An old woman, 95 years of age, is a patient at a certain Staten island hospital. On 9 June 1998, she became comatose, cyanotic and unresponsive after she became disconnected from her ventilator machine. An employee of the hospital heard the old woman’s room alarm sound but the alarm at the nurses’ station failed to sound. Hence, it could not be determined as to how long the old woman remained disconnected from the ventilator. Respirator assistance was then provided to the old woman by the medical staff of the hospital. Thereafter, she was immediately transferred back to the cardiac care unit, which is where she had been prior to the ventilator incident, and there she received intensive therapeutic care and massive blood transfusions. From 10 June 1998 through 11 June 1998, the consulting neurologist indicated in his progress notes that the old woman had a guarded prognosis and was not receptive to outside stimuli. From 12 June 1998 through 17 June 1998, the progress notes indicated that the old woman was improving. The old woman’s neurologist then noted that she was at baseline, neurologically stable. In other words, the old woman’s neurological condition returned to the state that it had been prior to the ventilator disconnection. Thereafter, the hospital took several remedial measures to prevent any future incidents of this type. The hospital’s Code 15 committee reviewed the old woman’s case to decide whether or not it warranted Code 15 treatment, which consists of reporting to the Agency for Health Care Administration or AHCA within fifteen days of the incident, but later voted against such Code 15 treatment, believing that since the old woman recovered to her neurological baseline, no brain damage or brain injury had occurred. Instead of filing the incident as a Code 15, the hospital reported the occurrence as an adverse incident in its Annual Report of Incidents.
Consequently, the AHCA filed an administrative complaint against the hospital and contends that the hospital violated the law by reason of their failure to report a hypoxic event that caused brain damage to a patient as a Code 15 occurrence.
Sometime in December 2000, a formal hearing was held. After that, the administrative Law Judge or ALJ concluded that the old woman did in fact suffer from a brain damage, a transient or temporary brain damage, and the hospital should have reported the incident as a Code 15; and recommended that AHCA had justification to levy a $5,000.00 administrative fine against the hospital.