pros occ dali aM a ae ll w W) ! STATE OF FLORIDA ah AGENCY FOR HEALTH CARE ADMINISTRATION 1 i D HEALTH CARE ADMINISTRATION, Vis! Petitioner, acti anes 3 vs. AHICA NO: 02-99-009-NH(C) PINEHURST RHABILITATION & SPECIALTY CARE CENTER, Respondent. / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (“Agency”) intends to impose an administrative fine in the amount of $20,000.00 upon Pinehurst Rehabilitation & Specialty Care Center. As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1, The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part Il, Florida Statutes. 2. Respondent, Pinehurst Rehabilitation & Specialty Care Center, is licensed : - by the Agency: to operate a nursing home at 2401 NE 2°4 Street, Pompano Beach, Florida! 33062 and is obligated to operate the nursing ‘home in compliance with Chapter 400 Part Il, Florida Statutes, and Rule 59A-4, Florida Administrative Code. - STATE OF FLORIDA, AGENCY FOR 00 JAN -7 AM 10: 41 aaa ad Ww 3. Asa result of a survey conducted at Pinehurst Rehabilitation & Specialty Care Center by the Agency’s Area 10 office on or about April 1999 through April 21, 1999, the following Class II deficiencies were cited: 4A. Pursuant to 42 CFR §483.13(c)(1)(), the facility must develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. This requirement was not met as evidenced by the following observations: (1) During the initial tour on April 19, 1999, Resident #3 was observed in bed at 9:00 a.m. The resident appeared pale, frail and thin. Her eyes were open, but she did not respond when her name was called. a) An attendant in the room identified herself as a hospice employee assigned to provide “Crisis Care” to the resident. 1) A Foley indwelling catheter was noted as was a dressing to the left elbow. An empty tube feeding bag and tubing hung from a pole at the head of the bed. 2) A review of the clinical record at 9:20 a.m. revealed that Resident #3 was a hospice patient with a diagnosis of end-stage cardiovascular disease. The facility documented that the resident had contractures of both lower extremities, a flaccid left side, multiple decubitus ulcers requiring extensive wound care, and was receiving Morphine around _ the clock for pain management. Observation of the - dressings to the decubitus ulcers being changed by facility staff on April 20, 1999 at 3:00 p.m. revealed that the resident had open areas on her left scapula, right thoracic area, left hip, and coccyx (large Stage IV) with cream colored exudate. During the wound care, the resident looked frightened and frowned as the procedure was in progress. 3) The initial dietician’s assessment of December 10, 1998 determined that the resident needed 1424 calories per day, including 37-56 grams of protein. ome = ue ogame ser pe ee 4) The January 1999 dietician assessment notes that the resident needed 1441 calories per day, including 38-57 grams of protein. 5) The resident was unable to eat or drink orally and was fed 240cc of tube feeding formula and 600ce of water via a PEG each day. Although the facility stated that the resident required 1424 to 1441 calories per day, a daily feeding of 240 calories and 15 grams of protein were provided, much below the amount of calories and protein required to sustain the resident and assist in healing the decubiti. 6) Upon interview with facility staff and hospice staff on April 20, 1999 to determine the reason adequate nutrition was not provided to the resident, it was reported that the resident’s feeding was decreased due to the resident’s congestion. Facility staff implied that adequate nutrition was not provided because the resident was a hospice patient and death was imminent. 7) There was no documentation found that the facility was planning to modify the resident’s dietary plan. The reduced feeding continued for 2 % months until the date of the survey. The dietary order was documented as being done “per hospice recommendations,” however, the hospice nurse stated on April 19, 1999 at 10:00 a.m. that she had not made those recommendations. 8) Clinical record review revealed that without adequate nutrition to assist in healing, the resident’s decubitus ulcers became larger, deeper and infected. 9) Due to the facility’s failure to provide adequate nutrition to the resident, it was determined that the facility allowed the resident to endure increased pain due to the development of decubitus ulcers and the deterioration of the coccyx wound. 10) At the completion of the resident review, it was also determined that withholding services to the resident was “not palliative. rs ad Ww 11) Repeated attempts by the surveyor to clarify the source of the recommendation failed. There also was no documentation that indicated that the resident’s health care surrogate/proxy was aware of the ramifications of the reduction of the feeding to one can per day. (2) Based on observation, record review and staff interview, it was determined that the facility violated the following: 400.022(1)(j), 400.022(1)(k), and 400.022(1)(L), E.S., for failing to obtain informed consent, failing to document that informed consent was obtained, and failing to provide adequate and appropriate health care services and Rule 59A-4.106(4)(x), F.A.C., for failing to maintain policies and procedures regarding informed consent. 4B. Pursuant to 42 CFR §483.13(c)(1)(i), the facility must ensure that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. This requirement was not met as evidenced by the following: (1) During the initial observation tour of the facility on April 19, 1999, it was noted that Resident #1 had a large bruise to the “upper left forehead area. ‘ a) An interview with the resident at the time of the tour revealed that the resident was confused and did not know how the bruise had occurred. b) A review of the medical record, which included the ~ nurses? daily notes, revealed that there was no nursing documentation concerning the resident from February 10, 1999 through April 15, 1999. The April 15, 1999 documentation did not refer to any bruises of unknown origin. a si aii a te es Ww c) Further review of the facility’s Incident Follow-Up Sheet did not reveal any documentation of a forehead bruise to any resident from March 11, 1999 through April 19, 1999. d) The bruise was brought to the attention of the facility DON on April 20, 1999 by the survey team and the medical record was reviewed by the DON, which again did not reveal any information regarding the incident. e) On April 20, 1999 during an interview with the facility DON, it was noted the facility failed to follow its policy and procedure regarding the investigation and reporting of incidents involving injuries of unknown source. (2) Based on observation, interview, and record review, it was determined that the facility violated Rule 59A-106(4)(cc), for failing to have policies and procedures for reporting accidents and unusual incidents in 1 of 20 sampled residents. 4C. Pursuant to 42 CFR §483.25(o), the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable, and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. This requirement was not met as evidenced by the following observations: (1) During the initial tour on April 19, 1999 at 9:00 am., Resident #3 "was observed in bed in her room appearing frail and thin. Empty tube feeding equipment was hanging by the bedside and a pressure relieving “Mattress was in place. ~(a) Interview of the hospice staff member present noted that the resident was in “Crisis Care” which was defined as continuous are provided when death is thought to be imminent. The hospice ‘staff member present told the surveyor the resident had multiple “pressure sores. —_ _ (b) WV 1) A review of the resident’s clinical record on April 19, 1999 at 9:20 a.m. revealed that she had been admitted in December 1998 with a Stage III decubitus ulcer on her left hip. 2) Observation of the wounds by the surveyor on April 20, 1999 at 3:00 p.m. with a facility staff member noted that the resident still had the ulcer on the left hip and additionally, a Stage IV on the coccyx, a Stage III on the left scapula and a Stage II on the right thoracic area with drainage. The ulcers were all draining thick, cream colored odorous discharge. 3) The elbows had dry dressings and heel booties were in place which were not removed during the observation as the staff member stated these were preventative measures. The resident was quiet during the procedure but looked afraid and often winced as if in pain. 4) There was no documentation found that the facility was planning to modify the resident’s dietary plan. 5) Based on staff interview and review of the clinical record, the resident’s enteral feeding was noted to consist of one 240cc can of tube feeding formula per day in addition to 6 flushes. of 100cc each of water. A daily feeding of the product being utilized provided 240 calories and 15 grams of protein, much below the amount needed to sustain and assist in healing the resident. 6) A review of the clinical record failed to locate a _ care plan to address the nutritional needs of the resident. ) Clinical record review noted that the resident’s decubitus ulcers became larger, deeper and infected. Without adequate nutrition to assist in healing, the decubiti had gotten much worse. Resident #1 was admitted to the facility on September 4, 1998 with a diagnosis that included a Stage IV decubitus ulcer. 1) A review of the medical record of Resident #1 revealed that a physicians order for Pro Mod Powder (2 scoops mixed in juice twice per day), 20gm. protein as part of the nutritional therapy for healing the decubitus. 2) A review of the MAR revealed that the Pro Mod was not listed with the resident’s medications to ensure that the resident was being administered the 2 scoops of Pro Mod BID. Further review revealed that the Pro Mod was mixed in the dietary department and was being sent on the resident’s breakfast and lunch meal tray. 3) Meal observations conducted during the lunch meal on April 19, 1999 and breakfast on April 20, 1999 revealed that the resident did not drink the juice that the Pro Mod was mixed into. 4) An interview with the facility DON on April 20, 1999 revealed that there was no system in place to document that the physician order had not been followed nor was the attending physician ever notified that the resident was not receiving the Pro Mod. (c) Based on observation, record review and staff interview, it was determined that the facility violated Rule 59A-4.1288, F.A.C. and §400.022(1)(L), F.S., for failing to ensure that two residents in _ twenty in the sample received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. peepee eeepc wenppe ne 4D. Pursuant to 42 CFR §483.25(i)(1), the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident’s clinical condition demonstrates that this is not possible. This “requirement was not met as evidenced by the following observations: (1) Resident #3 appeared pale, frail and malnourished during the initial tour on April 19, 1999 at 9:00 a.m. (a) Review of the clinical record determined that the resident was admitted to the facility on December 15, 1998 from the inpatient hospice unit of a hospital. No documentation was found in the record to provide evidence of a care plan for nutritional needs.’ ws | 1) Staff, including the DON, floor nursé and hospice ' representative, reviewed the clinical record on April 19, 999 at 10:00 a.m. and determined that there was no care plan for nutrition in place for the resident. 2) According to the record, the resident was unable to tolerate intake of food or fluid by mouth and had been admitted with a PEG access for enteral feeding. 3) A review of the December 15, 1998 dietician’s assessment revealed that the resident’s admission weight was 81.8 lbs. or 77.9% of ideal body weight. The dietician’s assessment from January 1999 noted her weight to be 84.3 Ibs. or 80% of her ideal body weight. 4) The resident’s nutritional needs were assessed in January 1999 by the dietician and found to be 1441 calories per day, including 38-57 grams of protein. She began to receive her tube feeding at the rate of 60cc per hour to provide her with these needs. 5) This was reduced to 3 cans per day by gravity when - the family objected to the continuous feeding. A physician’s order dated February 16, 1999 decreased her feeding to one can per day, which provided 240 calories, including 15 grams of protein. 6) The facility and hospice staff members were interviewed at 9:30 a.m. in April 21, 1999 to determine what nutritional measures were being provided to promote healing of Resident #3’s multiple pressure sores and prevent the development of new ones. 7T) Staff members stated that feedings were at a low level because it was believed the larger amounts caused the resident respiratory congestion. Once the congestion . x stabilized, there is no documentation to show that increasing the feeding was considered. 8) ° Record review noted that the resident’s decubitus _ulcers were growing larger, deeper and infected. New ~ ulcers had developed since admission. The daily feeding | being provided is much below the amount needed to sustain and assist in healing the resident. on va 9) During the record review on April 21, 1999 at 9:00 a.m., it was noted that the resident had been placed on multiple vitamins, zinc, vitamin C and iron supplements on January 18, 1999 to promote the healing of the pressure ulcers. 10) The Medication Administration Record for February 1999 shows that all were discontinued on February 2, 1999. The physician’s order dated January 28, 1999 was to discontinue the zinc and vitamin C, but did not specify discontinuing the multi-vitamins and iron. 11) The DON reviewed the medical record on April 21, 1999 at 2:00 p.m. and noted that the order to discontinue the vitamin C and the zinc did not include discontinuance of the multi-vitamins and iron. 12) Resident #3 did not receive the supplements, as ordered, from February 2, 1999 up until the survey date of April 21, 1999. (b) Based on clinical record review and interview with staff, it was determined that the facility violated §400.022(1)(L), F.S. and Rule 59A-4,109(2), F.A.C., for failing to maintain the acceptable parameters of nutritional status for one resident out of the sample of twenty. Based on the foregoing, Pinehurst Rehabilitation &Specialty Care Center has violated the following: a. Tag 224 incorporates 42 CFR §483.13(c)(1)(), §400.022(1), @), _(k), & CL), Florida Statutes, and 59A-4.106(4)(x), Florida Administrative Code. ~b. ‘Tag 225 incorporates 42 CER §483.13(c)\(1)Gi) and Rule 59A- “© 4,106(4)(cc), Florida Administrative Code. C. Tag 314 incorporates 42 CFR §483.25(c), §400.022(1)Q), (kK), & (L), Florida Statutes and Rule 59A-4.1288, Florida Administrative Code. dd Tag 325 incorporates 42 CFR §483.25(i)(1), §400.022(1)(L), _F lorida Statutes and Rule 59A-4.109(2), Florida Administrative Code. ‘ \w le 6. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.23(8) and Section 400.102(1)(a)(d), Florida Statutes, and Rule 59A-4.1288, Florida Administrative Code, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of a Nursing Home. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel (at its expense), to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute material issues of fact in the request for a hearing, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the Agency for Health Care Administration, Attention: R.S. Power, Agency Clerk, Senior Attorney, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5403, All payment of fines should ‘be made by check, cashier’s check, or money order and payable to the Agency for Health Care Administration. All checks, cashier’s checks, and money orders should identity the AHCA number and facility name that is referenced . on page 1 of this complaint. All payment of fines should be sent to the Agency for 10 ed Ned Health Care Administration, Attention: Christine T. Messana, Staff Attorney, General Counsel’s Office, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5403. 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. Issued thisg/{< Tay of December, 1999. Patricia Feeney Supervisor, Area 10 Agency for Health Care Administration Health Quality Assurance 1400 W. Commercial Boulevard, Suite 135 Ft. Lauderdale, Florida 33309 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original complaint was sent by U.S. Mail, Return Receipt Requested, to: Administrator, Pinehurst Rehabilitation &Specialty Care Center, 2401 NE 2™ Street, Pompano Beach, Florida 33062 on this Xl Stay of December, 1999. Christine T. Messana, Esquire Office of the General Counsel Ik Ww Copies furnished to: Christine T. Messana Staff Attorney Agency for Health Care Administration (interoffice mail) Pete J. Buigas, Deputy Director Managed Care and Health Quality Agency for Health Care Administration (interoffice mail) Area 10 Office Jim Mitchell, Finance & Accounting 12 epee ape oer

Docket for Case No: 00-000049

Orders for Case No: 00-000049