CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0439 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, @ , a: , Ww Petitioner, 0 4 ; OF 4 og. a Oy vs. of Y ‘a % ENGLEWOOD HEALTH CARE ASSOCIATES, LLC, © d/b/a ENGLEWOOD HEALTHCARE AND eo REHABILITATION CENTER Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against ENGLEWOOD HEALTH CARE ASSOCIATES, LLC, d/b/a ENGLEWOOD HEALTHCARE AND REHABILITATION CENTER (hereinafter “Respondent”). This amended complaint replaces the administrative complaint of AHCA number 200246867 sent by certified mail number 7106 4575 1294 2050 0866 on December 30, 2002. AHCA alleges: and alleges: NATURE OF THE ACTION 1) This is an action to impose a conditional licensure status effective July 26, 2002 through August 26, 2002 pursuant to §§ 400.23(7)(b) and 400.23(8), Fla. Stat. AHCA seeks to impose a Conditional Licensure Status effective based upon one Class I deficiency as defined by § 400.23(8) Fla. Stat. 2) The Respondent was cited for the deficiencies set forth below as a result of a complaint survey conducted on or about July 24 - 26, 2002. JURISDICTION Page 1 of 9 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0439 3) The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4) Venue lies in Charlotte County, Division of Administrative Hearings, pursuant to Section 120,57 Florida Statutes, and Florida Administrative Code Rule28-106.207. PARTIES 5) AHCA is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. 6) Respondent is a skilled nursing facility located at 1111 Drury Lane, Englewood, Florida 34224. The facility is licensed under Chapter 400, Part IJ, Florida Statutes and Chapter 59A-4, Florida Administrative Code. Its license number is 1144096] effective through 11/30/2003. COUNT I THE FACILITY FAILED TO ENSURE THE SAFETY OF THREE (3) OF ELEVEN (11) RESIDENTS WHO SMOKE. 400.022, 400.102(1), 400.121(1), and 400.23(8)(b), FLA. ADMIN. CODE R. 59A- 4.1288 (INCORPORATING BY REFERENCE 42 CFR § 483.13 CLASS I DEFICIENCY 7) AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8) Based on observation, clinical record review, and interviews with residents, visitors and facility staff and review of the facility's policy and procedures, the facility failed to provide services necessary to ensure the safety of 3 of 11 residents who smoke (Residents #4, #6 and #7). This is evidenced by: 1) Failure to reassess the ability to safely smoke cigarettes for Resident #4 resulting in a burn to the thumb, burns on leg braces and burn holes in clothing. 2) Failure to assess the ability to safely smoke cigarettes for Resident #6 resulting in burn holes in clothing. 3) Failure to assess the safety issue of a cognitively impaired Resident #7 who smokes cigarettes, resulting in burn holes to residents clothing. 4) Failure of facility staff to intervene and assist residents (as necessary) who have become a danger to themselves as evidenced by observations of the facility staff aware of the residents with bum holes in clothing (confirmed in nursing notes and staff interviews). 5) Failure to follow facility policy and procedure in regards to resident smoking assessments. 9) The facility's neglect of these residents has caused a situation that could, if not immediately corrected, cause Immediate Jeopardy with great harm or death to these residents. 10) The findings include the following: a) Resident #4 was originally admitted to the facility on 10/16/01 with a primary diagnosis of Friedreich's Ataxia, an inherited, progressive disease of the nervous system affecting balance, coordination, movement and sensation. Speech and swallowing difficulties may occur as well, and the resident may exhibit slurred, halting speech with noted volume loss. Freidreich's Ataxia causes cardiac disease in most patients and Resident #4 is recovering from a MI (myocardial infarction - heart attack) and has a history of angina, congestive heart failure and hypertension. Page 2 of 9 b) c) qd) e) 8) h) D k) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0439 The resident is in contact isolation for an upper respiratory infection, which is positive for MRSA (Methicillin Resistant Staph Aureus). The staff has required the resident to wear a mask whenever he/she leaves the room. Friedreich's Ataxia does not affect cognition and this is confirmed by the admission MDS (Minimum Data Set) dated 6/24/02 (post MI) where it is noted the 42 year-old resident has a cognition of “0” - Independent - decisions consistent/reasonable. The resident is on approximately 24 different daily medications. The following are related to the Friedreich’s Ataxia. i) Neurontin 800 mg. po (per mouth) at bedtime. ii) Neurontin 600 mg. at 9:00 A.M. and 1:00 P.M. ili) Remeron 45 mg. po bedtime. iv) Klonopin 2 mg. po bedtime. v) Klonopin 1 mg. at 9:00 A.M. and 1:00 P.M. vi) Baclofen 20 mg. po at 9:00 A.M. - 5:00 P.M. - 9:00 P.M. vii) Valium suppository 10 mg. every 12 hours as need for severe muscle spasms up to 5 times per week. viii) Prozac 20 mg. po daily. ix) Lortab 10 mg. 1] tablet for moderate pain - 2 tablets for severe pain every 4 hours as needed. x) OxyContin 40 mg. po twice a day. xi) Ativan 1 mg. po every 8 hours as needed. All of the above medications have noted central nervous system side effects including drowsiness and decreased reaction time. On 7/24/02 at approximately 10:30 A.M., the resident was observed smoking in the courtyard of the facility. The resident was holding the cigarette in the right hand. The resident's posture was noted to be leaning to the right and bent forward. The resident's hand would move slowly to the mouth with a slightly spastic motion. The surveyor approached the resident for an interview. At this time the surveyor noted the resident was wearing bilateral lower leg braces. Braces were held in place with Velcro straps at the upper ankle area and directly below the knees. The surveyor noted a bur on the Velcro strap of the right brace above the ankle. There were ashes scattered all over the resident's shirt, shorts and shoes. The resident stated, in a slow, halting, slurred, low volume voice, that he/she was aware of the burned strap and it had just happened when an ash from another cigarette fell on it. The resident stated he/she did know if his/her leg was burned because sensation has diminished in the legs. The surveyor then approached the Unit Manager and told her about the burn mark. The Unit Manager acknowledged the need for a skin assessment of the leg. Review of the resident clinical record revealed the resident had a smoking evaluation completed on 6/11/02. The resident was assessed as able to smoke independently. A care plan dated 6/21/02 reads, "Monitor for changes in status that would result in non safety awareness." On 6/30/02, a nurse writes, "...Resident observed on lanai area driving into tables and chairs, when re-directed resident became very defensive. Resident - appears? (unable to fully read word) to be experiencing loss of motor control @ (at) this X (time). M.D. not notified today - will continue to monitor and observe and will report observations to Dr. ----- a On 7/1/02, a nurse writes, "Resident requested 2 Lortab 10 mg. @ 9 AM - had received 1 Lortab @ 6 AM. Resident waited until 10 AM to receive med (Medication). ------- (Resident's name) usual demeanor was changed. Became increasingly uncoordinated.” On 7/4/02, a nurses note reads, "... A resident reported to me (Resident) bumped 2 residents on the lanai, episodes unwitnessed. At 12:30 PM, I saw (Resident), and smelled something burning. I discovered a "bib” on the floor of her cart - the bib was buming - the bib was burnt from a Page 3 of 9 D CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0439 cigarette, I've requested that staff accompany resident when he/she wants to smoke. Will report to unit manager and risk manager." Review of the care plan does not reflect any of the above actions were taken. m) On 7/25/02 at approximately 10:25 A.M., the surveyor observed the resident smoking in the n) 0) P) q) r) 8) t) u) v) courtyard. The resident had the mask used for isolation hanging from the left ear. The mask was covering 1/2 of the resident's cheek and mouth. The resident was holding a lit ci garette that was almost burned down to the filter. The resident's posture was such that he/she was listing over to the right and leaning forward. The resident was noted to slowly lower the cigarette towards the direction of the ashtray. However, before the resident could reach the ashtray, the resident was noted to be slowly slumping to the right and dosing off. The resident would suddenly awake and try to raise the cigarette to his/her mouth. At this time, staff went out to assist the resident. On 7/25/02 at approximately 10:50 A.M., the surveyor interviewed both the Risk Manager and the Unit Manager. Neither staff person was aware of the incident with bumt bib. The surveyor requested the facility's accident and incident log. The log did not reflect this incident. The surveyor requested to speak with the nurse who wrote the note to ascertain if the fire was inside or outside of the building and whether an incident report was filled out, The staff nurse was not working and was not able to be reached by telephone. Review of the plan of care lacks any documentation the resident now needed supervision to smoke. Interview with the facility's DON on 7/30/02 at approximately 9:10 A.M., revealed she was unable to locate the nurse who had written the note regarding the bumt bib on 7/4/02. The DON made several phone calls and was unable to reach the nurse. The nurse does not have an answering machine and the DON was unable to leave a message. The nurse has not worked her shifts (called off from work). The DON gave the surveyor the nurses phone number. Due to the unavailability of the nurse for interview during the survey from 7/24/02 to 7/26/02, contact was made by telephone on 7/30/02 at approximately 9:15 A.M., with the nurse who wrote the note dated 7/4/02. During the interview, the nurse stated the resident was outside in an electric wheelchair. The nurse stated she smelled something burning and found a cigarette burning in a clothing protector (bib). The nurse then took the clothing protector and poured water on it and threw it away. The nurse stated, "He/She drops things all the time." On 7/13/02, a nurses note reads, "Non-Compliant with resp. (Respiratory) precautions. ...When precautions are discussed with resident, resident denies staff has observed all behaviors. Decreased coordination. ... Has been accepted by hospice." A weekly/monthly summary report dated 7/17/02 reads, "Decisions poor; cues/supervisor needed." Nurses note 7/21/02 reads, "12 AM complains of severe muscle spasms and requested Valium. ..2 AM good effect from diastat. No further muscle spasms noted." On 7/24/02 between the times of 3:35 P.M. and 3:40 P.M., an interview was held with a CNA (Certified Nursing Assistants) who has direct contact with Resident #4. Interview with the CNA revealed she noted burn holes mainly in the resident's shorts approximately 2 months ago. w) On 7/25/02 a group interview was held with the DON (Director of Nursing), Administrator, x) y) 2) facility Nurse Consultant, Risk Manager, Social Workers, and Unit Manager. The Risk Manager began employment at the facility May 15, 2002. She has been trending falls. She is responsible for logging accidents and incidents. She was unaware of the problems staff has been having with Resident #4 in regards to the smoking incidents. Interview with DON reveals a CNA does not fill out an incident report. The CNA must go to the nurse. The Social Workers stated they are responsible for conducting the smoking evaluations along with nursing services. Page 4 of 9 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0439 aa) The Unit Manager stated she was not aware of the "burned bib" incident. When asked if she was aware of the burns in the clothing, she stated, "yes.". When asked how she knew about the burned clothing she stated she noted it herself, especially on the shirts. When asked what she did about this she replied she instructed the resident to change the shirt. The Unit Manager stated the resident told her ashes had fallen on the shirt. The surveyor asked if the facility carried smoking aprons. The Unit Manager stated aprons are available but she had not offered one to the resident. bb) The surveyor then asked the Unit Manager if she noted any change or decline in the resident's ability or cognition. The Unit Manager gave the following information. Over the past 3 months she has noted an escalation of behaviors. The resident has had increased incidents of choking. The resident is refusing a change in consistency of diet or fluid. The Unit Manager has noted more limitations in function. cc) At this time the surveyor requested the Unit Manager to ask the resident if a skin assessment could be conducted in the presence of the surveyor. The resident agreed. dd) On 7/25/02 at approximately 11:25 A.M., the surveyor was called to Resident #4's room. The resident was being assisted to bed by 2 staff members using a Hoyer lift. The resident was placed into bed and the leg braces removed. There were no visible burn marks to the legs. The resident stated he/she had burned the left thumb and showed the surveyor and facility staff, a healed area on the anterior left thumb, The resident stated it was a burn that was sustained outside while the resident was trying to light a cigarette. The resident stated he/she went to the nurses station to get a Band-Aid but the nurse told the resident the area did not need one. The surveyor then noted scorch marks and ashes scattered over the lower part of the resident's shirt. The resident stated a lot of his/her clothes are burned from ashes. With the resident's permission the surveyor and staff nurse looked through the residents closet. Several pieces of clothing, randomly picked, proved to have multiple round and oblong holes. The surveyor asked the resident if any one had offered the use of a smoking apron. The resident stated, "no." The surveyor then asked the resident if she had any objection to the use of an apron and the resident stated, "No. I'm tired of burning my clothes." ee) At 11:40 A.M., the surveyor asked the Social Workers for a list of all residents who smoke in the facility. ff) The surveyor also requested the DON to contact the staff nurse who did the skin assessment for the burned strap on 7/24/02 and the staff nurse who charted the burnt bib incident. gg) At approximately 1:10 P.M., the surveyor spoke with the nurse who did the skin assessment on 7/24/02. The nurse stated no burned area was found. When asked if he wrote an incident report for the burned brace he said no. The nurse stated the CNA actually took off the braces and he did not see the burn mark. The surveyor did not find any documentation the burned brace was treated as an incident. The surveyor asked the nurse if he noticed any other resident's who may have burned clothing from cigarette, The nurse gave the resident's name and the surveyor added this resident to the extended survey (Resident #7). hh) Resident #6 was admitted to the facility on 10/17/01 with multiple diagnoses including but not limited to Diabetes and Cerebral Vascular Accident. ii) On 7/25/02 at approximately 2:00 P.M., the surveyor observed the resident sitting in the courtyard smoking a cigarette with Resident #2. A staff person was present. The surveyor noted ashes present on the resident's shirt front and shorts. The surveyor asked the resident if he/she had trouble with burn holes in clothes from cigarettes. The resident stated a lot of his/her clothes had burn holes. The staff member stated that at one time the resident used a smoking apron but it was too heavy and the resident stopped using it. Jj) Review of the MDS dated 7/3/02, reveals the resident's cognition to be 1 - Modified independence - some difficulty in new situations only. The section B. 5 Indicators of delirium - periodic disordered thinking and awareness - a = 1 Easily distracted - (e.g. difficulty paying attention: gets sidetracked). Page 5 of 9 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0439 kk) A smoking evaluation dated 6/21/02, revealed the resident has mild confusing and can smoke safely with supervision. ll) A care plan for smoking is dated 7/24/02 and address policy and procedure only. An updated problems and approach page is dated 7/25/02. Problem has been identified as decreased motor skills -resident is dropping ashes on clothes. Resident is now to be within eyesight of staff when smoking. mm) With the resident's permission and with the facility's Nurse Consultant in attendance the surveyor removed a t-shirt form the resident's closet. The t-shirt had approximately five burn holes in it. nn)3. Resident #7 was admitted to the facility on 6/17/02 with multiple diagnoses including but not limited to Schizophrenia and Organic Brain Syndrome. 00) Review of the MDS dated 7/10/02, reveals the resident's cognition to be 2- Moderately impaired - decisions poor; cues/supervision required. pp) A review of the resident's clinical record reveals a smoking evaluation and care plan were not conducted or completed until 7/25/02. Computer printout 8:12 A.M. The hand written smoking evaluation reads the last care plan date was 7/2/02. The smoking evaluation is signed as of 7/25/02. The evaluation reads resident has moderate confusion and is not able to call for help if a cigarette or ash falls on his/her person. It continues with the resident being unable to use fire safely and has a history of burned clothes. The resident has a tendency to enter the facility with a lit cigarette. Facility staff must store, assist and supervise resident when smoking. It concludes with the resident being instructed in the facility's smoking policy but the resident does not understand. qq) At approximately 4:30 P.M., the surveyor with the facility's Nurse Consultant went to find this resident. The resident was found in the enclosed lanai area in the courtyard. The resident had a lit cigarette. The resident had obvious burn holes in the crotch of the pants and burn holes to the right pant leg. There was no staff in attendance. tr) Review of the facility's policy and procedures for smoking assessment include: i) Assessment on admission and quarterly. ii) Once the assessment is completed the interventions that are appropriate will be care planned and implemented. iii) The facility failed to provide care and services necessary to ensure the safety of 3 of 11 residents who smoke. 11) Based upon the foregoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which required the Respondent to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property, including physical abuse. That mule incorporates by reference 42 CFR § 483.13(c). 12) The foregoing also constitutes a violation of § 400.022, Fla. Stat., which requires the Respondent to ensure the residents’ right to receive adequate and appropriate health care and protective and support services. Page 6 of 9 CERTIFIED ARTICLE NUMBER 7108 4575 1294 2050 0439 13) The foregoing also constitutes an intentional or negligent act materially affecting the health or safety of residents of the facility as defined by § 400.102 (1)(a), Fla. Stat. and is subject to a fine under § 400.121 Fla. Stat. 14) The foregoing constitutes a Class I deficiency as defined by § 400.23(8)(a) Fla. Stat. as follows: A class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. 15) The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which imposition of a conditional license is authorized pursuant to § 400.102(1)(d), and 400.23(7)(b) Fla. Stat. 16) Section 400.19(3) states in relevant part: The agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licensee with statutes, and with rules promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and rights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class I deficiency, has been cited for two or more class II deficiencies arising from separate surveys or investigations within a 60-day period, or has had three or more substantiated complaints within a 6- month period, each resulting in at least one class I or class II deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be $6,000, one- half to be paid at the completion of each survey. The agency may adjust this fine by the change in the Consumer Price Index, based on the 12 months immediately preceding the increase, to cover the cost of the additional surveys. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of AHCA on Count I, Page 7 of 9 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0439 B. Uphold the issuance of the conditional license attached hereto as Exhibit “A”. EXHIBIT LIST Exhibit “A” CONDITIONAL LICENSE License #SNF 11440961; Certificate 9501 Effective Date: 07/26/2002 Expiration Date: 8/26/2002 DISPLAY OF LICENSE Pursuant to §§ 400.062(5) and 400.23(7)(e), Fla. Stat., Respondent shall post its current license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Joanna Daniels, Assistant General Counsel, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, FL 32308. 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. Respectfully submitted, aoe A, 4 Ee } EE Zee. Joanna Daniels FL Bar #0118321 Assistant General Counsel Agency for Health Care Administration 2727 Mahan Dr., MS #3 Tallahassee, FL 32301 (850) 922-5873 Fax (850) 413-9313 Page 8 of 9 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0439 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Administrator, Englewood Healthcare and Rehabilitation Center, 1111 1 TA, 2003. 7106 4575 1294 2050 0439 on January Copies furnished to: Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 (Interoffice Mail) JD/ghm rury Lane, Englewood Florida 34224 Return Receipt No. na Daniels “Assistant General Counsel Joanna Daniels Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, FL, 32308 (Interoffice Mail) Page 9 of 9

Docket for Case No: 03-000193

Orders for Case No: 03-000193