AGENCY FOR HEALTH CARE PRINTED: 05/11/2018

FORM APPROVED
ADMINISTRATION
STATEMENT OF X1) PROVIDER/SUPPLIER/CLIA X3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED

HL100250 04/27/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

JOHNS HOPKINS ALL 501 SIXTH AVENUE SOUTH

CHILDREN'S HOSPITAL SAINT PETERSBURG, FL 33701

SUMMARY STATEMENT OF DEFICIENCIES

FINDINGS PRECEDED BY TAGS AND REGULATORY IDENTIFYING INFORMATION)

0000 - INITIAL COMMENTS

An unannounced Risk Management survey was conducted at John Hopkins All Children 's Hospital on
04/26/2018 through 04/27/2018, License # 4042. The facility was not in compliance in accordance with
the state licensure requirements, found in Chapter 395 of the F.S. (Florida Statute) and Chapters 59A-3,
F.A.C. (Florida Administrative Code)
Deficiencies were found at the time of the visit.

0409 - RM Prog - Pt Notification of Adv Incidents - 395.0197 (1)(d), 395.1051 F.S.

Based on review of medical records, staff interview and review of policy and procedure it was
determined the facility failed to disclose to the patient/patient representative a was
the patient following a for one (#12) of fourteen patients sampled.

Findings included:

Review of the facility policy, "Adverse Medical Incidents and Sentinel Events", states the organization
shall disclose to the patient the unintended of a and keep a record of the
to identify trends and patterns that may identify opportunities for improvement.

Review of the medical record for patient #12 revealed a was conducted on
on a Review of the documentation revealed a count discrepancy which
identified (1) one was unaccounted for at the end of the Review of the
dated post revealed a curved measuring
approximately 5 mm (millimeters) which most likely represents the missing Review of the
physician documentation revealed no evidence the physician informed the patient's guardians of the

Review of the medical record revealed patient #12 returned to the for another
Review of the physician's report revealed an extensive search was made for the
but the search did not yield any

Review of the physician progress note, dated at 4:29 a.m., and the dated
stated review of the revealed a like that projects over
the just to the left of the It likely does represent a The was
first appreciated on exam from at 8:38 pm. It has remained stable in its position through to the
current examination. Review of the physician documentation revealed no evidence the physician

AHCA Form 5000-3547

FORM
2STATE
DF4711 If continuation sheet 1 of
AGENCY FOR HEALTH CARE PRINTED: 05/11/2018
FORM APPROVED
ADMINISTRATION

STATEMENT OF X1) PROVIDER/SUPPLIER/CLIA X3) DATE SURVEY

DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED

HL100250 04/27/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

JOHNS HOPKINS ALL 501 SIXTH AVENUE SOUTH

CHILDREN'S HOSPITAL SAINT PETERSBURG, FL 33701

SUMMARY STATEMENT OF DEFICIENCIES

FINDINGS PRECEDED BY TAGS AND REGULATORY IDENTIFYING INFORMATION)

informed the patient's guardians of the Review of the record revealed the patient
was discharged from the facility on

Review of the medical records revealed the patient returned to the facility ED (Emergency Department)
on ED physician documentation revealed the patient's parents reported the patient was seen
by the logist on at which time the logist attempted to provide reassurance
regarding the in the Documentation stated the parents had not previously
been told of the and presented with the patient for removal. At the time of the ED visit
the patient was evaluated and determined to be stable, required no further treatment at that time and
was discharged home.

Interview with the Risk Manager on 4/27/2018 at approximately 1:35 p.m., confirmed the above findings.

0416 - 15 DAY REPORTS - 395.0197(5 &7) FS; 59A-10.002(5) FAC

Based on review of medical records and staff interview it was determined the facility failed to ensure an
adverse incident, which occurred in the facility, was reported to the agency within 15 calendar days after
its occurrence for two (#11, #12) of fourteen patients sampled.

Findings included:

1. Review of the record for patient #11 revealed on a was identified

post Review of the facility documents revealed no evidence the facility reported the
adverse event to the agency within 15 calendar days after its occurrence.

2. Review of the record for patient #12 revealed on a was identified

post Review of the facility documents revealed no evidence the facility reported the
adverse event to the agency within 15 calendar days after its occurrence.

Interview with the Risk Manager on 4/27/2018 at approximately 1:35 p.m., confirmed the above findings.

AHCA Form 5000-3547

FORM
2STATE
DF4711 If continuation sheet 2 of