Ld - ASIF Go b STATE OF FLORIDA a AGENCY FOR HEALTH CARE ADMINISTRATION - ar AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2002013331 Return Receipt Requested: 7000 1670 0011 4847 2963 7000 1670 0011 4847 2970 PINEHURST HEALTH CARE ASSOCIATES, 7000 1670 0011 4847 2987 LLC d/b/a SEAVIEW NURSING AND REHABILITATION CENTER, Vv. Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Pinehurst Health care Associates, LLC d/b/a Seaview Nursing and Rehabilitation Center (hereinafter “Seaview Nursing”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes, (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $25,000 and $6,000 survey fees pursuant to Sections 400.23(8) (a) and 400.19(3), Florida Statutes (2001), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes, (2001). 3. venue lies in Broward county, pursuant to Section Rule 28.106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Florida Statutes (2001), and Chapter 59A-4 Florida Administrative Code. 5. Seaview Nursing operates an 83-bed skilled nursing facility located at 2401 N. E. 2™ Street, Pompano Beach, Florida 33062. Seaview Nursing and Rehabilitation Center is licensed as a skilled nursing facility, license number SNF1441096; certificate number 8309, effective February 8, 2002 through November 30, 2002. Seaview Nursing and Rehabilitation Center was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I SEAVIEW NURSING AND REHABILITATION CENTER FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS. § 400.022(1) (1), FLORIDA STATUTES, RULE 59A-4.109(1) (c) (2), (3), FLORIDA ADMINISTRATIVE CODE AND TITLE 42, § 483.25(h) (2), CODE OF FEDERAL REGULATION AS INCORPORATED BY RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS I 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to Rule 59A-4,.1288, Florida Administrative Code, nursing homes such as Seaview Nursing, which participate in Title XVIII or Title- XIX, must follow certification rules and regulations found Title 42 Code of Federal Regulations, Chapter 483, including §483(25) (h) (2), which states: Accidents: The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 8. Seaview Nursing must also comply with chapter 400, Florida Statutes, including §400.022(1) (1), which states in pertinent part: (1) All licensees of nursing facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the Rule following: (1) The right to receive adequate and appropriate health care and protective and support services...” 9. Seaview Nursing is also required to comply with 59A-4.104(1) (c), (2), Florida Administrative Code, which requires that: (1) Each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of: (c) A complete, comprehensive, accurate and reproducible assessment of each resident's functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months thereafter. The assessment shail be: 1. Reviewed no less than once every 3 months. 2. Reviewed promptly after a significant change in the resident’s physical or mental condition. 3. Revised as appropriate to assure the continued accuracy of the assessment. (2) The facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well- being. The care plan must be completed within 7 days after completion of the resident assessment. I. Based on complaint investigation of February 6, 2002 through February 8, 2002 and on record review, staff interviews and observation it was determined the facility did not ensure the safety of 3 of 8 residents sampled by providing adequate supervision for residents with known special needs and those who are cognitively impaired with known elopement risk (Residents #3, #4, and #7). This noncompliance by the facility placed these residents and others at the facility at risk of serious injury, harm, impairment or death thus causing AHCA to cite the facility for a Class I violation pursuant to § 400.23(8) (a), Florida Statutes. The findings include: a. During review of Resident #7's clinical record on 02/06/02, it was revealed that this resident was admitted to the 2nd floor of the facility on 09/21/01 with the following diagnosis: Alzheimer's disease, alcoholic dementia, and orthostatic hypotension. The initial minimum data set (MDS) dated 09/28/01 revealed this resident had short term memory problems, displayed repetitive physical movements such as pacing, hand wringing, restlessness, fidgeting and picking, and was physically abusive and resistive to care. b. Review of nurse’s notes for resident #7 revealed a note dated 09/26/01 at 10:45 PM, which states: "needs constant supervision as resident tries to go through doors." A review of the plan of care revealed that the interdisciplinary team developed a care plan on 09/28/01 for risk of elopement related to pushing on exit doors. A review of the pertinent interventions for this care plan revealed that the facility was to evaluate the need for a wandering management program and check resident every hour to monitor whereabouts. Interview with the administrator and director of nursing (DON) on 02/06/02 at 3:45 PM revealed that the DON had never heard of a wandering management program and therefore could not produce any documentation of an evaluation for this program. Neither was there any documentation related to monitoring of the resident’s whereabouts. c. Continued review of the nurses notes for resident #7 revealed the following for 09/28/01: Resident is alert and confused and moves about haliway freely. In addition, a nurse’s note dated 12/02/01 at 11:02 PM states resident is alert and grossly confused out of bed to wheelchair and moving about hallways freely and aimlessly. Late afternoon patient kept riding up and down hallway banging on other residents and trying to push the alarm doors open. d. Review of the care plan for elopement revealed that no new approaches or interventions had been implemented following this incident of 12/02/01. Continued review of the record revealed a quarterly MDS was completed on 12/28/01, which indicated that this resident continues to have short-term memory problems, repetitive physical movements, and was physically abusive and resistive to care. In addition, the MDS identified a new behavioral symptom of wandering (with no rational purpose, seemingly oblivious to needs or safety). A review of the care plan relating to elopement performed on 01/03/02 by the interdisciplinary team as part of the quarterly assessment revealed that the facility still had _ the original interventions dated 09/28/01 in place with no revisions and no new approaches or interventions in place to protect this resident's safety and well-being. Additionally, Resident #7 had been found outside the facility on at least two occasions in December and the facility failed to document these two incidents and failed to take this into consideration for the Resident’s Care Plan issues. e. Surveyor review of the nurse’s notes following 12/02/01 revealed an entry on 01/09/02 at 8:10 PM, which states resident was: "propelling wheelchair by self along hallways. Came to nurses station and gave nurse a draw sheet then left. CNA came to nurses station asking where the (resident) was. CNA was told by nurse that resident just left and went down the hallway. Staff started to check rooms for resident. Staff went down to first floor to check for resident. While down stairs checking for resident, a family member notified nurse that resident was outside the facility. Resident was found lying on right side at bottom of stairs. Alert and responsive to name. Stated, "I fell from way up top," when asked what happened. Skin tears noted to left elbow and right forearm. Unable to move right arm. 911 called. Resident transported to... ER for evaluation.” £. Continued review of the nurse’s notes revealed an entry on 01/12/02, which stated that the hospital contacted the facility to inform them that resident #7 had expired. A review of the certificate of death revealed that the cause of death was determined to be complications of bilateral chronic subdural hematomas with a recent left subdural hematoma due to blunt head trauma. g. Staff interview on 02/06/02 at approximately 3:10 PM with the nurse and the CNA present on the date of the incident revealed that the CNA on duty at the time of the incident revealed that she had last seen resident #7 on 01/09/02 at approximately 7:30 PM when she gave the resident a snack in the dining room on the 2nd floor. Following the passing of the snack, the CNA stated she went to perform care on another resident and left resident #7 in the dining room. The CNA stated that when she completed caring for the other resident, she returned to the dining room and did not see resident #7. At this time she went to check with the nurse regarding the resident's whereabouts. The CNA indicated that she was very concerned as to the whereabouts of resident #7 as this resident was always attempting to leave the facility. The CNA and the nurse stated that they never heard a door alarm on the date of the incident. General observations revealed that the door that resident #7 probably used to exit the facility in his wheelchair was located next to the 2nd floor dining room where resident #7 was last seen by CNA. The door leads to a 19-steps exterior stairway. Resident #7 was found at the bottom of the stairs strapped to his wheelchair on 1/9/02. h. During a review of resident #4's clinical record on 02/08/02, it was revealed that this resident was admitted to the 2nd floor of the facility on 11/23/01 with the following pertinent diagnosis: malignancy of the cerebrum. A review of the nurses notes dated 11/26/01 revealed that this resident attempted to get through the fire exit. Continued review of the record revealed an initial MDS dated 12/04/01, which indicated that this resident has short term and long-term memory problems, displays repetitive physical movements, and resists care. A review of the care plan dated 12/06/01 revealed that this resident was identified as at risk for elopement due to wandering with no rational purpose. The pertinent interventions to assist in managing this problem include checking resident and monitoring whereabouts. Interview with the facility's care plan coordinator on 02/08/01 revealed that this resident needs to be reoriented on a continuous basis secondary to confusion resulting from brain cancer. The care plan coordinator stated that the resident asks to go to visit family. Continued interview revealed that the facility has no specific system in place to monitor the resident's whereabouts. i. Resident # 3, residing at the second floor of the facility on the day of survey was admitted on 11/15/00 with multiple diagnoses, which includes Alzheimer disease, other Organic Psychosis, and Neurotic Disorders. The Minimum Data Set (MDS) contained in the medical record, dated 11/22/01 at section E4 triggered the resident as having the behavior "wandering" and was described as having ‘occurred 1 to 3 days in last 7 days”. i. The resident had two (2) care plans (numbered #001 & #070) which references the resident's behavior of wandering and a care plan for the problem of elopement identifying the problem's onset as of 11/29/01. k. According to care plan #070 ("Resident comes to activities on a daily basis, but typically only participate for short intervals of time. He/She tends to wander in and out of activities. . @oes not usually respond to redirection to remain in the activity and have a seat, does not usually respond to redirection .. 10 1. On the MDS at section B4 the resident's cognitive status is coded a "2 " indicative of a moderately impaired cognitive status. Furthermore section BS identifies, the resident as having "periods of altered perception of awareness of surroundings." In addition this section also documents the resident as having mental function, which varies over the course of the day. m. Regarding the resident's ability to understand at section C6 of the MDS the resident is coded nov, which specifies, "ability to understand others: sometimes understands." n. Care plan #001 documents, "Mr. / Mrs. exhibits behavioral concerns such as wandering into other residents room and laying in their bed, disrobing while in hallway, resisting care at times and at times yelling at peers." Relevant approaches for care interventions to manage the resident's behavioral problem of wandering includes "redirect to safe & appropriate area as needed; Inform of procedures prior to doing them, allow time for responses." Based on the resident’s medical record, AHCA determined that this approach was largely ineffectual since the resident does not respond to redirection; has a cognitively impaired status which includes periods of “altered perception of awareness of surroundings” and lk varies during the course of the day. These characteristics render the resident’s ability to comprehend information regarding procedures and to be astutely aware of his/her environment, questionable. Oo. The care plan/approaches for care does not state/record specific care interventions to be provided to prevent risk for accidents to or involving this resident; to manage the resident's behavior of wandering, or to ensure the residents physical safety with specific monitoring/supervision plan to be implemented. Upon review it was observed, the care plan for the problem of elopement has an approach, "check resident to monitor whereabouts." The care plan/approach did not contain specifics or instruction addressing how, when or how frequently the resident is to be check and monitored. Furthermore the care plan did not incorporate the facility's procedural mandates regarding care of the resident who elopes. p. Additionally, resident #3's care plan did not provide effective care measures to ensure the resident's safety and supervision as follows. Care plan (#511 developed 05/29/01 most currently reviewed on 11/28/01 for risk for falls due to poor safety awareness, has the following approach: "staff to monitor and redirect resident as needed." There is no specificity documented regarding 12 how or when or how frequently the monitoring is to be conducted. On 02/08/02 the medical record did not contain any documentation to substantiate the implementation of monitoring or supervision. However it does contain nurses notes dated 01/27/02 recording an "incident of fall reported to family & MD...." Even though this care plan's approaches were not instrumental in preventing the resident's fall, there is no evidence to substantiate that the Interdisciplinary Team (IDT) met subsequent to the resident's fall of 01/27/02 to review the effectiveness of the care plan as it relates to adequately supervising the resident to assist in managing the resident's risk for falls. This observation was brought to the attention of the MDS Coordinator. q. on 02/06/02 and on 02/08/02 this resident was observed to be wandering unsupervised and unmonitored on repeated occasions in the facility. Furthermore on 02/06/02 & 02/08/02 staff informed surveyor(s) upon inquiry that Resident #3 continually attempts to elope/leave the facility. During an interview with a staff on 02/08/02 at 3:25 PM, the staff informed the surveyor that resident #3 attempted to leave the facility twice last night (02/07/02) from the second floor exits. A review of the facility's policy for resident elopement revealed the definition of: 13 "resident elopement is defined as that situation where a cognitively impaired resident with impaired safety judgment leaves the facility without staff knowledge." The policy requires staff to "document in the medical record as the situation progresses. Such documentation shall include date and time resident last seen, steps taken to find the resident, and parties notified." A review of the medical record revealed the medical record did not contain any documentation regarding the residents attempted elopements as reported to surveyor by staff. r. During interview with Management staff on 02/08/02 at 1:00 PM, it was requested of the Managers and MDS Coordinator present to locate and provide documentation in the medical record of the resident's elopement episodes. The personnel were unable to locate and or provide the requested information. Ss. On 02/08/02 at 11:00 AM two surveyors along with the facility's Director of Maintenance checked the operation mechanism of the exit doors on the second floor of the facility. It was observed and learned that when the bar handle on the exit door is touched there is a 3 second delay. Whether or not one continues to touch the handle, in 15 seconds the door locking mechanism releases and the door can be opened. As such the operative mechanism of the exit 14 door does not offer safety / security or assist in preventing the cognitively impaired resident, (Alzheimer’s) who in addition is a known elopement risk from leaving the unit. t. On 02/08/02 at 6:00 PM and 6:13 PM the cognitively impaired resident with Alzheimer’s disease (resident #3) was observed to be present, (unsupervised and unmonitored) by the door that had been found to not have safety/security to prevent residents from eloping (this is the same door that the Agency determined was the most likely exit point for Resident #7, on 01/09/02 where resident was found at the foot of the stairs lying on his side and subsequently passed away as a result of blunt trauma). u. As such on 02/08/02 this unsupervised/ unmonitored resident and two (2) other residents residing on the second floor, who have Alzheimer’s disease and wander, as well as 7 other cognitively impaired residents residing on the facility's second floor were potentially at risk for harm and/or death similar to that a death which occurred related to resident #7 on 01/09/02. The Agency determined based on the stated facts that the facility’s non-compliance had caused and was likely to cause serious injury, harm, impairment or death to a resident receiving 15 care in the facility. A Class I deficiencies require immediate correction pursuant to § 400.23(8) (a). FOLLOW-UP SURVEY OF 2/21/02 II. Based on observation, interview and record review, on 2/21/02 it was determined that the facility still did not ensure the safety of 1 of 8 residents sampled (Resident #7) by providing adequate supervision for a resident who is cognitively impaired and identified by the facility as at risk for elopement, did not provide care planning adequate to facilitate proper supervision of 3 of 8 residents in the revisit sample (Residents #s 1, 2 and 7) identified by the facility as being at risk for elopement and did not ensure that all exits were adequately locked and/or monitored to prevent elopement of any cognitively impaired resident. a. During interview with the Director of Nursing on 2/21/02 at 2:44 PM, it was determined that Resident #7 was found alone outside the nursing facility building near one of the facility exit doors at 11:00 am on 2/20/02. The area where the resident was found was outside the facility adjacent to a parking lot, which was not fenced in and allowed direct access to a street with vehicular traffic. At the time of the survey the Director of Nursing reported it was believed a staff member brought the resident outside and left him/her there. However, the Facility has been 16 unable to provide evidence to support that statement and the staff member denies vehemently having taking the resident outside the building. The certified nursing assistant assigned to monitor the door where the facility reported that resident #7 was found on 2/20/02, reported that on 2/21/02 at 3:02 P.M., she turned her head for a minute and the next thing was that someone said he/she (Resident #7) was outside the exit door. She stated the laundry cart was there between where she was sitting and the exit door so she was not in full view of the entire exit door. At 3:05 PM on 2/21/02, a surveyor was able to enter the unlocked door to the laundry room in close proximity to the monitored exit door and leave the building through one of the Jaundry room exit doors. During interview with the Administrator, Risk Manager, and Director of Nursing, at 3:39 PM on 2/21/02, they reported that the interior laundry room door is supposed to be locked at all times. b, on 2/21/02 at 5:35 PM, the laundry door was noted again to be unlocked. There were no staff members in the laundry room and therefore no one to monitor if a cognitively impaired resident had exited the building through these doors. This observation was in the presence of the Administrator and Chief Operating officer. 17 c. Review of the clinical record of Resident #7 revealed an admission date of 11/15/00 with diagnoses, which included Alzheimer's disease, other Organic Psychoses and Neurotic Disorders. Included in the Resident's clinical record is a care plan with a problem onset date of 11/29/01 with the latest revision date of 2/9/01 which addresses the following: "XXXX is at risk for elopement related to him/her wandering with out rational purpose, seemingly oblivious to safety needs." For resident #7 as well as resident #1 and resident #2, it was revealed upon record review of their care plans that the facility failed to facilitate supervision of these residents at risk for elopement by not developing and disseminating resident care plans with measurable goals and interventions which specify the type, frequency and duration of monitoring and supervision necessary to meet the needs of each of these residents in order to ensure their well being. d. Further review of the clinical record of Resident #7 revealed no documentation regarding the incident in which the Resident was found outside the building on 2/20/02. This was brought to the attention of the Administrator, Director of Nursing and Risk Manager at 3:47 PM on 2/21/02 who reported that their preliminary findings were that a staff member brought the resident out so it is not considered an elopement. However, they were unable to present evidence to substantiate the resident made it to the outside of the building with a staff member. 10. Based on the foregoing, Seaview Nursing and Rehabilitation Center is in violation of Section 400.022(1) (1) Florida Statutes, Rule 59A-4.109(1) and Title 42, Section 483.15 (BE) (1), Code of Federal Regulation, as incorporated by Rule 59A-4.1288, Fla. Admin. Code, classified as a Class I deficiency pursuant to §400.23(8) (a), which carries in this case, an administrative fine of $12,500. COUNT II SEAVIEW NURSING FAILED TO ADEQUATELY IMPLEMENT POLICIES AND PROCEDURES FOR INVESTIGATING, PREVENTING, AND REPORTING ALLEGATIONS OF POSSIBLE NEGLECT. § 400.022(1) (1), FLORIDA STATUTES TITLE 42, § 483.13(c), CODE OF FEDERAL REGULATIONS, AS INCORPORATED BY RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (STAFF TREATMENT OF RESIDENTS) CLASS I 11. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 12. Because Seaview Nursing participates in Title XVIII or Title XIX, it must follow certification rules and 19 regulations found in Title 42 Code of Federal Regulations, Chapter 483 including § 483.13(c), which provides: Staff treatment of residents. The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 13. Seaview Nursing and Rehabilitation must also comply with Chapter 400, Florida Statutes including, §400.022(1) (1) which provides in pertinent part: (1) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facility and shall treat such residents in accordance with the provisions of that statement.. (1) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available planned recreational activities and therapeutic and rehabilitative services consistent with the resident care plan... I. During a complaint investigation on February 6-8, 2002, personnel from AHCA determined that there was deficient practice at Seaview Nursing, which constituted a Class I violation, pursuant to § 400.23(8) (a) requiring immediate corrective action. The violation was alleged as non-compliance with §483.13(c), Code of Federal Regulations and § 400.022(1) (1), Florida Statutes. It was determined that the situation in question had caused and/or was likely to cause serious injury, harm, impairment, or death to a 20 resident(s) receiving care in the facility. a. Based on record review and interview, AHCA determined that the facility did not adequately implement written policies and procedures. The alleged areas of violation were regarding (1) investigation, (2) corrective action, (3) prevention and reporting of alleged violations involving neglect and by failing to provide adequate and appropriate health care and protective and support services for 1 of 8 sampled residents (Resident #7). b. Review of Resident #7's clinical record on 02/06/02, revealed the resident was admitted to the 2nd floor of the facility on 09/21/01 with the following diagnosis: Alzheimer disease, alcoholic dementia, and orthostatic hypotension. Cc. A review of the nurse’s notes dated 01/09/02 at 8:10 PM revealed the following: This resident was noted propelling wheelchair by self along hallways. The resident came to the nurse’s station and gave nurse a draw sheet then left. A Certified Nurses Assistant (CNA) came to the nurses station asking where resident was. The CNA was told that resident just left and went down the hallway. Staff started to check rooms for resident. Staff went down to first floor to check for resident. While down stairs checking for resident, a family member notified nurse that resident was outside the facility. Resident was found lying on right side at bottom of stairs. 911 was called and resident was transported to the emergency room for evaluation. 21 d. Continued review of the nurses’ notes revealed an entry on 01/12/02, which stated that the hospital called to inform the facility that resident #7 had expired. Cause of death on Resident 7's death certificate was complications of bilateral chronic subdural hematomas with a recent left subdural hematoma due to blunt head trauma. e. It was determined that Resident 7 could have exited the facility by the South East door on the second floor since he was found strapped in his wheelchair at the bottom of the stairs. f. The facility's policy and procedure for resident elopement dated 08/30/99 revealed that in order to prevent resident elopement the facility would test door alarms on each shift once per month. Interview with the administrator and maintenance director on 02/08/02 at approximately 11:00 AM revealed that testing to determine if the alarms were audible enough had never been done. The alarms were being tested but only to determine if the keypads were working. On 2/08/02, the second floor Southeast fire exit door’s alarm was not audible enough to be heard at the nurse’s station. The alarm could not be heard past the dining room, which is approximately 57 steps and around a corner from the nurse’s station. 22 g. A review of the facility's policies and procedures regarding investigation and reporting of alleged violations of federal or state laws involving neglect revealed the following components of the policy were not implemented: investigation, corrective action, and reporting. Specifically, the facility's policy requires the investigation to include interviews of associates, visitors or residents who may have knowledge of the alleged incident. Interview with the director of nursing on 02/06/02 at 3:45 PM and a record review of the facility's verification of investigation revealed that the only individual interviewed was the nurse assigned to the resident. The facility had no documentation or other such evidence to substantiate that they had interviewed additional staff members, the family member who located the resident, or any residents for possible knowledge of the alleged incident. h. The facility's policy requires that the medical record be reviewed to determine the resident's past history and condition as to its relevance to the alleged violation as part of the investigation. A review of the facility's verification of investigation revealed that the medical record review did not include any information relating to the resident's condition or diagnosis of Alzheimer's 23 disease and did not include any information relating to the resident's care plan for elopement and history of two documented attempts to push open exit doors on 09/26/01 and 12/02/01. i. In addition, the facility did not implement their policy and procedure for corrective action, which requires the facility to take appropriate steps to prevent recurrence of the incident. A review of the verification of investigation revealed the facility's only step toward corrective action was to readjust the door alarm to buzz in the hallway. Although the incident occurred on 1/09/02, on 2/8/02, when the Agency’s personnel tested the alarm door it was discovered that the alarm was not audible enough to be heard at the Nurse’s” station. Additionally, the facility did not identify any other residents who may be at risk for a similar incident and take any precautionary steps to provide additional supervision for such residents. The surveyor noted other residents on the second floor with cognitive impairment, some of whom wander. Also, the facility failed to take corrective action after Resident #7 had been found outside the facility, alone and unsupervised on two occasions in December 2001 thereby placing all the residents at risk of serious harm or death. 24 j- Further investigation and interview with the facility's administrator and director of nursing on 02/06/02 at 3:45 PM revealed that the facility had not reported this incident to adult protective services/the abuse hotline. A review of the facility's policy and procedure revealed that the executive director or his designee would report the results of all investigations to the appropriate state agency as required by state law within 5 working days. A Class I deficiency requires immediate correction pursuant to §400.23(8) (a). FOLLOW-UP VISIT OF 2/21/02 II. Based on observation, interview and record review conducted on 2/21/02 it was determined that the facility had not implemented and/or operationalized policies and procedures to ensure the protection of at-risk cognitively impaired residents. One of eight sampled residents (resident #7) had been discovered alone and unsupervised outside the facility on 2/20/02. a. The Director of Nursing reported to surveyors that on 2/20/02 Resident #7 was found outside the nursing facility building in an area that is adjacent to a street with access to vehicular traffic. b. The certified nursing assistant assigned to monitor the exit near where Resident #7 was found on 25 2/20/02 was interviewed at 3:02 PM on 2/21/02, She reported a laundry cart partially obscured her view of the exit door. c. On 2/21/02 a member of the survey team was twice able to exit the first floor of the building through an unlocked door, which is in proximity to the monitored exit door. During interview with the Administrator, Risk Manager and Director of Nursing at 3:39 PM on 2/21/02, they reported that the interior laundry room door is supposed to be locked at all times. On this day the doors were twice found unlocked. d. Resident #7’s was admitted to the facility on 11/15/00 with a diagnosis, which included Alzheimer’s disease, other Organic Psychoses and Neurotic Disorders. The Resident’s care Plan included problem identification dated 11/29/01, revised on 2/9/02 which reads as follows: “XXXX is at risk for elopement related to him/her wondering without rational purpose, seemingly oblivious to safety needs.” The record did not contain any reference to Resident #7 being found outside the facility on 2/20/02. On 2/21/02 at 5:35pm this surveyor observed that the laundry door was again unlocked and there were no staff members available within the4 laundry room to monitor at- risk residents with the potential to elope through these 26 doors. This observation was made in the company of the Administrator and Chief Operating Officer. 14. Based on the foregoing, Seaview Nursing violated §400.022(1) (1), Florida Statutes and § 483.13{(c) Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code herein classified as a Class I violation pursuant to §400.23(8) (a) which carries, in this case, an assessed fine of $12,500. COUNT III SURVEY FEE § 400.19, Florida Statutes 15. § 400.19, Florida Statutes (2001), provides that a survey shall be conducted every 6 months for the next two year period when the facility has been cited for a class I deficiency and that in addition to any other fees or fines the agency shall assess a fine of $6,000, one half to be paid at the completion of each survey. Based on the Class I deficiencies identified on Count I and II of this complaint, the Agency is hereby assessing a fine of $6,000 against Seaview Nursing. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the 27 following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Seaview Nursing and Rehabilitation Center on Counts I through III. 2. Assess against Seaview Nursing and Rehabilitation Center an administrative fine of $25,000 on Counts I through II for the above-captioned violations. 3. Assess against Seaview Nursing and Rehabilitation Center a survey fee of $6000 pursuant to Section 400.19, Florida Statutes. 4, Assess against Seaview Nursing and Rehabilitation Center a total of amount of $31,000 [$25,000 in administrative fines + $6000 in survey fee). 5. Grant such other relief as the court deems is just and proper on Counts I through III. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, 28 First Floor, 8355 N. W. 53rd Street, Miami, Florida, 33166; Attn: Alba M. Rodriguez. 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. ‘ Q Alba M. 1 Wp.Lh Assistant General Counsel Agency for Health Care Administration 8355 N. W. 53 Street Miami, Florida 33166 Dated the far “of June, 2002 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive West Palm Beach, Florida 33407 (U.S. Mail) 29 Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE Seta NE RV SCE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Everton M. Spencer, Administrator, Seaview Nursing and Rehabilitation Center, 2401 N.E. 2 Street, Pompano Beach, Florida 33062; Pinehurst Health Care Associates, LLC, One Professional Center, One N. E. First Avenue, Suite 302, Ocala, Florida 33470; CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on this /2day of June, 2002. me” a dei oien Q 6 30 Ze) STATE OF FLORIDA Dn ey AGENCY FOR HEALTH CARE ADMINISTRATION <2.” Ae RE: PINEHURST HEALTH CARE ASSOCIATES, LLC AHCA No.: di/bla SEAVIEW NURSING AND REHABILITATION CENTER ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT PLEASE SELECT ONLY 4 OF THE 3 OPTIONS An Explanation of Rights is attached, OPTION ONE (1) 6 ! do not dispute the allegations of fact contained in the Administrative Complaint and waive my right to object or to be heard. | understand that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) 6 ! do not dispute and | admit the allegations of fact in the Administrative Complaint, but do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penaity imposed. OPTION THREE (3) 0 Ido dispute the allegations of fact contained in the Administrative Complaint and request a formal hearing, pursuant to Section 120. 57(1), Florida Statutes, before an Administrative Law If you choose OPTION THREE (3), in order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to any hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. lf you have elected either OPTION TWO (2) of THREE (3) above and you are interested in discussing a settlement of this matter with the Agency, please also mark this block. 0 Mediation under Section 120.573, Florida Statutes, is not available in this matter. SEND NO PAYMENT NOW ~— REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (Please sign and fill in your current address. ) Respondent (Licensee) Address: License. No. and facility type: Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: Alba M. Rodriguez, Assistant General Counsel, Agency for Health Care Administration, 8355 N. W. 53 Street, Miami, Florida 33166, STATE OF FLORIDA (To be used with Election of Rights for Administrative Complaint form — attached) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (“AHCA” or “Agency’), you must make one of the following elections within twenty- one (21) days from the date of receipt of the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If you do nat dispute the allegations in the Administrative Complaint and waive your right to be heard, you should select OPTION 1 on the election of tights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Complaint. You will be provided a copy of the final order. OPTION 2. If you da not dispute any material fact alleged in the Administrative Complaint (you admit each of them), you may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, you should select OPTION 2 on the Election of Rights form. OPTION 3. If you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to a hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty- one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint.

Docket for Case No: 02-002899

Orders for Case No: 02-002899