vs. ) Case No. 04-0998
) AYINTOVE ASSOCIATES, LLC, d/b/a ) HARMONY HEALTH CENTER, f/k/a ) INTEGRATED HEALTH SERVICES AT ) GREENBRIAR, )
Respondent. )
Pursuant to notice, a final hearing was held in this case on October 20, 2004, in Miami, Florida, before Errol H. Powell, a designated Administrative Law Judge of the Division of
Administrative Hearings.
For Petitioner: Nelson E. Rodney, Esquire
For Respondent: Theodore E. Mack, Esquire
The issue for determination is whether Respondent committed the offenses set forth in the Amended Administrative Complaint and, if so, what action should be taken.
The Agency for Health Care Administration (AHCA) issued a four-count Administrative Complaint against Ayintove Associates, LLC, d/b/a Harmony Health Center, f/k/a Integrated Health Services at Greenbriar (Harmony Health Center) on February 9, 2004, for violations of Chapter 400, Florida Statutes (2003), and Florida Administrative Code Rule 59A-4.1288, imposing administrative fines totaling $35,000, a survey fee of $6,000, and a conditional license. Harmony Health Center disputed the material allegations of fact and filed a Petition for Formal Administrative Hearing. On March 18, 2004, this matter was referred to the Division of Administrative Hearings.
A final hearing in this matter was scheduled. A continuance of the hearing was granted, and the hearing was rescheduled. Subsequent thereto, AHCA was granted leave to file an Amended Administrative Complaint. AHCA filed a two-count Amended Administrative Complaint against Harmony Health Care: Count I--charging a failure to ensure that a resident entering the facility without a pressure sore does not develop one in violation of Title 42, Section 483.25(c), Code of Federal
Regulations, as incorporated by Florida Administrative Code Rule 59A-4.1288, classified as an isolated Class II deficiency pursuant to Section 400.23(8), Florida Statutes (2003); and Count II-- a failure to implement measures to protect one sampled resident from ongoing falls, resulting in actual harm to the resident, in violation of Title 42, Section 483.25(h)(2), Code of Federal Regulations, as incorporated by Florida Administrative Code Rule 59A-4.1288, classified as an isolated Class II deficiency pursuant to Section 400.23(8), Florida Statutes (2003), which gives rise to a conditional license pursuant to Section 400.23(7)(b), Florida Statutes (2003). As a result of the violations alleged in the Amended Administrative Complaint, AHCA seeks to impose an administrative fine of $5,000 ($2,500 for each count) and a conditional license upon Harmony Health Center. After the filing of the Amended Administrative Complaint, another continuance was granted and the final hearing was rescheduled.
Prior to hearing, the parties filed a Joint Prehearing Stipulation. At hearing, AHCA presented the testimony of two witnesses and entered 16 exhibits (Petitioner’s Exhibits numbered 1 through 16) into evidence. Harmony presented the testimony of two witnesses and entered one exhibit (Respondent's Exhibit numbered 1) into evidence, which was deposition testimony. The undersigned took official recognition of AHCA's
request for admissions and Harmony Health Center's amended response to the request for admissions.
A transcript of the hearing was ordered. At the request of the parties, the time for filing post-hearing submissions was set for more than ten days following the filing of the transcript. The Transcript, consisting of one volume, was filed on November 17, 2004. The parties requested and were granted an extension of time to file their post-hearing submissions. Both parties timely filed their post-hearing submissions, which have been considered in the preparation of this Recommended Order.
At all times material hereto, Harmony Health Center was a skilled nursing facility operating at 9820 North Kendall Drive, Miami, Florida, and was licensed under Chapter 400, Florida Statutes.
On December 5, 2003, AHCA conducted a survey of Harmony Health Center during which three deficiencies were found, one Class I deficiency and two Class II deficiencies. As a result of the deficiencies being found, AHCA filed an Administrative Complaint against Harmony Health Center. Subsequently, AHCA filed an Amended Administrative Complaint, citing two Class II deficiencies.
Count I: Failure To Ensure That A Resident Entering The Facility Without A Pressure Sore Does Not Develop One
Resident No. 31 was admitted to Harmony Health Center on May 9, 2003. Her records at Harmony Health Center indicate that she had suffered a stroke, paralyzing her on the left side, and that she had a swallowing problem, abnormally high blood pressure, and a feeding tube.
Resident No. 31's records did not indicate that she had a pressure sore upon admission.
An initial nursing assessment was performed on Resident No. 31 at the time of admission. Relating to pressure sores, the nursing assessment indicates that a Braden Scale for Predicting Pressure Sore Risk (Braden Scale) was performed. The Braden Scale is scored, with the lowest being 6 and the highest being 23, and has six categories, which are Sensory Perception-- ability to respond meaningfully to pressure-related discomfort; Moisture--degree to which skin is exposed to moisture; Activity-
-degree of physical activity; Mobility--ability to change and control body position; Nutrition--usual food intake pattern; and Friction and Shear. As to Friction and Shear, Resident No. 31 received a score of one, which designates a "Problem" and states as follows: "Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible.
Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction."
Resident No. 31 received a total score of 12 on the Braden Scale. As to scoring, the Braden Scale provides, among other things, that a total score of 18 or below indicates that a resident is considered a risk and that "CAN Daily Skin Checks FFWP008 must be initiated."
Recognizing the risk of Resident No. 31 developing pressure sores, Harmony Health Center ordered a heel protector for her right foot to prevent pressure sores.
Resident No. 31's wound treatment and progress records for May 11, June 18, and July 1, 2003 do not reflect the presence of a pressure sore.
The first mention of any pressure sore in Resident No.
31's medical records was on August 8, 2003, when a family member, not a staff person, observed a wound on Resident No. 31's right inner heel and pointed it out to a member of the nursing staff. The wound was described in the progress notes as a "blister like area." Resident No. 31's medical records refer to this wound as "in-house acquired."
Harmony Health Center admits that Resident No. 31 developed a pressure sore while a resident but characterizes the pressure sore as "unavoidable."
On August 8, 2003, Resident No. 31's physician ordered a podiatric consult.
A progress note on August 12, 2003, indicates that the pressure sore was at Stage II.
The podiatrist, Ann Marie Millar, DPM (Dr. Millar),who was at Harmony Health Center at least twice a week, usually performs consults within 24 hours. However, the consult did not occur until October 10, 2003, approximately two months after the consult was ordered. Dr. Millar was not contacted for the consult when the physician ordered the consult. The wound care nurse requested and the treating physician authorized the consult by Dr. Millar. No evidence was presented to explain why approximately two months elapsed before the consult was performed.
When the consult was performed on October 10, 2003, the pressure sore had progressed to Stage IV, which is the most serious classification for a pressure sore.
On October 15, 2003, Resident No. 31 was sent to the hospital for debridement of the wound to promote healing. The process of debridement involved either the chemical or surgical removal of necrotic (dead) tissue of the wound.
In December 2003, the pressure sore was eventually resolved.
Resident No. 31's medical records do not show that another pressure sore presented itself.
Dr. Millar testified1 that Harmony Health Center did all that it could to prevent the pressure sore. Resident No. 31 had a heel protector and a Geo mat. Dr. Millar also testified that she was certain that the staff turned or rotated Resident No. 31; however, no documented evidence or any other testimony was presented which showed that the staff turned or rotated Resident No. 31 or which showed the actual care provided to Resident No. 31 by Harmony Health Center prior to the discovery of the pressure sore. According Dr. Millar, Resident No. 31's clinical condition causes contractures, which in turn causes more pressure to the affected heel and, unless the patient can be suspended, causes a heel ulcer. As a result, according to Dr. Millar, a heel ulcer, as experienced by Resident No. 31, is unavoidable.
Dr. Millar further testified that Harmony Health Center had additional interventions, other than those used by it, to prevent a pressure sore. However, according to
Dr. Millar, the other interventions were "not covered," as to being cost-covered, and, therefore, were not ordered or used.
A registered nurse of 25 years, Eleanore Kennedy (RN Kennedy), performed the survey of Harmony Health Center for AHCA. RN Kennedy testified that for a family member, and not staff, to observe and report a pressure sore is unusual; and that, with protective equipment and proper turning, no reason
existed for Resident No. 31 to develop a pressure sore. Consequently, according to RN Kennedy, Resident No. 31's pressure sore was avoidable.
A registered nurse of 16 years, Jennifer Mata (RN Mata) testified, as an expert in nursing home care, on behalf of Harmony Health Center. RN Mata was also Harmony Health Center's director of nursing. RN Mata opined that Resident No. 31's pressure sore was unavoidable because, in
essence, a resident in a nursing home with Resident No. 31's clinical condition develops pressure sores.
The undersigned finds the testimony of RN Kennedy to be more credible than RN Mata. The evidence is irrefutable that the pressure sore developed after the admission of Resident No.
31 to Harmony Health Center. The evidence presented was insufficient to satisfactorily explain why a staff person had not observed the skin area at Resident No. 31's heel if Resident No. 31 had a heel protector, was being rotated or turned, and was having daily skin checks, as required by the Braden Scale. Furthermore, a lack of documented evidence exists showing that Resident No. 31 was turned or rotated and that her skin was checked daily although the evidence showed that her skin was checked weekly. This lack of sufficient evidence and lack of evidence causes the undersigned to find the testimony of
RN Kennedy more credible.
Further, RN Kennedy's testimony is found to be more credible than Dr. Millard’s as to whether the pressure sore was avoidable. The evidence was insufficient to satisfactorily explain why approximately two months elapsed before Dr. Millar was called to perform a consult on Resident No. 31. Furthermore, a lack of documented evidence exists to show that Resident No. 31 was turned or rotated and that her skin was checked daily although the evidence shows that her skin was checked weekly. This lack of sufficient evidence and lack of evidence causes the undersigned to find the testimony of
RN Kennedy more credible.
Hence, a finding is made that Harmony Health Center failed to prevent Resident No. 31's pressure sore and that, therefore, the pressure sore was avoidable.
Count II: Failure To Implement Measures To Protect A Resident From Ongoing Falls, Resulting In Actual Harm To The Resident
Resident No. 18 was admitted to Harmony Health Center on April 5, 2002.
Resident No. 18's nursing assessment upon admission indicated that she had several conditions and needs. She had Alzheimer's Disease and right-side weakness. Her decision- making was severely impaired, with her never or rarely making any decisions. Resident No. 18 was a wanderer, moving with no
rational purpose, seemingly oblivious to needs or safety. She required the assistance of two persons in her daily living activities (ADLs)--ambulation, transfer, bed mobility, eating, toileting, personal hygiene, and bathing. Resident No. 18 also used a wheelchair.
Upon admission, Harmony Health Center identified Resident No. 18 as being at risk for falls and injury and prepared an Interdisciplinary Resident Care Plan (Care Plan) for her regarding falls. On April 5, 2002, the Care Plan indicated that she was at risk for falls and injury and indicated nine interventions to lessen her risk for falls, which were implemented. The interventions were as follows: (1) access/record full risk factors; (2) report to M.D. incidence of fall; (3) monitor possible causes of fall; (4) bed in low position; (5)items within easy reach; (6) maintain environment clutter-free; (7) call bell within reach; (8) provide PT/OT therapy evaluation and treatment as prescribed; and (9) orient to surroundings as needed.
In spite of the interventions, Resident No. 18 fell six times at Harmony Health Center. Falls were documented on the Care Plan for April 15, 2002 (ten days after admission), June 5, 2002, August 28, 2002, May 22, 2003, June 25, 2003, and August 11, 2003. At the time of each fall, the documentation
indicates that Resident No. 18 was found on the floor in her room.
The Care Plan for Resident No. 18 indicates that another intervention was added on June 5, 2002, after the fall on the same day; on August 28, 2002, after the fall on the same day; on May 22, 2003, after the fall on the same day; on
June 26, 2003, after the fall on June 25, 2003; and on August 11, 2003, after the fall on the same day. The
intervention on June 5, 2002, was to use one-half side rails, to instruct her to use call light when needed, and to assist with ADLs; on August 28, 2002, was to place in well-supervised area; on May 22, 2003, was to instruct her to use call light when needing help; on June 26, 2003, was to have close supervision; and on August 11, 2003, was to monitor closely and frequently.
As to the intervention added on June 5, 2002, the staff at Harmony Health Center was aware that Resident No. 18 would, on her own, get out of bed and go to the bathroom. One- half side rails make it easier for and assist a resident to get out of bed. Consequently, the one-half side rails made it easier for Resident No. 18 to get out of bed, which would contribute to her falling. Based on the evidence presented, this intervention to reduce the risk of falls was unreasonable for Resident No. 18, who was a high risk for falls.
As to instructing Resident No. 18 to use the call light when needed, this intervention was essentially contained in the original Care Plan before her falls. As a result, this intervention on June 5, 2002, was not a new or different intervention.
Further, Harmony Health Center was aware that Resident No. 18 was cognitively confused and suffered from sundowner's syndrome, which meant that she became more confused at night. An example of Resident No. 18's confusion and sundowner's syndrome occurred during the fall of August 11, 2003, when she was questioned, after the fall, as to where she was going; she responded that she was going to visit her sister. Based on the evidence presented, to instruct Resident No. 18 to use a call light, as an intervention to lessen the risk of falls, was unreasonable.
A nursing assessment for Resident No. 18 was performed on July 17, 2003, a little over 15 months after her admission and after five falls. The nursing assessment indicates that, as to bed mobility (moving to and from lying position, turning side to side, and positioning body while in bed), Resident No. 18 required limited assistance, with one person assistance; and that, as to transfer (moving between surfaces to and from the bed, chair, wheelchair, and standing position), she required extensive assistance, with one person assistance. Further, the
nursing assessment indicates that, as to cognitive skills for daily decision making (making decisions regarding tasks of daily life), Resident No. 18’s cognitive skills were independent (decisions were consistent and reasonable).
The restorative nurse for Harmony Health Center, Adrienne Underwood, LPN, provided a service to Resident No. 18. Nurse Underwood's role was to maintain or increase Resident No. 18's level of care after Resident No. 18 completed rehabilitation.
Nurse Underwood testified that Resident No. 18 could ambulate independently but could not recall when Resident No. 18 became independent. No medical records or assessments or Care Plan entered into evidence supports Nurse Underwood's testimony as to Resident No. 18's independence in mobility and/or transfer. Nurse Underwood's testimony, as to Resident No. 18's ability to ambulate independently, is found not to be credible.
Regarding the falls on June 26, 2003 and August 11, 2003, for which the interventions of close supervision and to monitor closely and frequently, respectively, were added, Harmony Health Center's expert, RN Mata opined that the two interventions were appropriate. However, RN Mata also testified that Harmony Health Center was already performing these interventions, before the falls. A finding is made that the
interventions added on June 26, 2003, and August 11, 2003, were not new or different interventions.
Related to close supervision is the intervention on August 28, 2002, which was placing Resident No. 18 in a well- supervised area. As aforementioned, Harmony Health Center was already closely supervising and monitoring Resident No. 18 before the falls. Consequently, a finding is made that this intervention was not a new or different intervention.
Restraining Resident No. 18 to lessen her risk of falls was not an option available to Harmony Health Center. She had no physician order for restraints. Without a physician order, Harmony Health Center could not and would not restrain Resident No. 18.
No determination, as to the cause of Resident No. 18's falls, was made by either AHCA or Harmony Health Center. AHCA made no determination in its survey. Neither Resident No. 18's records presented into evidence nor testimony presented showed that Harmony Health Center determined the cause of the falls.
AHCA did not contact the physician for Resident No. 18 regarding her falls as to whether the interventions were adequate or the cause of the falls. Whether to contact a physician is a judgment call for AHCA's consultants. AHCA's consultant made a judgment call not to contact Resident No. 18's physician.
As an intervention, AHCA suggests that Harmony Health Center could have used bed alarms. Harmony Health Center does have bed alarms for some residents. RN Mata testified that bed alarms are used for residents who have a history of falling out of bed, i.e., from the bed to the floor. Furthermore, according to RN Mata, the purpose of bed alarms is to alert the staff to assist a resident before the resident falls. Resident No. 18's records indicate that she was found on the floor in her room. No evidence was presented that Resident No. 18 was found on the floor next to her bed, which would be an indication that she fell moving from the bed to the floor. However, the evidence does show that Resident No. 18 needed assistance to ambulate. An inference is drawn and a finding is made that, based on Resident No. 18's fall history, her cognitive ability, her need for assistance to ambulate, and the failure of prior interventions, a bed alarm would have been a reasonable intervention.2
Regarding Resident No. 18's fall on August 12, 2003, which was at 3:00 a.m., she sustained an injury, i.e., a hematoma to the right frontal area of her head.
After the fall on August 12, 2003, Resident No. 18 was a total care resident.
According to Harmony Health Center, the interventions were added after Harmony Health Center investigated each fall,
the treating physician was contacted, and a team of Harmony Health Center's personnel reviewed each investigation and reached a consensus as to how to address the falls. To Harmony Health Center, the interventions were appropriate and adequate.
No evidence was presented to indicate that an investigation of a resident's fall would not produce the cause of the fall. Based on the evidence presented, an inference is drawn and a finding is made that the investigations were inadequate and not thorough and failed to produce sufficient information to assist Harmony Health Center in determining the cause of Resident No. 18's falls.
AHCA has no expectation that a facility will prevent all falls.
AHCA has no rule or requirement that a new or different intervention must be developed and implemented for every fall by a resident at a nursing home.
Based on the evidence presented, a finding is made that all the interventions added in Resident No. 18's Care Plan after her falls, except for the interventions on June 5, 2002, found to be new and different, were not new or different from the interventions developed by Harmony Health Center, before the falls.
Based on the evidence presented, a finding is made that the interventions added after Resident No. 18's falls
failed to lessen the risk of her falls and were, therefore, inadequate and inappropriate.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the subject matter of this proceeding and the parties thereto pursuant to Sections 120.569 and 120.57(1), Florida Statutes (2004).
To impose a fine, AHCA has the burden of proof to show by clear and convincing evidence that Harmony Health Center committed the offenses in the Amended Administrative Complaint. Department of Banking and Finance, Division of Securities and Investor Protection v. Osborne Stern and Company, 670 So. 2d 932 (Fla. 1996); Ferris v. Turlington, 510 So. 2d 292 (Fla. 1987).
The parties agree that, to impose a conditional license, AHCA has the burden to show by a preponderance of the evidence that a basis exists for reducing the licensure status of Harmony Health Center from standard to conditional. See Florida Department of Transportation v. J.W.C. Company, Inc., 396 So. 2d 778 (Fla. 1st DCA 1981); §120.57(1), Fla. Stat.(2003).
Nursing home facilities are required to be in compliance with Title 42, Chapter 483, Code of Federal Regulations, which are incorporated and made applicable in
Section 400.23, Florida Statutes (2003), and Florida Administrative Code Rule 59A-4.1288.
Florida Administrative Code Rule 59A-4.1288 provides:
Nursing homes that participate in Title XVIII or XIX must follow certification rules and regulations found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference. Non-certified facilities must follow the contents of this rule and the standards contained in the Conditions of Participation found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference with respect to social services, dental services, infection control, dietary and the therapies.
Title 42, Section 483.25 Code of Federal Regulations, entitled "Quality of care," provides in pertinent part:
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
* * *
Pressure sores. Based on the comprehensive assessment of a resident, 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.
* * *
Accidents. The facility must ensure that--
The resident environment remains as free of accident hazards as is possible; and
Each resident receives adequate supervision and assistance devices to prevent accidents.
As to Resident No. 31, regarding pressure sores, AHCA presented evidence demonstrating that, upon admission to Harmony Health Center, Resident No. 31 had no pressure sores but was at risk for the development of pressure sores because of her medical condition; and that she did develop an in-house pressure sore after admission. Harmony Health Center attempted to present evidence showing the measures that it took to prevent Resident No. 31 from developing pressure sores, but the evidence was insufficient and lacked credibility. AHCA presented credible evidence demonstrating that Harmony Health Center failed to provide the care necessary to prevent the development of a pressure sore and that the in-house pressure sore was avoidable. Hence, Harmony Health Center failed to show that the in-house pressure sore developed by Resident No. 31 was unavoidable, whereas AHCA demonstrated that the in-house pressure sore was avoidable. See Emerald Oaks v. Agency for
Health Care Administration, 774 So. 2d 737 (Fla. 2nd DCA 2000);
Beverly Enterprises-Florida v. Agency Health Care Administration, 745 So. 2d 1133 (Fla. 1st DCA 1999).
Furthermore, the evidence presented demonstrates that, with the debridement of the pressure sore and care afterwards, Harmony Health Center provided Resident No. 31 the "necessary treatment and services to promote healing, prevent infection and prevent new sores from developing," in that no new sores developed. 42 CFR §483.25(c)(2).
As to Resident No. 18, regarding falls, the evidence demonstrated that a facility is not expected by AHCA to be fall free. AHCA demonstrated that, even though Harmony Health Center developed a Care Plan upon admission, Harmony Health Center failed to properly investigate the falls of Resident No. 18 to determine the cause of her falls; that all of the interventions, except for two, added to the Care Plan after the falls to lessen her risk of falls were not new or additional interventions, but a continuation of the interventions developed prior to Resident No. 18's falls, resulting in inadequate assistance being provided to Resident No. 18 to lessen her risk of falls. Furthermore, AHCA demonstrated that one of the two new or additional interventions (the one-half bed rails) made it easier for Resident No. 18 to fall by making it easier for her to get out of bed unassisted; and that the other new or additional intervention (instructing her to use the call light) was
ineffective because of Resident No. 18's cognitive impairment and periods of confusion due to Alzheimer's disease and sundowner syndrome.
Section 400.23, Florida Statutes (2003), provides in pertinent part:
The agency shall . . . assign a licensure status of standard or conditional to each nursing home.
A standard licensure status means that a facility has no class I or class II deficiencies and has corrected all class III deficiencies within the time established by the agency.
A conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency.
If the facility has no class I, class II, or class III deficiencies at the time of the followup survey, a standard licensure status may be assigned.
* * *
The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. . . The agency shall indicate the classification on the
face of the notice of deficiencies as follows:
* * *
(b) A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of
$2,500 for an isolated deficiency . . . A fine shall be levied notwithstanding the correction of the deficiency.
AHCA demonstrated that an isolated Class II deficiency existed as to Resident No. 31 and Resident No. 18 at Harmony Health Center. Consequently, AHCA demonstrated the existence of two Class II deficiencies at Harmony Health Center.
Having shown that a Class II deficiency exists, Harmony Health Care's licensure status can be changed from standard to conditional.
Further, having shown that a Class II deficiency exists, a fine of $2,500 per deficiency can be imposed.
DONE AND ENTERED this 22nd day of March 2005, in Tallahassee, Leon County, Florida.
ERROL H. POWELL
Filed with the Clerk of the Division of Administrative Hearings this 22nd day of March, 2005.
1/ The testimony of Dr. Millary was presented by deposition, Respondent's Exhibit No. 1.
2/ RN Underwood's deposition testimony differed from her testimony at hearing regarding the bed alarm. In her deposition, she testified that she did not know why a bed alarm was not used for Resident No. 18. But, at hearing, she testified that a bed alarm was not appropriate for Resident No. 18. RN Underwood did not convincingly explain the change in her testimony.
RN Underwood's testimony at hearing, regarding the appropriateness of the bed alarm, is not credible.
Nelson E. Rodney, Esquire
Theodore E. Mack, Esquire Powell & Mack
Valda Clark Christian, General Counsel Agency for Health Care Administration Fort Knox Building, Suite 3116
15 days from the date of this recommended order. Any exceptions to this recommended order should be filed with the agency that will issue the final order in this case.
