or) \ nad STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 11-00-114 NH METRO DADE CO. PUBLIC HEALTH TRUST, d/b/a PERDUE MEDICAL CENTER, Respondent. ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty one (21) days from the receipt of this complaint, the Agency for Health Care Administration (the "Agency") intends to impose an administrative fine in the amount of twenty thousand ($20,000) Dollars upon Metro Dade Co. Public Health Trust, d/b/a Perdue Medical Center ("Respondent"). As grounds for this administrative fine, the Agency alleges as follows: 1. The Agency has jurisdiction over Respondent by virtue of the provisions of Chapter 400, Part II, Florida Statutes (“F.S.”) 2. Respondent is licensed to operate, under license number SNF1435096, a 163 beds. nursing home at 19590 Old Cutler Road, Miarni, Florida 33157, pursuant to Chapter 400, Part Il, F.S., and Chapter 59A-4, Florida Administrative Code (F.A.C.) 3. On or about June 9, 2000, as a result of a survey conducted by personnel from the office of the Agency for Health Care Administration it was found that: (A) The facility failed to implement effective written policies and procedures to ensure that residents are free from mistreatment, neglect and abuse. The findings included: bane Nd (1) Staff interview and review of clinical records, the facility’s policies and procedures, and employee’s personnel files, revealed that an employee had been hired by the facility as a custodial worker II, for the environmental services department, on 12/29/96. Review on 6/07/00, of this employee’s personnel file, failed to reveal a documented background abuse registry check for him prior to his being given access to the resident population. Moreover, interview with the Agency Tallahassee central office at 2:00 p.m. on 6/09/00, revealed that a review of the abuse registry checks conducted for the facility failed to show a request for an abuse clearance for this employee. Further specific request of the above-mentioned abuse registry check was made to the Assistant Director of Patient Care Services/Abuse Reporting Coordinator (ADPCS) on 6/07/00 at 11:40 a.m. At that time, the ADPCS stated she might not have an abuse background screening check for this employee, as she did not feel that they had an abuse registry for non-license/non-certified personnel. On eight separate instances throughout the survey period, surveyors repeatedly requested the abuse background screening from the Director of Patient Care Services, ADPCS and/or Acting Administrator. When the request was made of the Administrator, she replied that they were in the process of attempting to acquire that information from Jackson Memorial Hospital (JMH)/Public Health Trust (PHT) Human Resources Department since the Perdue Medical Center is a satellite nursing home owned/overseen by the PHT. Interview on 6/09/00 at 11:00 am, with administrative staff from the Risk Management division of the PHT/JMH revealed that they were still in the process of trying to find the abuse background screening check for this custodial worker. JMH/PHT failed to produce the record throughout the survey. Further review of this employee’s personnel file revealed that although he was hired on 12/22/96, the only Florida Department of Law Enforcement (“FDLE”) criminal background check available in his personnel file was date 9/23/98. On 6/07/00 at 3:00 p.m., the administrator stated that she relied on the screening of all employees on the PHT/JMH Human Resources Department for confirmation that they (PHT) had performed and obtained a clearance from the FDLE and Abuse Registry on each employee and that they send only 2 ined \ aed employees that had cleared the FDLE and Abuse Registry to work at the facility. In addition, the interview with the Administrator revealed that current system, in place at the time of survey, to screen employees did not include actual documentation made available to her for inclusion in the employees personnel files maintained at the facility that verified results indicating the actual status of the FDLE and Abuse background check of the employee. Interview on 6/09/00 at 11:00 a.m. with administrative staff from the Risk Management division of the PHT/JMH revealed that they were still in the process of trying to find the abuse background screening check for this custodial worker. (2) Review of the facility’s policy and procedure for Resident Abuse (code number 420, with last revised date 2/22/00) revealed that the facility failed to develop a policy and procedure that delineates the facility’s screening process to verify that all hired employees are screened for a potential history of abuse, neglect or mistreatment, or disqualifying offenses that would prevent an employee from being hired. (3) Interview with ADPCS on 6/07/00 2:30 p.m. regarding written evidence on how an investigation was conducted for a substantiated allegation of abuse revealed that only one case had occurred of possible sexual assault and that she would provide the documentation surrounding the incident. Review by the surveyors on 6/06/00 at 4:45 p.m. of the offered documentation regarding the possible sexual assault incident revealed the following materials: documentation by the witness who identified the custodial worker as the employee responsible for the witnessed fondling of sampled resident #22 and a statement written by the Environmental Supervisor on 4/19/00 of the interview conducted by the Acting Administrator with the custodial worker on 4/17/00 where the custodial worker admitted to “putting his hands on her (resident #22) butt and her breast.” Review of the documented interview of the custodial worker reveals that he stated “he got caught re-handed, but that it was not the first time that it had happened.” (4) ‘Further review of the custodial worker’s employee file revealed witness statements from the DPCS and ADPCS. Review of the statement revealed that he! \nd Administrator, the DPCS and ADPCS were aware on 4/14/00 at 4:50 p.m. of the fondling of a resident by the custodial worker. Review of the statement written by the DPCS, where she, the acting Administrator and the ADPCS were present on 4/24/00 stated that on 4/14/00 at 4:50 p.m. an employee “came to the administrative office in tears.” At this time, the employee stated, that she had seen the custodial worker: “pat” the bottom of one of the female residents. She stated also, that she “had seen him hold the same resident to escort her in the hallway in such a manner that his hand was touching the resident’s breast, demonstrated on the DPCS, both the “pat” and how he was holding the resident to touch her breast. She stated she had seen his inappropriate behavior on numerous occasions and had reported it to the nurses. She reported the “patting” incident to the charge nurse on 4/14/00, but stated “J just can’t take it anymore and I am going to report it to (ADPCS) too.” (5) Review of personnel files for newly hired employees within the last six months revealed that seven of eight employees had not been formally trained in the abuse policy and procedures to protect residents from potential abuse. The employees hired between February 7, 2000 - May 15, 2000, did not receive formal abuse training. Interview with the ADPCS on 6/06/00 at 11:40 a.m. concerning the lack of abuse training for the newly hired employees, revealed that their regular abuse trainer resigned on May 12, 2000. At that time, the ADPCS took over the position. She then stated that she had been on vacation from May 22, 200 — June 5, 2000, at which time the DPCS took over for that time period. Surveyor again requested for any formal abuse training documentation that newly hired employees had been formally trained in the facility’s policy and procedures to protect residents from abuse. At that time, the ADPCS stated that she did not have any documentation available to show that the newly hired employees had been formally trained in the facility’s policies and procedures to protect residents from abuse. Interview with ADCPS on 6/06/00 at 2:30 p.m. revealed that formal documented training for identifying and assessing potential or actual victims of alleged or suspected abuse or neglect is to be conducted the second week of orientation upon hire at the facility. Review of staffing logs 4 rw] wd and employee-staffing list revealed that at least four of the seven newly hired and untrained employees, with regards to potential resident abuse, are currently working in the facility with direct resident contact. (6) _ Interview on 6/06/00 at 2:30 p.m., with ADPCS, while conducting the Abuse Prohibition Review revealed that the facility had only one substantiated allegation of abuse. At that time, surveyor requested the written documentation of the investigation conducted. Review on 6/06/00 at 4:45 p.m. with the ADPCS, in her office of the written documentation of the substantiated allegation revealed the following: A handwritten note on a plain white piece of paper, dated 4/21/00, where it is documented by ADPCS that she called Department of Children and Families Adult Protective Services on 4/21/00 and who she spoke with. The note also contained the information the ADCPS gave with regards to the employee/alleged perpetrator; a handwritten note dated 4/19/00 written by the Environmental Supervisor detailing the interview conducted on 4/17/00 with the employee suspected of abuse by the Acting Administrator. Review of the note on 6/06/00 at 4:45 p.m., revealed that the employee admitted to the alleged fondling, consisting of “putting his hand on her butt and breast.” He also admitted that he “got caught red-handed, but it was not the first time that it had happened”; a typed and signed letter dated 4/19/00 from the employee documenting the conversation his statement discuss the employee’s concern with regards to his/her witnessed fondling of a resident by another employee. After review of the aforementioned documentation on 6/06/00, at 4:45 p.m., surveyors requested further information ‘documentation regarding the investigation of the sexual assault and possible identification of other possible victims and/or incidents, as referred to in the custodial worker/ perpetrator’s statement. Surveyors also requested the examination performed on the resident in question in regards to the sexual assault. A request was also made for the time card of the alleged perpetrator/custodial worker for 4/14/00; the employee’s file, including the FDLE and Abuse Background Check, the disciplinary action report and his/her termination letter. Further teview of this requested documentation revealed. that there were typed and signed witness 5 bee Need statements by the DPCS and the ADPCS which revealed the following: Review of the statement written by the DPCS, where she, the Acting Administrator and the ADPCS were present on 4/24/00. It states that on 4/14/00, at 4:50 p.m., an employee “came to the administrative office in tears.” At this time the employee stated, that she had seen the custodial worker: “pat” the bottom of one of the female residents. She stated also, "had seen him hold the same resident to escort her in the hallway in such a manner that his hand was touching the resident’s breast, and she demonstrated on me (DPCS), both the “pat” and how he was holding the resident to touch her breast. She stated she has seen his inappropriate behavior on numerous occasions and has reported it to the nurses. She reported the “patting” incident to the charge nurse on 4/14/00, but stated “I just can’t take it anymore and I am going to report it to ADPCS too.” Interview on 6/06/00, at 1:45 p.m., with the ADPCS revealed that it is the facility’s policy to complete an incident/accident report for all suspected abuse cases and accidents. Review of the facility’s policy and procedure, “Incident Report Procedure for Care of Resident/Visitor/Volunteer (ADMIN 422/NSG162, initial approval date October 2, 1995) states that: “An incident report shall be completed in full on all resident/visitor/volunteer incidents at the time of their occurrence. If the incident involves a resident, a nursing investigation of Accident/Incident/Suspected Abuse Form shall be completed by the supervisor.” The interview further revealed that the ADPCS stated, “you know she (resident) was a lady of the evening.” Interview with the ADPCS on 6/06/00, at 5:00 p.m., revealed that she had not completed an Incident Report on the alleged sexual assault on 4/14/00 with sampled resident #22, The interview further revealed that she did not feel that an incident report needed to be completed due to the sensitive nature of the incident. The interview with the ADPCS also revealed the facility failed to document that an examination to the sampled resident #22 had been done after an employee witness reported the resident being fondled by a staff member. At this time, the ADPCS was questioned as to whether the resident was able to express what had happened in regards to the sexual assault. The ADPCS explained at that time, that the resident does try to express things, however, 6 he! i] most of the time they (the facility staff) are unable to understand what she is trying to express. The employee witness reported the sexual fondling incident on 4/14/00, at 4:45, p.m. yet the next available entry in the resident’s clinical record revealed that he/she was not assessed by a registered nurse till 4/14/00, at 10:50 p.m., who wrote “resting comfortably in bed at this time-spent a quiet evening. Three little red areas 0.5 cubic centimeter each on RT (right) buttock. Will monitor clinical record review failed to identify the source of these red areas noted by the nurse on 4/14/00, at 10:50 p.m. Interview with the ADPCS on 6/06/00, 5:00 p.m., revealed that she stated that sampled resident #22 had been examined with a general body assessment, right after the incident occurred, but confirmed that the facility had not documented this assessment. The interview with the ADPCS further revealed that when questioned regarding an examination/investigation to determine the extent of the sexual assault, she stated that no further examination was completed. She stated that she did not feel it was necessary because the employee witness only saw the custodial worker touch sample resident #22’s breast and buttock (over her clothes). The ADPCS was then questioned by surveyors as to the custodial worker/alleged perpetrator’s written admission of having been “caught red-handed, but it was not the first time that it had happened. The ADPCS then stated that she thought “he was gay”, and that the custodial worker was a little crazy and had exaggerated his statements and that he was incapable of committing these acts because of these reasons.” (7) | Clinical record review of sampled resident #22 the alleged victim of the sexual assault, admitted on 8/12/93 with a diagnosis of a closed head injury/intracranial injury, seizure, dementia, failed to document the sexual assault or the actions taken by the facility when it was reported by the witnessing employee. Further clinical record review revealed that at the time of the incident, the facility had assessed the resident’s cognitive status as a 2(B4) moderately impaired/decisions poor; cue/supervision required as recorded on the Minimum Data Set (MDS) from 3/13/00. Review of the facility’s policy and procedure, (Resident Abuse, code number 420 for all departments, last revision date February 7 Mae \need 2, 2000) states that “documentation of the suspected abuse/neglect is to be entered in the resident’s medical record by qualified clinical staff.” Interview with ADPCS on 6/06/00. at 5:00 p.m., revealed no further investigation, as noted by comments made above. The ADPCS also stated that the police did not need to be called to investigate because she felt it was not warranted. The ADCPS confirmed that sexual assault incident occurred to sampled resident #22 on 4/14/00 at 4:45 p.m. and the facility did not call the Department of Children and Families(DCF)-Adult Protective Services(APS) division till 4/21/00 at 11:06 a.m. This was confirmed, via facsimile transmittal, obtained from the (DCF) District 11 APS. Further clinical record review of sampled resident #22’s chart, revealed a picture taken by the facility on 8/07/99 (copy available), which revealed two large bruises to the right forearm. Review of the progress records reveal documentation on 8/07/00 at 1:00 p.m. that stated “resident was observed with a few discolored areas “resident was observed with a few discolored areas on right arm and right wrist while giving care....K-RAY of right hand wrist ordered. Resident was unable to tell how and when it happened.” Interview with the ADPCS on 6/07/00, at 2:00 p.m., for further information regarding this injury, revealed that she did not know how the injury had occurred and that she did not have any documentation to show that Incident Report or investigation of the incident was conducted. The ADPCS further stated that an investigation to determine if the injury was a result of abuse or neglect, and was not done and when asked why it was not done she stated she did not think it was warranted. (8) | Based on the evidence discovered with regards to the bruising of unknown origin for sampled resident #22 and the facility’s inability to provide documentation the etiology for the injury’s origin/source and the rationale for not investigation of the incident to rule out possible abuse or neglect, further information was requested from the facility on 6/07/00 in the morning. Upon review of nine incident reports between 01/27/00 through 5/11/00, it was discovered that there appeared to be injuries of unknown origin. These incidents were then presented to the facility for documentation of an investigation into these incidents and/or rationale for not investigating these injuries if unknown origin to rule out abuse or neglect. On 6/07/00, at 2:45 p.m., the Acting Administrator stated to surveyor that in the process of reviewing the incident reports in question and in speaking to the Risk Management Department of JMH/PHT, that she agreed that the facility’s investigative process did have faults. The Acting Administrator stated that their only explanation as to not determining that these incidents were not a result of abuse was because “they know their residents.” A subsequent meeting on 6/7/00, at 2:50 p.m., with the Acting Administrator, DPCS and the ADPCS, revealed that five incidents involving four separate residents of the nine incident reports presented showed that the facility did not have a reason as to the origin of the injury not an explanation/rationale as to why an investigation was not conducted to rule out possible abuse or neglect. The following incidents described were reviewed with the above mentioned individuals revealing their lack of investigative process to rule out abuse: Incident #1, dated 01/27/00, which reports “resident observed during rounds with fading bruise around RT ... resident unable to explain what happened;” incident #2, dated 01/30/00, reports “resident was found in bed showing an ecchymotic area, noted over the right eyelid measuring 2.5 cm (cubic centimeters) x (by) 0.5 cm;” incident #3 dated 2/21/00, “resident noted with purple discoloration on left upper arm (outer aspect) 3 cm circumference, also 4 small scratches (1 cm +0.5 cm + 0.5 cm + 0.5 cm) on face. Resident unable to explain what happened.” incident #4, dated 4/28/00, which reports, “small ecchymotic area about % cm noted on resident’s right upper eyelid.”; incident #5, dated 5/11/00, which reports “resident noted with a discoloration about 3.5 cm x circ. To the right breast. Resident unable to state how incident occurred.” During the interview on 6/07/00, at 2:50 p.m. with administrative/clinical staff, it was revealed that they were unable to provide the surveyors with documented evidence as to their determination that these injuries did not occur as a result of abuse or neglect. (9) After admission from the Acting Administrator regarding the faults in the facility’s investigative process for incidents with injuries of unknown origin, which could he Ww be the result of abuse or neglect, a request was made for the Acting Administrator’s job description. (10) Further review of the policy and procedure for Resident Abuse code 420, revealed that “the Administrator or designee shall assure that a comprehensive investigation of the suspected abuse has been conducted.” The job description afforded the surveyor by the Acting Administrator, entitled Health Services Administrator III — Perdue, working title — Administrator, delineates the following: the Administrator “conducts investigations for alleged resident abuse.” The job description also states that it is the administrator’s responsibility to ensure, “the development and implementation for program operations.” Interview with the Acting Administrator in her office on 6/09/00, revealed that she knew the ultimate responsibility for ensuring that the policies and procedures were implemented to ensure that investigations were completed for incidents where injuries of an unknown source had occurred to rule of possible abuse or neglect, was hers. This is in violation of rule 59A-4.1288, F.A.C., and chapters 483.13(b), 483.13(c) and 483.13(c)(1), CFR. Class I deficiency. $10,000 administrative fine. (B) Based on a review of the facility’s policies and procedures, and other facility documents, it was determined that administration has not taken the necessary action to identify and resolve systemic problems of a serious and reoccurring nature to effectively and efficiently use its resources to maintain residents at their highest practicable physical well being. The findings were as follows: (1) — Administration failed to ensure and protect individuals from possible abuse, neglect, and mistreatment. Based on record review, and substantiated abuse reports, sampled resident #22 was sexually assaulted on 4/14/00 by an employee that had not been screened by the abuse registry prior to being allowed access to the resident population. (2) Administration failed to ensure that an investigation was conducted into extent of the sexual assault on resident #22 and identification of other possible victims, as referenced to in a statement given by the perpetrator on 4/17/00 and documentation from 10 hee! Nd the witness’s statement to the DPCS on 4/14/00 at 4:45 p.m., to protect and provide any necessary care that resulted from the abuse. (3) | Administration failed to ensure that formal abuse training was conducted with 7 of the 8 new employees hired between 02/00 and 5/00 to enable the employees to identify and protect residents from abuse, neglect, and mistreatment, and to be knowledgeable on the facility’s reporting process. (4) | Administration failed to ensure that all injuries of unknown etiology are investigated to determine if these injuries occurred as a result of abuse, neglect and mistreatment. Based on record review, interviews with administration and clinical staff, and other facility documentation, six of ten incidents of injuries of unknown source were found to have no documentation as to any investigation conducted to determine that the injuries were not result of abuse, neglect, and mistreatment. This is in violation of Rule 59A-4.1288, F.A.C., Chapter 483.75 CFR. Class I deficiency. $10,000 administrative fine. 4. The above referenced violations constitute grounds to levy this administrative fine pursuant to Sections 400.121, and 400.23(8)(a) , F.S., in that Respondent has violated the minimum standards, rules and regulations promulgated by the Agency under.Chapter 400, Part II, F.S. 5. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, F.S.; to be represented by counsel (at its expense); to take testimony, to call and cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding, your request for an administrative hearing must conform to the requirements in Rule 28-106.201, F.A.C., and must state which issues of material fact you dispute. Failure to dispute material issues of fact in your request for a hearing may be treated by the Agency as an election by you of an informal proceeding under Section 120.57(2), F.S. ve ky VY All requests for hearing and payment of fines shall be made to Agency for Health Care Administration Manchester Building, 1st Floor 8355 N.W. 53rd Street Miami, Florida 33166 Attention: Pury Lopez Santiago, Assistant General Counsel 6. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY ONE (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. THEREBY CERTIFY that a true copy hereof was sent by U.S. Certified Mail, Return Receipt Requested, to Terry Reardon, Administrator, Perdue Medical Center, 19590 Old fy Cutler Road, Miami, Florida 33157 on this’” day of (hug hha A , 2000. Jan Kimball, Fiefd Office Manager Agency for Health Care Administration Manchester Building 8355 N.W. 53rd Street Miami, Florida 33166 Copy to: Pury Lopez Santiago, Assistant General Counsel Agency for Health Care Administration Manchester Building, 1st Floor 8355 N.W. 53rd Street Miami, Florida 3316 Nursing Home Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 12

Docket for Case No: 00-003660