulf Coast’s application. On July 14, 2011, Tallahassee Memorial Healthcare, Inc. d/b/a Tallahassee Memorial Hospital (hereinafter “TMH) filed a Petition for Administrative Hearing challenging the Agency’s approval. This petition was forwarded to the Division of Administrative Hearings (‘DOAH”), by the Agency and assigned to an Administrative Law Judge. Filed November 21, 2011 9:11 AM Division of Administrative Hearings A 9 Ae 253 On October 27, 2011, the parties entered into a settlement agreement and a Joint Motion to Relinquish Jurisdiction was filed. On October 28, 2011, the Department of Administrative Hearings (hereinafter “DOAH”) issued an Order Relinquishing Jurisdiction and Closing the File. Prior to Final Hearing, the parties entered into a Settlement Agreement (Exhibit 1) which is attached hereto, and the Agency being otherwise well advised in the premises: It is ORDERED AND ADJUDGED: 1. The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Settlement Agreement. 2. | The Agency shall issue CON 10111 to Gulf Coast. 3. The Parties shall abide by the terms and conditions of the Settlement Agreement. 4. Each Party shall be responsible for its respective own costs and attorney’s fees. 5. | The above-styled case is hereby closed. DONE and ORDERED this _/4/ day of Nive-d- , 2011, in Tallahassee, Florida. oo 2
Findings Of Fact The agency hereby adopts and incorporates by reference the findings of fact set forth in the Recommended Order. CONCLUSIONS OF LAW, The agency hereby adopts and incorporates by reference the conclusions of law set forth in the Recommended Order. Based upon the foregoing, it is ADJUDGED, that the applications of Variety Children’s Hospital d/b/a Miami Children’s Hospital and South Miami Hospital, Incorporated, for CONs 8640 and 8641 are DENIED. DONE and ORDERED this ln davenbee. 1997, in Tallahassee, Florida. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION . Cook, Director we A PARTY WHO IS ADVERSELY AFFECTEB’BY THIS FINAL ORDER IS ENTITLED TO A JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS _ ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. -2- Copies furnished to: J. Lawrence Johnston Administrative Law Judge DOAH, The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-3060 Richard Patterson, Esquire Senior Attorney, Agency for Health Care Administration 2727 Mahan Drive, Suite 3431 Fort Knox Building Il Tallahassee, FL 32308-5403 Gerald B. Sternstein, Esquire Sternstein, Rainer & Clarke, P. A. 314 North Calhoun Street Tallahassee, FL 32301 Wendy A. Delvecchio, Esquire Blank, Rigsby & Meenan, P. A. . 204 South Monroe Street Tallahassee, FL 32301 Thomas D. Watry, Esquire Parker, Hudson, Rainer & Dobbs 1500 Marquis Two Tower 285 Peachtree Center Avenue, NE Atlanta, GA 30303 Kenneth Hoffman, Esquire Oertel, Hoffman, Fernandez & Cole, P. A. Post Office Box 6507 Tallahassee, FL 32314-6507 Elfie Stamm (AHCA/CON) CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished to the above named addresses by U. S. Mail this LX day of , 1997. 11/6/97 State of Florida, Agency for Health Care Administration 2 727 Mahan Drive, Suite 3431 Fort Knox Building II Tallahassee, FL. 32308-5403 (904)922-3808 -3- . S. Power, Agency Clerk — _
Conclusions This cause came on before me for the purpose of issuing a final agency order. The Administrative Law Judge assigned by the Division of Administrative Hearings (DOAH) in the above-styled case submitted a Partial Recommended Order to the Agency for Health Care Administration (AHCA). The Partial Recommended Order entered J. Lawrence Johnson by Administrative Law Judge September 19, 1997, is incorporated by reference.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant facts are found: On or about June 9, 1975, petitioner Holy Cross Hospital filed with respondent its certificate of need application for the expansion of angiographic service facilities. The applicant is a 597-bed, privately operated, nonprofit and fully accredited medical center located in Fort Lauderdale, Florida. Petitioner seeks to add to its existing facility a laboratory for cardiac catherization and coronary angiography. The application was referred to the Broward County Community Health Planning Council (hereinafter referred to as BCCHPC) for initial review, comments and recommendations. On July 14, 1975, the staff of the BCCHPC issued its Staff Analysis on petitioner's capital expenditure proposal. This document concludes that the proposal "can conceivably be construed as duplication of services." Among the factors considered by the staff were the existence of two hospital-based cardiac catherization diagnostic programs within Broward County and their capacities and utilization rates; the opening of a third hospital-based facility around mid- October of 1975; and the standards and guidelines for cardiac diagnostic centers as reported by the American Heart Association. It was concluded that the presently existing facilities were being utilized at a rate of ten percent of their combined capacity of 1,750 procedures per year, and that the third facility to be opened in mid-October would provide an additional capability of 1,000 procedures per year. (Exhibit No. 4) The Project Review Committee of the BCCHPC met on July 24, 1975, to review the petitioner's proposal. After hearing the views of both proponents and opponents to the application, this Committee voted to postpone its recommendation with the understanding that an impartial panel of experts, under the auspices of the Broward County Heart Association, would be brought in to review the needs of the community for additional angiographic services. An extension of the review period to December 1, 1975, was thereafter sought by petitioner and granted by respondent. (Exhibit No. 7.) For one reason or another, the survey was never conducted. On October 17, 1975, the staff of the BCCHPC issued its second staff summary. This second report, although differing in some figures and statistics from the first report, again concluded that current and projected utilization barely justifies the two existing facilities. It recognized the third facility to be opened shortly at North Ridge General Hospital and found that the applicant's proposal would be additionally counterproductive, reducing overall quality and increasing average cost. (Exhibit No. 5.) Thereafter, on October 27, 1975, the Project Review Committee of the BCCHPC again met to review petitioner's application. In addition to a representative for the applicant, the Committee heard the opposing views of North Ridge General Hospital, which included the presentation of an analysis as to need for additional cardiovascular diagnostic laboratory services in Broward County. This analysis was prepared by Lillian Guralnich, a biostatistician, and concluded that (based upon actual utilization rates in Dade County) a valid statistical estimate of potential cases requiring the subject diagnostic studies in Broward County is 2,500 per year, and that the existing facilities and the soon-to-be-opened North Ridge facility would provide a capacity substantially in excess of such estimated demand. Additionally, the Committee heard the view of Dr. Manuel Viamonte, a member of the Inter-Society Commission for Heart Disease Resources, that an additional catherization laboratory in Broward County would be counterproductive. A motion to accept petitioner's application was defeated by a vote of five to two, with six abstentions. (Exhibit No. 5.) The BCCHPC met on October 30, 1975, to discuss the Project Review Committee's recommendations. The Council heard a presentation in support of the proposed laboratory and were presented supporting documents. North Ridge again spoke in opposition and again presented the Guralnich analysis concerning need. The study of the Inter-Society Commission on Heart Disease Resources was also presented. Thereafter, the Committee unanimously voted, by a vote of 17-0 with two abstentions, to deny petitioner's application. (Exhibits A, C and U.) By letter dated November 24, 1975, Mr. Art Forehand notified petitioner that all the reviewing agencies (the BCCHPC, the Office of Comprehensive Health Planning, and the Office of Community Medical Facilities) had not favorably considered petitioner's capital expenditure proposal. The reason given for such unfavorable consideration was that there were three existing, underutilized cardiac catherization labs in Broward County and that the creation of an additional lab at petitioner's facility would be a duplication of services, an unnecessary capital expenditure and would not lend itself to health care cost containment concepts. (Exhibit D.) The petitioner was advised of its right to a fair hearing, stated its desire to avail itself of such right, and the undersigned Hearing Officer was assigned to conduct the hearing. Holy Cross Hospital opened on December 7, 1955, and enjoys a good reputation among both physicians and the community at large. It is a full service hospital with 597 beds, 498 of which are staffed. Last year, some 2,100 heart patients were admitted to Holy Cross. Petitioner did its first open heart surgery on November 23, 1975, and, as of January 26, 1976, had performed a total of eight such procedures. The pre-surgery catherizations were performed at other hospitals without difficulties in scheduling or transportation. Cardiac catherization is a diagnostic tool utilized to discover the condition of the coronary arteries. It is an invasive technique involving the insertion of a small flexible tube into the veinous or arterial system and passing it by way of a peripheral vein or artery into the heart or the major structures of the great vessels arising from the heart. While the first procedures began in the early 1940's, the technique is a relatively new development within the past ten to fifteen years. The procedure determines the location and severity of coronary obstructions and is a definitive method to rule out a diagnosis of heart disease. It provides a confirmation of the less risky non-invasive techniques (such as the clinical treadmill tests, radiological studies, etc.) and is a prelude to coronary artery surgery. Such a procedure would be unnecessary if the patient were unable or unwilling to undergo heart surgery. Approximately ninety percent of such catherizations are done electively, as opposed to a ten percent emergency usage. Emergency patients are generally nontransportable, but there is no problem or risk in transporting the ninety percent elective patients to other facilities for the purpose of catherization. While not mandatory, it is desirable to have heart surgery facilities and capabilities at the same hospital as the catherization laboratory. There is an inverse relationship between mortality, morbidity and complication rates and the number of cardiac catherizations performed in any given facility. When volume and experience increases, complications decrease. Also, underutilization of a cardiac catherization laboratory often results in higher patient costs and unnecessary procedures being performed. The minimally acceptable utilization rate for any given facility is 300 procedures per year. The estimates of the actual and potential need for catherization procedures in Broward County varied widely. It ranged from a high of 20,000 present potential candidates for the procedure to a low of 2,500 potential cases per year. Factors affecting need include the education of the public and physicians, the reputation and persuasive abilities of the treating physician, cost and risk to the patient, adequacy and reputation of the lab, and professional limitations. Professional opinions and philosophies differed as to the use of cardiac catherization. While one physician felt that no more than ten percent of patients with heart disease needed such a procedure, another felt that the procedure was necessary to detect the absence of heart disease as well as its presence and that every good hospital should have such a lab. There are presently three hospital-based cardiac catherization laboratories in Broward County. One lab, which opened in September of 1974, exists at Broward General Medical Center, located some eight to ten miles from petitioner. Another, opening in October of 1974, exists at Florida Medical Center Hospital, formerly called Lauderdale Lakes General Hospital and located approximately six miles from Holy Cross Hospital. A third lab was opened in November of 1975 and is located about one mile from petitioner at North Ridge General Hospital, the intervenor in this proceeding. Testimony differed as to the actual daily or monthly number of procedures capable of being performed at these institutions. The highest figure given was that of Dr. Frank Masone Sones, a world renown authority on coronary angiography. He stated that a diagnostic laboratory of this sort can easily perform ten or twelve, and under real stress, fifteen procedures per day. This would average out to 60 per week or 3,000 per year per facility if the figure of 12 were used. This figure assumes an eight-hour shift. Another physician testified that most labs could perform four catherizations per day. Actual catherizations performed at two of the existing labs in Broward County average out to be 20 per month and 33 per month. The capability figures given for the three existing facilities based upon one eight-hour shift, totalled 2,700 procedures annually. One hospital administrator testified that its lab could perform six per day on an eight-hour shift, or 120 per month. This administrator saw no difficulty with operating two shifts, should the need arise.
Recommendation Based upon the findings of fact and conclusions of law recited above, it is recommended that the determination of the Office of Community Medical Facilities to deny petitioner's application for the expansion of angiographic service facilities be upheld. Respectfully submitted and entered this 4th day of November, 1976, in Tallahassee, Florida. DIANE D. TREMOR, Hearing Officer Division of Administrative Hearings Room 530, Carlton Building Tallahassee, Florida 32304 (904) 488-9675 COPIES FURNISHED: Mr. William F. Leonard Coleman, Leonard & Morrison 2810 E. Oakland Park Boulevard Fort Lauderdale, Florida 33306 Mr. Douglas E. Whitney Attorney 1323 Winewood Boulevard Tallahassee, Florida 32301 Mr. Sheldon M. Simons professional Building 3661 South Miami Avenue Miami, Florida 33133
