PRBR 6G ER Su bho ~ Hundred ($1,400) Dollars upon Integrated Health Services at Central Florida, d/b/a AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA. AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No: 09-01-0044 NH INTEGRATED HEALTH SERVICES AT CENTRAL FLORIDA, INC., d/b/a INTEGRATED HEALTH SERVICES OF VERO BEACH, 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 (hereinafter referred to as the " Agency") intends to impose a civil penalty in the amount of One Thousand Four Integrated Health Services of Vero Beach (hereinafter referred to as "Respondent"). As grounds. for the imposition of this ¢ civil i penalty t the © Agency alleges a as follows: 32960, as a nursing home in compliance with » Chapter 4 400 Part II Florida Statute and Rule 50A- 4, Florida Administrative Code. 3. The Respondent has violated the provisions of Chapter 400, Part II, Florida Statutes, and the provisions of Chapter 59A-4, Florida Administrative Code, in that it STATE OF FLORIDA Lo H ! rc 5 IOV -6 PH 2:4} ON OF MSE SAUIVE failed to correct within the mandated time frame of March 23, 2001 (Section 400.23(4)(c), Florida Statutes) (2) Class III deficiencies, cited during the survey of February 21, 2001. These deficiencies set forth below were still uncorrected when a follow-up visit was made on March 28, 2001. (a) Tag F281. Resident Assessment. The facility failed to follow the physician’s orders regarding medication and treatments. Based on clinical record review, resident and staff interviews, and observations during the annual recertification survey of 2/19-21/01, it was determined that the facility did not practice accepted professional standards of quality. Findings include: dd) Clinical record review of Resident #12 revealed that a nurse documented in the nurses notes on 12/11/00: “Stomach very distended and hard. Digital check indicated impaction. Pt. (patient) refused digital disimpaction. Enema given Await results.” There was no documentation that a physician had been notified of this impaction, and there was no physician’s order for a digital disimpaction or an enema There were no further nurses’ notes regarding this resident’s distended stomach, bowel movements, or results of the enema. The next note that addressed bowel movements was on 12/30/00, which read “focus loose stool data CNA (certified nursing assistant reported loose stool with mal odor throughout hallway. Action will report to 7-3 shift.” There was no further documentation in the nurses’ notes assessing the bowel rhovernentd of this resident or communication with the physician of the abnormal bowel conditions The physician’s progress notes do not reflect any information addressing abnormal bowel eer! - Magnesia every ‘three days. Review of the medication administration record (MAR revealed that this medication had never been administered to this resident. Interview with the Director of Nursing on 02/21/01, at 10:30 am, revealed that there was no system in 2 place for the nurse to assess for bowel movements, and/or to determine if this resident had not had a bowel movement for three days. Therefore the nurse relied on the CNA’S to report all bowel movements to them. The current facility policy does not require the nurse to document this information in the MAR or on any other clinical record. | (3) Resident #20 was readmitted to the facility on 01/19/01 with diagnoses of cardiovascular accident (stroke), dementia, hyperlipidemia, deep vein thrombosis (DVT), and non insulin dependent diabetes (NIDDM). The resident was receiving coumadin 5 mg (an anticoagulant) everyday to treat his/her DVT. The resident was observed in the hallway on the B wing on 02/20/01 at 1:40 pm., with a tegaderm dressing to his/her right elbow, with a pocket of blood underneath the dressing. Chart review of the nurse notes written on 02/17/01 at 5:00 am, revealed that the resident had sustained a fall which resulted in an “abrasion to the upper outer right arm and a scratch on the middle back. The abrasion was cleansed and a tegaderm was applied and the doctor’s answering service was notified”. Further record review revealed that a physician’s treatment order was not available to treat and monitor the abrasion and there were no further documentation in the medical record to indicate that the abrasion was been monitored by the staff. The unit manager was interviewed and was unable to A treatment plan to address the abrasion, she then notified the resident’s physician after the surveyor brought it to her attention. The physician ordered to clean the right elbow with normal saline and apply triple antibiotics ointment everyday. Observation of the resident’s right elbow revealed a laceration approximately 4 inches long with slight redness around the edges. The resident stated the dressing was not changed for 3-4 days. The resident also had a physician order have nothing by mouth except ice chips due tb swallowing problems (dysphagia), the resident also has a gastrostomy tube for feedings, which puts him at a high risk for aspiration. The resident was observed with a pitcher ‘ water with a straw at this bedside on 02/20/01 at 1:30 pm. The resident states that hi & b . cee per drinks from the pitcher. The unit manager was made aware ‘and she stated that the resident is allowed to have ice chips. (4) Based on observation of the 100 wing medication room/pantry the small medication refrigerator had open insulin vials with no date when opened. The staff was not dating insulin when it was opened. The two nurse surveyors observed six vials of insulin that had been opened, there was no date on the bottle or envelope when they were opened. The labels documented discard thirty days after opening. Based on the observation there was no way to determine if the insulin was over the 30 days tl discarding. (2a) This deficiency remained out of compliance during the 3/28/01 revisit, based on the following: ; (1) Resident #10 receives dialysis 3 times a week (M-W-F). The resident was to receive 1! various medications at 10:00 am each day. The physician wrote an order to hold only the hypertensive medications (HTN) prior to the dialysis treatments. Interview with the medication nurse on 3/28/01 at 12 noon revealed the resident did not receive any of his/her medications prior to going to dialysis that morning. (2) The physician ordered Prevacid 30 mg. by mouth every morning. The medication was to be given 30 minutes before the morning meal for sampled resident @#11). The medication ‘ was given at 930 am on 3/28/01. The resident “itd breakfast between 8:00 and 8:30 am. . “B) Random resident (R1) was ordered to Teceive Norvase swith food “ Ae each 1 morning, The n nurse was observed administering the medication at ‘10: 30 am. The} nurse initialed the medication administration record indicating the Norvase was given at 8:30 am. . ; (4) Resident #7 was observed on 3/28/01 to have a soiled dressing on the Right heel. The surveyor asked to see the date on the dressing. The wound nurse 4 ication was given with water. She stated the resident had, just finished breakfast. ‘The ed could not read the date on the dressing and neither could the facility nurse consultant. Review of the treatment record revealed the last date a nurse had signed the dressing was changed was on 3/24/01. The physician ordered the dressing to be changed daily and there was no documentation this was done for 3/25, 3/26 and 3/27/01. This is in violation of rule S9A-4.1288, F.A.C., and 483.20k(3)(i), code of Federal Regulations, uncorrected Class III deficiency, carrying in this instance a $700 civil penalty. (b) Tag F432. Pharmacy Services. Nurses left drugs on top of medication carts in hallway, unattended and not in locked compartment. The facility failed to, provide separately locked, permanently affixed compartments for storage of controlled drugs and to store all drugs and biologicals in locked compartments that only authorized. personnel have access to. Findings include: (1) Inspection of the medication. room on the B wing on 02/21/01 revealed that the emergency drug kit containing schedule II medications was locked with plastic tabs and was not locked with a key and not affixed. The emergency drug kit contains other non scheduled II drugs as: Propoxyphene (Darvocet), Valium ampules, Morphine Sulfate injectable, Ativan tablet, Percocet tablets, and Roxilox (tylox) tablet. Interview with the director of nurses revealed that the pharmacy sends the kit with plastic lock tablets, and the 2 nurses and the supervisor all have access to the kit, Further observations revealed that the staff development coordinator also has a key to the hee “medication room and also has access to the gency narcotic kit. (2) ~~ ~‘During the initial tour on 02/19/01, at 10:20 am, a large tube off medication labeled “Bengay” was on the bedside stand of the resident in room 111] There were confused and disoriented residents wandering the hallways of this unit, that could potentially have access to this medication. (3) On 02/20/01, at the nurse’s station on side “A”, the “Crash Cart” was observed to be unlocked and unattended by personnel authorized to have access to 5 medications. In this cart were two vials. One vial was labeled Heparin and the other labeled Heparin and the other labeled Saline Solution. There were also numerous syringes and a topical germicidal agent in this cart. There were numerous unlicensed personnel with access to these medications. (2b) This deficiency remained out of compliance as observed during the revisit of 3/28/01. Findings include: (1) One nurse was observed at 9:15 am to prepare the following medications for administration: Bactrim DS 1 tablet, Enteric Asprin 325 mg one tablet. Glucotrol 10 mg. 1 tablet, Potassium 20 MEQ | tablet, Lasix 40 mg. 1 tablet, Slo-Bid 1 capsule, Prednisone 20 mg | tablet, Metoprolol 50 mg % tablet. The nurse left the cup of pills on top of the medication cart unattended while he/she went down the hall to get a - stethoscope. (2) A second nurse was observed at 10:15 am to leave a vial of Heparin and a Nitroglycerin patch that had been removed from the sealed envelope it was packaged in. lying on top of the medication cart unattended. The nurse left the cart t4 obtain a syringe from the supply cart. This is in violation of rules 59A-4.1288, F.A.C., 59A-4.112(1) and 483.60(e) Code of Federal Regulations, uncorrected class III deificiency, carrying in this instance 4 $700 civil penalty. Oe . : 4. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.102(1)(c), Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules and regulations for " the operation of a nursing home. 5. Notice was given in writing to the respondent of each of the above violation and the time frame for correction. ELECTION AND EXPLANATION OF RIGHTS FORMS ATTACHED 3 7 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 COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. I HEREBY CERTIFY that a true and correct copy of the foregoing was sent by US. Certified Mail, Return Receipt Requested to Thomas L. McDaniel, Administrator, Integrated Health Services of Vero Beach, 3663 15" Avenue, Vero Beach, Florida 32960, Integrated Health Services at Central Florida, Inc., 910 Ridgebrook Road, Sparks Glencoe, MD 21152m, and to National Corporation Research, Ltd, Inc. 1406 Hays Street, Suite 2, Tallahassee, Florida 32301 on this 7 Vesa of , 2001. | Lie Dia eiland, Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, Florida 33407 Copy to: Nursing Home Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Alba M. Rodriguez, Assistant General Counsel Agency for Health Care Administration 8355 N.W. 53rd Street Miami, Florida 33166 Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 RR Fe OE EI Rp rete ere mae epee spe ee ee a eer EEE

Docket for Case No: 01-004332