lon. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2012007293 1061 VIRGINIA STREET OPERATIONS LLC d/b/a LAKESIDE OAKS CARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT. COMES NOW the Agency for Health Care Administration (hereinafter “A gency”), by and through the undersigned counsel, and files this Administrative Complaint against 1061 Virginia Street Operations LLC d/b/a Lakeside Oaks Care Center (hereinafter “Respondent”), _ pursuant to §§120.569 and 120.57 Florida Statutes (2011), and alleges: NATURE OF THE ACTION ' This is an action to change Respondent’s licensure status from Standard to Conditional commencing May 17,-2012, and ending June 14, 2012, to impose administrative fines in the amount of ten thousand dollars ($10,000.00), and to impose a six month survey cycle and assess a survey fee of six thousand dollars ($6,000.00) for a total assessment of sixteen thousand dollars ($16,000.00) based upon Respondent being cited for one (1) Isolated State Class I deficiency, JURISDICTION AND VENUE 1, The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2012). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. . PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing Filed October 22, 2012 1:09 PM Division of Administrative Hearings -) ) facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapters 400, Part II, and 408, Part II, Florida Statutes, and Chapter 59A-4, Florida . Administrative Code. 4. Respondent operates a ninety-three (93) bed nursing home, located at 1061 Virginia Street, Dunedin, Florida 34698 and is licensed as a skilled nursing facility license number 15100962, 5, Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to’ comply with all applicable rules, and ~ statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to Florida law, all licensees of nursing homes 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 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, with established and recognized practice standards within the community, and with rules as adopted by the agency. § 400.022(1)(1), Fla. Stat. (2011). 8. That Florida law provides the following: “Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. A practical 2 nurse is responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.” § 464.003(19), Fla. Stat. (2011). 9. That Florida law provides the following: “Every licensed facility shall comply with all applicable standards and rules of the agency and shall ... Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner.” § 400.141(1)(h), Fla. Stat, (2011): 10. That on May 17, 2012, the Agency completed a complaint survey of the Respondent facility, CCR number 2012005064. 11, That based upon the ieview of records, observation, and interview, Respondent failed to ensure the provision of 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, with established and recognized practice standards within the community and or failed to ensure the facility was maintained in a safe manner where Respondent failed to ensure that needed services for resuscitation were initiated for one (1) of forty (40) residents identified as full code, the same being contrary to the provisions of law and Respondent’s policy and procedure. 12, _ That Petitioner’s representative interviewed Respondent’s administrator and director of nursing on May 15, 2012, at 9:39 a.m. who indicated as follows: . a, The facility recently had ai incident in which two (2) nurses did not honor the advanced directives of resident number two (2). b. The resident was found unresponsive on April 29, 2012, by employee “A,” a certified nursing assistant. . c. Employee “A” immediately alerted employee “B,” a licensed practical nurse, who described the resident as blue in color and already deceased. d. Employee “B” then got the nurse assigned to the resident, employee-“C,” a : 3 a en Ee Senne a licensed practical nurse. e. Employee “C” reviewed the resident's chart and did not see a “Do Not Resuscitate Order (hereinafter ‘DNR’),” but stated she didn't see anything that indicated cardiopulmonary resuscitation (hereinafter “CPR”) was needed because the resident was on hospice. 13. That Petitioner’s representative telephonically interviewed the adult child of resident number two (2), who was also the resident’s health caré proxy, on May 16, 2012, and the following was noted: a. The individual was surprised when the individual: received a call informing that . the parent had died, _b. The individual indicated the parent had been doing really well. c. The individual knew that the resident was being treated with antibiotics for pneumonia about a week before the death, but everything was going okay. d, The individual didn't ask for any details on how the resident had died when first called by the facility. e. The death certificate stated the cause of death as natural causes; lung cancer metastasized to the brain. f. When asked if the individual had wanted the resident to have any life saving measutes, the individual responded "[The resident] was not a DNR. They were supposed to do anything they needed to." g, The individual was not aware that Respondent had not attempted to perform CPR and transfer the resident to the hospital in accordance with the expressed wishes. 14. That Petitioner’s representative telephonically interviewed Respondent's employee “A,” a certified nursing assistant, on May 15, 2012 regarding resident number two (2) and the following was noted: ae > ‘ ‘ . ) . He works at the facility on an as needed basis approximately four (4) to five (5) times a week on the 3:00 p.m. - 11:00 p.m. shift. . He has no set assignment but recalled caring for the resident in the past and remeinbered the resident as a resident who wore a helmet on the head and was a very quiet person. . He thought this resident was under the care of hospice. . The resident was total care and could not do anything for self; required the use of a hoyer lift for all transfers to the bed and chair; and-needed assistance with eating. | e. On April 29, 2012, he had come back from the dining room and the resident was in the resident’s room in the geri-chair around: 6:00 p.m. - 6:15 p.m. He went to care for the resident directly across the hall, and when that was complete he entered the resident's room around 7:00 p.m. to get the resident ready _ for bed. . He noticed the resident was not moving and was leaning back in the chair. . The resident was not breathing and he knew this because he looked up close and did not see the chest moving up or down. The resident's fingers and face were discolored and pale, but the resident was not blue. He immediately called for employee “B,” a licensed practical nurse, who was at the nurse's station, just two steps from the resident's room. . He told employee “B” the resident was not breathing and employee “B” then came in and "checked [the resident’s} pulse and everything." Employee “B” then got another nurse to check the resident as well. . He then went to went to get another aide to get the resident out of the chair and 5 n, put the resident in bed while the nurses were making their calls. This was the normal procedure for preparing the body once somebody dies. 15, That Petitioner’s representative telephonically interviewed. Respondent’s employee “B,” a. licensed practical nurse, on May 15, 2012 regarding resident number two (2) and the following was noted: = & She had been a licensed practical nurse since January of 2006 and caine to work -at this facility in late February 2012 on a full time basis on the 3:00 p.m, - 11:00 — p-m. shift. She was somewhat farniliar with the resident prior to the day the resident expired - because she had been on the resident’s assignment for a little while and was later moved to a different room. She recalled the resident had a brain injury, was aphasic and didn't speak. On April 29, 2012,.she was at the nurse's station charting when employee “A” , asked her to come into the resident's room. She was not the nurse for the resident that night; employee “C,” a licensed practical nurse, was the nurse for the resident that night, but employee “C” was on her lunch break, When she entered the resident's room, she saw the resident seated in a geri-chair and at that point it was very clear the resident had expired. She checked apical and radial pulses, and the resident was cold to the touch, stiff, and cyanotic. The resident's eyes were wide open and no pulses were palpable with a stethoscope and no respirations were present. She then proceeded back to the nurse's station to page employee “C,” who responded right away. yo — _j. She informed employee “C” that the resident had expired. k. Employee “C” asked her "What am I supposed to do?" L. She told the resident's nurse to call the supervisor as both she and employee “C” were new to the facility. m. In addition, she thought employee “C” was a new nurse, n. She heard employee “C” speaking with the director of nurses by telephone so she assumed that everything was under control, and went back to work. 0. She recalled employee “C” grabbing the chart and entering the resident's room. p. She was on the treatment cart, but stated she called out to employee “Cc” that she was right there if she needed her. "I thought she had it under control." q. She spoke with the hospice nurse that night on April 29, 2012, exact time unknown, but did not discuss anything specific.about the resident. rt, She did not look at the resident's chart on the night of April 29, 2012. s. She had received training on how to respond when a resident was found without vital signs in other facilities, but not at this facility. Orientation at this facility was one day on the floor and she had to learn the policies and procedures as she worked. t. She did not call the physician, hospice, or family that night. u. Her CPR certification was up to date. v. This incident happened on a Sunday evening and she was called in that Monday morning to give a statement. w. They in-serviced her on the facility code guidelines and then suspended her that Monday morning. x, She was terminated the following Friday, May 4, 2012. 16. That Petitioner’s representative telephonically interviewed Respondent’s employee “C,” 7 a licensed practical nurse, on May 16, 2012 regarding resident number two (2) and the following was noted: a. She had been a licensed practical nurse since January 14, 2012. b. She began working at the facility in February 2012 on a full time basis on the 3:00 p.m. - 11:00 p.m. shift, c. She was not too familiar with the resident because she had just moved onto the resident’s assignment about a week or so before the resident expired, d, ‘She recalled the resident had surgery on the head because the resident wore a helmet whien out of bed. e, All of the resident's medications were crushed. or liquid because the resident had trouble eating and swallowing so had to be watched very carefully. f. The resident needed total care with activities of daily living (ADL's), and received ’ breathing treatments on her shift at 5:00:p.m. and 9:00 p.m. g. On April 29, 2012, she remembered being on her lunch break when the resident passed away. h. She had given the tesident medications at 6:15 p.m. on April 29, 2012, and was fine. She went on.her lunch break at 7:00 p.m. and told employee “B” she was going on break. i, She received an overhead page around 7:15 p.m. on April 29, 2012, to come back to the floor. j. She went back to the floor and was informed by employee “B” that the certified nutse’s assistant found the resident was not breathing and employee “B” had already checked the resident out and "pronounced her dead." k. She informed employee “B” that nurses can't pronounce a patient. 1, She went into the resident's room to look at the resident and the resident was 3: already turning a dark color from lack of oxygen, was not breathing; there was no heartbeat, and no pulse. . She used her stethoscope to check and: could not find a carotid pulse. . ‘She tried to call the person who was on call, but they. did not answer the call so she immediately proceeded to call the director of nursing and informed the director of the situation. . The director of nursing asked her if the resident was on hospice and she stated yes," . The director of nursing told her to call the resident's physician and get a telephone order for two (2) licensed practical nurses to pronounce the resident as deceased and get a telephone order from the doctor to release the body to the funeral home. . The director of nursing also told her to call hospice, . Employee “B” called the doctor and got the telephone orders while she called hospice, . The hospice nurse came out to the facility about an hour later and the hospice nurse contacted the family and the funeral home for her. She called the director of nursing that night because she didn't know what the procedure was when somebody died, . Employee “B” was new to the facility also and she didn't know what to do, . She looked at the resident's chart and did not see a DNR order, but she thought the resident was a DNR because the resident was on hospice. . f When hospice came in that night, she didn't say anything about the resident's code status, and the hospice nurse had reviewed the resident's chart too. . She had not received any training from the facility on how to respond when.a resident was found without vital signs; they only showed her where the oxygen 9 = ey | ; 5 was kept and other rooms like clean and dirty utility rooms. y. She knew the crash cart was kept in the dining room because she had asked them , where it was. , z, She only called the director of nursing and hospice that night. | aa. She had current CPR certification. bb. She came into work the following Monday morning, April 30, 2012, to cover for someone who had called off on 7:00 a.m. -3:00 p.m., and was already on the schedule to work that day from 3:00 p.m. ~ 11:00 p.m. and had planned on working a double that day. cc, She was pulled off the medication cart on April 30. 2012, at around 9:15 a.m., to give a statement relating to the incident. dd. She was suspended that Monday morning and Jater terminated because she did not know what the facility's procedure was. 17. That Petitioner’s representative again telephonically interviewed Respondent’s employee | “B a licensed practical nurse, on May 16, 2012 regarding resident number two (2) and the following was noted: a. When asked if she had spoken to the resident's doctor on the night of April 29, 2012, as was reported in the telephone interview with employee “C,” she replied: "T actually thought about it last night and that is absolutely right." . b. She spoke to the Advanced Registered Nurse Practitioner (ARNP) for the resident’s physician on April 29, 2012, and the ARNP gave orders to pronounce and release. 18. That Petitioner’s representative interviewed the Hospice registered nurse for resident number two (2) on May 15, 2012, regarding the resident and the following was noted: a, She was the resident's regular hospice registered nurse; had been coming to the 10 yO | ) facility for nine (9) years; works on the burgundy team; and was familiar with the resident. b. She recalled the resident having come to the facility from the hospital where the - , resident had undergone brain surgery and developed an infection in the flap. c. The resident was very young, in the resident’s forties, d. When the resident was first admitted to the nursing home back in late March of 2012, the resident was discussed as a possible hospice resident, but the resident’s adult child and health care proxy needed time to think about it. e. The resident's adult child was very young, only about twenty (20) years old, and " was down in Florida for about a week and then-returned back up north. f. The adult child later decided, to have hospice for the resident, and hospice evaluated and admitted the resident for services on April 2, 2012. g. The resident also had a fourteen (14) year old child who lived in a neighboring county and required psycho-social help. h. Hospice worked with the neighboring county to obtain special services and counseling to help the resident's teenage child. i, When the resident was first admitted to hospice, the flap was healing, j. She recalled the resident speaking only one time, saying "yeah." k. She also recalled holding the resident's ‘hand on one occasion and the hospice nurse said to the resident "fourteen (14) year old [kids] can be a real pain in the butt sometimes." The resident squeezed her hand and smiled when she said this, l. She also recalled another time about a week before the resident passed when the resident had kissed her hand. The resident did this after she had told the resident she was really sorry for everything the resident had been through. m. The resident would follow with eyes, but she could not necessarily tell for sure if rey ace ae stense ss a ee the resident understood what was happening or if thie responses she received were true responses. . The resident fed self at the beginning of the resident’s stay when the utensil was placed in the hand, but towards the end, the last week, she thought staff were helping the resident with meals because the resident was eating less and less. . She clearly recalled discussing advanced directives with the resident's adult child © and stated she documented this in the resident's chart. She thumbed through the resident's clinical record and pulled out a form labeled "Progress Notes," dated April 6, 2012, which noted Hospice nurse spoke with patient's adult child regarding resident's current status and adult child states "I want my [parent] to go to the hospital if [the resident] needs to." Facility nurse and ADON made aware that patient's adult child wants hospitalization for patient if needed. It was her understanding that the resident had no advanced directives and the adult child was not ready to discuss that, The adult child was so young and "we weren't going to, shove DNR or advanced directives down {the child’s] throat." There really wasn't time to'sit and work through this with the adult child as we didn't have the resident under our care for a very long time. . 19, .That Petitioner’s representative interviewed the Hospice social worker for resident number two (2) on May 15, 2012, regarding the resident and the following was noted: a. She had a difficult time assessing how much the resident was aware of because the resident had had major brain surgery. The resident was either in bed or in a reclining geri-chair, and always wore a helmet. She. never could get a real good read as to whether of not the resident could : 12 understand her or not. The resident's family dynamics were difficult to navigate with an adult child who ~ lived out of the state who was a young parent about twenty (20) years old with an , infant. She called the adult child to introduce herself and explain her role when the _ tesident was first admitted to hospice and she did not think the adult child’s take on the situation was realistic. The adult child was asking questions like "Is [the resident] going to get chemo?" . She asked the resident's adult child questions about what the resident was like before getting sick. She talked to the adult child about a DNR, but the adult child didn't want one, at least at that point in time, and was still asking questions about chemo, She was slowly trying to educate the adult child to understand the finality of the situation, but the adult child was not there yet. . She sent the resident's adult child a booklet about end of life, what to expect, and advance directives, and that was about as far as she got with the adult child as the social worker went on leave and the resident died during that timeframe. 20. That Petitioner’s representative interviewed the Hospice evening/ weekend registered nurse. for the burgundy team on May 16, 2012, regarding resident number two (2) and the following was noted: a. b. She was the nurse that came out to the facility on the night of April 29, 2012. The facility had called the evening/weekend office when the resident died and the office in turn notified her to come out to the facility. She probably came out to the facility around 7:30: p.m. on April 29, 2012, and offered to call the funeral home and the physician but both had already been done. 13 , . She did notify the resident's family as the facility nurses had not been able to get in contact with anyone. . She could not reach the resident's adult child at the home phone number so she called the adult child’s fiancé and asked to please speak to the resident's adult child. . She told the adult child who she was and informed her that the resident had expired. ;. The adult child started to cry and thanked me for calling. . She informed the adult child of counseling that they could provide and provided her personal number in case the adult child had any questions because the child seemed to be in shock. The adult child: called her later, probably around 9 p.m., told her about some family things that were going on, and asked if the hospice had called the resident's - significant other who cared for resident's fourteen (14) year old child. She informed the child that she had called the significant other but did not get an answer and had not heard back. yet, . The adult child then sent someone over to the significant other’s house to notify the individual, dnd the individual then called her around 9:30 p.m. to find out if the resident's death was in fact true, and she confirmed. The resident's adult child and significant other never asked what happened to the resident that night. . The facility told the hospice nurse that the resident had no visitors and the significant other had never brought the fourteen (14) year old child to visit. . The facility nurses never informed the hospice nurse that the resident did not have ~ aDNR order. a. She noticed that there was no DNR order in the record and when she asked the nurses, "Was she able to be revived?" the nurses said "No." 21. That Petitioner’s representative interviewed Respondent’s director of nursing regarding resident number two (2) on May 15, 2012, and the following was noted: a. b. The nurses normally call her wheti residents go to the hospital or expire. Employee “ce called her on the night of April 29, 2012, about twenty-five (25) rhinutes after the resident expired. Employee “C” informed her that the resident was on. hospice and employee “C” asked "What's the procedure for a death in the facility?" She proceeded to tell the employee to call the doctor, call hospice, and explained the orders the nurse needed to retrieve. Employee “C” never told her that the resident didn't have a DNR order. "I don't know all of them right off the top of my head." She did not remember if she asked employee “C” if the resident had a DNR order, but "I will from now on." 22. That Petitioner’s representative telephonically interviewed the advanced registered nurse practitioner for the attending physician for resident number two (2) regarding the resident who indicated as follows: a. c He recalled the facility contacting him in regards to the resident's death on April 29, 2012. Nothing stood out in his mind about the call as typically they are just asking for orders to pronounce and release which he provided. He did not recall the nurse telling him of any problem related to the resident’s death such as-it being unexpected or anything out of the ordinary. He remembered the resident as "... younger..." with failure to thrive who had 15 ‘) ~~ lung cancer. which metastasized to the brain. He remembered the resident looked terrible about a week before death. "[The resident] was ... not doing well at all and it was really a terrible, terrible case." He did not recall being informed that the resident did not have a DNR order. He would expect facility staff to in institute CPR, call a code, and do all of the things necessary for a resident who was found without pulse and respirations and. no DNR order. "Legally you would need to call a code." 23. That Petitioner’s representative interviewed Respondent’s medical director, who was also the attending physician for resident number two (2) regarding the resident on May 16, 2012, and ’ the physician indicated as follows: a.” b. He was not on call the night the resident had passed. He confirmed that the advanced registered nurse practitioner was on call that evening, and the doctor had found out indirectly about the resident's death. He could not recall exactly when he was informed or who had informed him. He recalled that the resident was not at the facility for very long and had a “horrible past history," including metastatic lung cancer to the brain with a couple — of craniotomies and an infection of the flap. The resident was non-communicative and would sort of stare at you. He never spoke to the resident's family. _ He communicated with the facility nurses and hospice in regards to the resident. He had been informed that the resident did not have DNR orders and stated "I guess they assumed that since [the resident] was hospice." He could not recall when he was informed of the lack of DNR orders for this resident. His expectation for a resident who had no DNR orders and was found without 16 . ~ a oe 4 pulse of respirations would be to call 911 and start CPR procedures. 24, That Petitioner’s representative reviewed Respondent’s records related to resident number two (2) during the survey and noted the following: a. A face sheet reflected a date of birth of August 22, 1968, was forty-three (43) years old, and had a date of admission to the facility of March 23, 2012, b. The face sheet also indicated the resident's payor source was Hospice. c. Advanced directives contained in the record revealed a health care proxy/acceptance of designation form dated March 28, 2012, which appointed the resident’s adult child as the “individual who shall be responsible for making healthcare decisions on behalf of" the resident. ‘d The resident had a certificate of incapacity signed by the resident’s attending physician on March 25, 2012 which documented that this resident "is unable to make health care decisions for him/herself or provide informed consent to medical treatment." | ) / e. A hospital history and physical dated’ February 21,2012, revealed the following: 1. History of present illness: Patient was aphasic at that time and was unable to give information. All of this history and physical had been done through chart review. 2. "The patient is a 43 year-old white [] with a diagnosis of lung cancer in the past and now status post brain tumor, also status post resection on 09/ 16/2011. The patient has a history of cerebrospinal fluid leak status post craniotomy, status post wound re-exploration with patch duraplasty and re-do craniotomy. Apparently, the patient has a history of metastatic cancer to the brain that initially was removed initially but the patient came back with a huge, 17 3. recurring lesion that required removal of the entire bone flap and postoperatively the patient did well but a small area of CSF leak was done so the reason the replacement was performed. The patient was admitted as transfer from [another area hospital] because of apparently 5 days of altered mental status, aphasia, and generalized weakness. On arrival to the ER the patient had an MRI, The MRI of the head showed a large calvarial lesion with — history of actual tumor extension intracranially causing ‘severe mass effect with left to right middle line shift with sub-falcine herniation and uncal herniation. The initial neurosurgeon is aware of that and the patient was transferred to ICU. The patient right now is clinically stable." | “Assessment and Plan: a, (1) The patient has history of lung cancer status post radio- chemotherapy with brain metastasis status post . initial removal of the brain lesion apparently complicated first initially with cerebrospinal fluid leak and also now with recurrence of the tumor, Neurosurgeon is consulted for evaluation of the patient. -b. (2) The patient has history of aphasia secondary to new lesions in the brain along. with evidence of increased intracranial pressure. c. (3) The patient has history -of -chronic obstructive pulmonary disease. d. (4) History of anxiety." i8 “ a = / f. The resident's care plans dated April 12, 2012, documented the following “Problems/Concerns:” 1. 10. Nutritional risk related to (r/t) cognitive loss. Diagnosis cancer, lung, chronic obstructive pulmonary disease (COPD), anxiety. Risk for complications r/t seizure activity. Comfort care measures 1/t end stage disease process and resident is under hospice comfort care. Potential to develop dehydration. Risk for falls r/t cognitive status. Impaired cognition 1/ cancer of the brain status post craniotomy. Impaired communication 1/t cognitive loss. Potential for signs and symptoms of pain: breakthrough, discomfort, intermittent, incision, cancer lung, cancer brain. At tisk for skin breakdown rt cognitive status, immobility, incontinent of bowel and bladder. Urinary incontinence: functional incontinence related to inability to transfer, unable to clean self, not aware of toileting needs, cognitive impairment. g. Facility nurses’ notes for April 29, 2012 contained the following entries: 1, 0120 - Vital signs: blood pressure 120/60, temperature 98.2, pulse 64, and respirations 18, . Continues on antibiotics for upper respiratory infection (URI) without side effect noted. No complaints voiced or cough, congestion, respiratory difficulties noted. Resting quietly in bed without discomfort noted. Will continue to monitor. 19 ) 2. 1:02 p.m, ~ Resident resting with eyes closed. No acute distress noted. Vital signs: blood pressure 139/70, pulse 62, respirations 20, and temperature 97.4. No signs and symptoms of pain or discomfort noted at present time. Resident has antibiotic Z pack in progress for URI. No adverse effect noted, No congestion or cough noted, Respirations even and unlabored. Will continue to monitor resident progress. 3. 8:00 p.m. - Resident up in wheel chair with helmet on to dining room for dinner ate 100%. Checked on [] at 6:15 p.m. resident showing no signs or symptoms of distress or pain. C.N.A. went in at 7:00 ‘pam, Resident had expired. No lung sounds present, no heartbeat heard, no pulse felt, patient's color had changed, Had CN.A, clean patient up and put in bed. Contacted physician at 715 p.m. after contacting nursing supervisor, DON, ARNP gave a: telephone order to pronounce resident expired at 7 p.m. and ok to release body. Called hospice. Hospice showed up by 8 p.m. called family members and funeral home picked up resident at 9:50 p.m. (signed by employee “C”). h, An April 29, 2012, telephone order read "Order to pronounce patient deceased at . 7:00 p.m. O.K. to pronounce and release the body." i. Hospice notes contained the following relevant entries: 1. April 6, 2012 - Handwritten progress note by the regular hospice nurse: "Hospice nurse spoke with patient's [adult child] regarding patient's current status. [Adult child] states I want my [parent] to go to the hospital if [the parent] needs to. Facility nurse and 20 -) a ADON made aware that patient's [adult child] wants hospitalization for patient if needed.” 2. April 6, 2012, computerized note by the regular hospice nurse: Patient in bed resting - appears weak, listless and moans when abdomen is palpated and also brings left arm up ‘over right forehead arca occasionally and moans. Patient unable to make needs known-does make-eye contact when spoken to. Staff nurse reports patient having difficulty taking meds by mouth today. Hydrocodone liquefied and patient was able to take without: difficulty ..,I also called patient's [adult child] today. We discussed patient status and the fact that patient has no advanced directives/DNR’ in place. [Adult child] just states “wants her [parent] to go to the hospital if needed." [Adult child] did not express any other decisions about DNR/advanced directives during this conversation ... I also spoke with the facility Social Worker: - (SW) regarding patient's [adult child’s] wishes that patient be hospitalized if needed and that 1 was concerned that patients [adult child] is very young and seems to be having difficulty making decisions regarding DNR/Advanced Directives. Facility SW stated that patient's "[adult child] is just not ready to make those decisions." 3. April 29, 2012, computerized note by the weekend/evening hospice nurse: Facility staff notified office of time of death of 7:00 ‘p.m. for this patient. No family present. Facility staff states there were no signs [patient] was eminent. Had seen patient 10 minutes 21 ptior to death and had went back to check on [patient] and [patient] had died. Death checklist completed. 25. That Petitioner’s representative interviewed Respondent’s unit manager for resident riumber two (2) on May 15, 2012 who indicated as follows: a b, He is a licensed practical nurse and has worked at the facility for about a year. He did not remember the resident ever talking or responding at all. The resident had a flap, surgery to the brain, was hospice, full code, and had to have a helmet on when out of bed. The resident required total care and had weight issues too. Hospice was talking to the family about possibly getting a peg tube for the resident if they planned to keep the resident a full code. He never spoke to the resident's family, but this information was relayed to him by Hospice personnel. On Monday morning, April 30, 2012, he reviewed the twenty-four (24) hour reports, telephone orders, and other documents to see what had happened over the weekend and, during this review, noticed that the resident had expired. Shortly thereafter, he ran into employee “C” in the hall and said "I heard you had " arough weekend," resident number two (2) expired. Employee “C” responded “Yes it was busy” and the unit manager stated to employee “C” “I know I would not have wanted to be here pumping and jumping ‘on [the resident]." Employee “C” looked at the unit manager and said “What do you mean?” The unit manager said “You know, doing CPR.” Employee “C” responded by saying "We didn't do CPR." The unit manager responded "Really. What did the paramedics say when they got 22 et a) . . , \ here?” . Employee “C” responded "We didn't call 911; we called the doctor and pronounced." . The unit manager told employee “C” "You know [the resident] was a full code?" . Employee “C” looked at the unit manager funny and did not say anything. . The unit manager proceeded to review the resident's chart to see if there was any change in DNR status and then he read the nurse’s note from April 29, 2012. . He remembered his chin just dropped as he read the nurse’s note. At that moment, the director of nursing was coming down the hall and the director of nursing said to employee “C” "Tell me you did CPR?" . The unit manager stated obviously the director of nursing had found out about the situation. Employee “C” was immediately taken off the floor arid gave a statement and was escorted off the property, . Employee “C” hadn't worked since that day. . Within ten (10) minutes of realizing this event, they immediately started in- " service with all the 7:00 a.m. - 3:00 p.m. staff, . The 3:00 p.m. -. 11:00 p.m, staff and the 11:00 p.m. - 7:00 a.m, staff were also in- serviced prior to starting their shifts. . The focus on the training was what to do ifa resident codes. . They went over all the steps in detail to include calling for help, having someone check the chart, initiating CPR if no DNR exists, the location of the crash cart, and calling 911, That Petitioner’s representative reviewed Respondent’s policy and procedure entitled "Cardiopulmonary Resuscitation (CPR)," effective March 2012 and noted the following 23 { : re * relevant information: a. Policy: 1,- Cardiopulmonary resuscitation is initiated on all residents except those with a "no code” order and appropriate documentation. 2. Cardiopulmonary resuscitation is performed only by individuals certified in CPR, - 3. All licensed nurses are to be certified in CPR and must be re- certified in accordance with certifying agency - American Heart Association-Red Cross, b. Procedure: i ; , 1. In the case of cardiac and/or pulmonary arrest, CPR is initiated immediately using the Red Cross Guidelines - American Heart a ; Association. 2. Use the paging system and call "Code. Blue" to Room Number __, three times. 3. CPR is continued until life support systems are available, or it may | be discontinued if} A. The resident responds. B. The physician orders CPR to be discontinued. C. EMS arrives and takes over, 4, Contact the physician and family. 5. Document details of occurrence in the Nursing Notes. \ 6. Update the care plan as needed. 27. That Petitioner’s representative reviewed Respondent's policy and procedure entitled — "Code Blue," effective March 2012 and noted the following relevant information: a. Policy: CPR will be provided to all residents who are found in Cardio Pulmonary arrest unless such resident has a DNR order written by a physician on 24 { oss we their medical records. b. Procedure: 1. When a resident is found without respiration and/or without a pulse the individual finding the resident will identify the resident's code status. *Confirm DNR status with the physician's written order. 2, In the event that the resident is identified as a Full Code and the person finding the resident is trained in CPR they will: a, Call for help and state “Code Blue." b. Initiate CPR. 3. The individual responding to the call for help will call "Code Blue" over the intercom, 3 times, identifying: a. The floor/unit. b. Room number or area where the resident is located. 4. If the first individual finding the resident is not trained in CPR, they will immediately call over the intercom a “Code Blue" identifying the specific floor and area, 5. Clinical staff in this facility will respond to the "Code Blue" pages. 6. The Nurse Manager/Supervisor/Clinical Nurse will assume responsibility for the code and delegate the following: a. Summon emergency equipment to the room. b. Activate the EMS system, c. Assign a person to document the on-going code. d. Notify the doctor. e. Complete a Transfer Form. ~ f. Call emergency room and give report to Admitting Nurse. 25 9: 5 g. Assure the family has been notified. h, Obtain order to transfer resident to hospital. i, Document code in medical record. j. Restock code cart. | . 28, That Petitioner’s representative interviewed Respondent's administrator and director of nursing on May 15, 2012, related to resident number two (2) and they indicated as follows; a. Respondent immediately began an investigation once this event was discovered - on the morning of April 30, 2012. b... The facility suspended employees “B” and “C” on the morning of April 30, 2012. ce. The facility's investigation revealed no malicious intent on the part of the nurses, but both nurses were terminated from employment. d. The facility completed federal and adverse incident reports and began re- _ educating all nursing staff on DNR/CPR/and code status. e. The facility conducted an audit on all current resident records to ensure all paperwork necessary for advanced directives was present in the clinical records in accordance with the resident's and family member's expressed wishes. f. The facility began an audit for CPR certification for all licensed/registered nurses. 29. That Petitioner’s representative reviewed Respondent’s records related to current CPR certification of Respondent’s nursing staff during the survey and noted as follows: a. The personnel record of employee “B” had current CPR certification with an issue date of March 7, 2011, and an expiration date of March 2013. . b. The personnel record of employee “C” had current CPR certification with an issue date of November 18, 2012, and a renewal date of November 30, 2012 c. Respondent’s CPR audit tool of May 15, 2012, reflected the facility has twenty- 26 “4 . ». | seven (27) regularly scheduled licensed practical nurses and four (4) registered nurses and at approximately 5:30 p.m., had seventeen(17) of the twenty-seven | (27) regularly scheduled nurses CPR certification’s on hand. d. The facility placed calls to the remaining ten (10) nurses to have them come in or fax their CPR certification cards. e. On May 16, 2012, at 4:40 p.m., the facility had possession of the CPR certification cards for twenty-six (26) of the twenty-seven (27) regularly | scheduled nurses. f. The remaining nurse was not able to be reached despite multiple documented attempts, normally works every weekend, but will not be placed on the schedule ae et until she provides proof of current CPR certification cards. i g. Arandom sample of eight (8) of the twenty-seven (27) nurse files were reviewed . for curent CPR certification cards to ensure the facility's CPR certification audit i was accurate and no discrepancies were found during this random sample. j 30. That Petitioner’s representative reviewed Respondent’s Charge Nurse (licensed practical nurse) job description signed by employees “B” and “C” on: February 7, 2012 and noted the following relevant information: a. Position Summary: The primary purpose of the Charge Nurse is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines and regulations that govern or facility ... b. Customer Service: 1. Demonstrates positive customer service when performing the role of the Charge Nurse, with residents, family members, facility staff 27 5. 1. and medical staff, . Displays flexibility, team spirit, compassion, respect honesty, politeness, and accountability when dealing with residents, family members and facility staff. Demonstrates an awareness and sensitivity for resident's rights in all interfaces with residents and family members. c. Charting and Documentation: Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor. d. Nursing Care Functions: Review the resident's. chart for specific treatments, medication orders, diets, etc., as necessary. Implement and maintain established nursing objectives and standards. Administer professional services such as: cate for the . dead/dying, etc., as required. Ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes. Inform family members of the death of the resident. e. Care Plan and Assessment Functions: 1. Review care plans daily to ensure that appropriate care is being rendered. Ensure that your nurses! notes reflect that the care plan is being followed when administering nursing care or treatment. f£ Resident Rights: 28 25 oo ; 1. Ensure that all nursing service personnel are knowledgeable of the residents’ responsibilities and rights ... 2, Ensure that nursing staff personnel honor the resident's refusal of treatment request. Ensure that such requests are in accordance with the facility's policies governing advance directives. g. Minimum Skills/Experience/Education: 1, Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long term care. 2. Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality of care, 31.‘ That Petitioner’s representative interviewed Respondent’s administrator and. staffing coordinator, reviewing with them in-service records and CPR certifications on May 16, 2012, and the following was noted: a, The facility had twenty-seven (27) regularly scheduled nurses. b, All twenty-seven (27) nurses had attended the re-education/in-servicing on code status, CPR, and DNR with the last nurse completed by telephone on May 16, 2012. c. On May 15, 2012, Respondent only had seventeen (17) out of twenty-seven (27) _ regularly scheduled nurse CPR certifications on file. d. On May 16, 2012, Respondent had obtained twenty-six (26) out of twenty-seven (27) CPR certifications on file and this was verified by random sampling. e. Respondent set up a CPR course in the facility on May 22, 2012 for any nurses whose certifications were close to expiring as well as any PRN staff that were 29 32. 33. ae lacking current certification. The staffing coordinator was provided. with a list of staff that needs CPR certification prior to being placed on the schedule. The assistant director of nursing was signing up for a “Train the Trainer” course so she would be a qualified teacher for the CPR course and could conduct it on- site whenever necessary. That Petitioner’s representative conducted random interviews on May 15 and 16, 2012 with seven (7) of the regularly scheduled nurses either in person or by telephone, the nurses being representative of all three (3) ‘shifts, and all of the nurses were able to correctly verbalize the facility's policy and procedure for responding in the event that a resident is found unresponsive and without vital signs That Respondent initiated the following action plan: a b, April 30, 2012 - Suspended nurses involved and 1:1 education provided to each. April 30, 2012 and on-going - In servicing of nursing staff. April 30, 2012 - Audit of all residents in facility to verify code status. April 30, 2012 - Audit of charts for yellow DNR form. May 15, 2012 and ongoing - Audit of licensed staff for CPR certification (25 of 27 are current). May 15, 2012 and on-going - Audit of C.N.A.'s for CPR certification, which is not requited per their job description, however they are going to get all C.N.A.'s certified that do not have it, May 15, 2012 and ongoing - Random code drills to include all shifts. May 15, 2012 on-going - Schedule CPR certification classes, with the first one scheduled May 22, 2012. Will be reviewed in QA for at least 3 months. 30 ~) 34, That the above reflects Respondent’s failure to ensure the provision of adequate: and appropriate health cate 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, and with established and recognized practice standards within the community and or failed to ensure the facility was maintained in a safe manner where Respondent failed, inter alia, to: a. Initiate CPR for a resident who had not executed a DNR when the resident was found absent of respirations and pulse. b, Implement Respondent’s policies and procedures entitled, Cardiopulmonary Resuscitation (CPR) and Code Blue, effective March 2012, for a resident found absent of respirations and pulse. c. Honor the expressed wishes of the health care proxy/family member of an incapacitated resident. . 35. That the Agency determined that these failures presented 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 the and cited this deficient practice as an Isolated State Class I deficiency. WHEREFORE, the Agency seeks to.impose an administrative fine in the amount of ten thousand dollars ($10,000.00) against Respondent, a skilled nursing facility in the State of - Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2011). COUNT II 36. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I of this Complaint as if fully set forth herein. - 37. Based upon Respondent’s cited State Isolated Class I deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, 31 o) ) or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(a), Florida Statutes (2011). WHEREFORE, . the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Flosida Statutes (2011) commencing May 17, 2012, and ending June 14, 2012. COUNT III 38. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I of this Complaint as if fully recited herein. 39. Respondent has been cited for a State Class I deficiency and therefore is subject to a six (6) month survey cycle for a petiod of two years and a survey fee of six thousand dollars ($6,000) pursuant to Section 400,19(3), Florida Statutes (2011). WHEREFORE, the Agency intends to impose a six 6 month survey cycle for a period * of two years and impose a sutvey fee in the amount of six thousand dollars (86,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2011). Respectfully submitted this’ ‘3 day of September, 2012. Thofads’J, Walsh II, Esquire FI6. BarNo. 566365 Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727,552.1947 (office) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2011), Respondent shall post the most current license in a prominent place that is in clear and unobstructed public view, at or near, the place where 32 a oY residents are being admitted to the facility. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg. #3, MS #3, Tallahassee, Florida, 32308, (850) 412-3630, RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY, ~ CERTIFICATE OF SERVICE - I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7012 1010 0000 5357 3412 to Joel Gaitan, Administrator, 1061 Virginia Street Operations LLC d/b/a Lakeside Oaks Care Center, 1061 Virginia Street, Dunedin, Florida 34698, and by Regular U.S. Mail to Corporation Service _ Company, Registered Agent for 1061 Virginia Street Operations LLC, 1201 Hays Street, Tallahassee, Florida 32301, on this _/} day of September, 2012. i “Walsh II; Esquire rp No. 566365 WY acy for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1947 (office) Copies furnished to: Joel Gaitan Corporation Service Company Thomas J. Walsh, II Administrator Registered Agent for Senior Attorney Lakeside Oaks Care Center 1061 Virginia Street Agency for Health Care Admin, 1061 Virginia Street Operations LLC 525 Mirtor Lake Drive, #330G ~ Dunedin, Florida 34698 1201 Hays Street St. Petersburg, FL 33701 (US Certified Mail) Tallahassee, Florida 32301 (nteroffice Mail) (Regular U.S. Mail) Patricia Caufnan Field Office Manager Cnteroffice Mail) 33 eta diet eon: ~~ RICK SCOTT Lo. ELIZABETH DUDEK GOVERNOR . SECRETARY August 14, 2012 LAKESIDE OAKS CARE CENTER 1061 VIRGINIA ST : DUNEDIN, FL 34698 Dear Administrator: ‘ The attached license with Certificate #17699 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for a status change to Standard, Sincerely, Re Mea Agency for Health Care Administration Division of Health Quality Assurance Enclosure ec: Medicaid Contract Management 2727 Mahan Drive, MS#33 Visit AHCA online at Tallahassee, Florida 32308 ahca.myfiorlda.com PIOUTEO ALVC NOLLWHldXa CLOC@/PI/0 “ALVC AALLOGSAa SONVHDS SO.LVLS Sdadd £6 -IVLOLE 869re Td ‘“NIGANNG LS VINIDUIA 1901 YaALNED WAV SAVO ACISAMVT Sarmoyjoy ap ayerado 0} pozuoune S] SastIsOT] otf se pue ‘sammEIS epUOLy ‘TT Wed ‘OOr Jaideyo um pezuowne ‘nonensimmapy aep Myeey 10,5 Aouasy ‘epioy{ Jo 721g amp Aq padope suonemsar pue sopni omy quam porduroo sey DTI SNOLLVYAdO LAFALS VINIDMIA T90T 32m wANZWOO'O} St STUY, AIWOH DNISUON GONVANSSV ALTIVND HETVaH AO NOISIAIG . NOLLVALSINUINGY dav0 HL TVaH YOd AONADV BPLIOL] JO 9381S CO6OOISTHNS -# FSNAOTT , ; 669LT # A LVOIMILYHO- . : FIORDAAGENCY FORHEATHCOEADMINGTEATON i RICK scoTT ELIZABETH DUDEK ° { GOVERNOR SECRETARY } ; August 14, 2012 LAKESIDE OAKS CARE CENTER | 1061 VIRGINIA ST ' DUNEDIN, FL 34698 Dear Administrator: The attached license with. Certificate #17698 is being issued for the operation of your facility: Please review it thoroughly to ensure that all information is correct and consistent with your records, If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for a status change to Conditional. ' ; Sincerely, A Mem Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce; Medicaid Contract Management 2727 Mahan. Drive, MS#33 Tallahasses, Florida 32308 Visit AHCA online at ahea.myflorida.com SCHd &6 “IVIOL se9re Ta ‘NIGENAG aoe LS VINIDSEIA 1901 “MELLNSS FAV SAVO ACISHAVT i ‘SUIMOTOE syeiedo 0} pazuoqne. ‘ST 2ast20{] oqy-se pue ‘souaeag epuogy T ued ‘oor Jodeyp a peznomne HOPBRSTMTAPY 3722 TPeoH JOF ionsy “epHOLy JO 212g. om Aq pexdobe ‘suonemsar pue semn oun pra peydarc5 ser OTL SNOLEWaadO LARALS VINIOUILA 1901 wm canto OF SISTYLE, “TWNOLLIGNOD TOOOISTANS #USNEOTT: SSE a ELWOELD RD! Tee got 35o B SENDER Administrator | Lakeside Oaks Care Center _ i 1061 Virginia Street { Dunedin, Florida 34698 7042-1010 0000 5357 3412

Docket for Case No: 12-003477

Orders for Case No: 12-003477