STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE Certified Article Number ADMINISTRATION, 7106 4575 1294 2050 3829 Petitioner, SENDERS RECORD vs. AHCA CASE NO. :2002015311 OddT40 ALI PALMER RANCH EAST, INC D/B/A z i ALTERRA HEALTH CARE RESIDENCE oo e Respondent. . / 2 ADMINISTRATIVE COMPLAINT _ aa COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (herein after referred to as PETITIONER), by and through its undersigned counsel, and files this Administrative Complaint against ALI PALMER RANCH EAST, INC, D/B/A ALTERRA HEALTH CARE RESIDENCE (hereinafter referred to as RESPONDENT), pursuant to Sections 120.569 and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine against Respondent pursuant to Section 400.102(1)(d) and Section 400.23(8), Florida Statutes (2001), and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 3. PETITIONER has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes (2001). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2001). PARTIES 5. PETITIONER is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. Respondent is and was at all times material hereto a licensed nursing home with a principal address of 5111 Palmer Ranch Parkway, Sarasota, Florida, 34238, with assigned license #130471010 COUNT I Respondent failed to maintain the highest practicable level of physical well being of a resident (resident #9) by failing to completely and accurately assess the physical needs of Resident #9 who is at risk for incident and/or accident. The facility failed to develop an adequate plan of care to prevent Resident #9 from an accident which resulted in a laceration on his head. 42 CFR §483.25 (2001) Section 400.022 Fla.Stat. (2001) Rule 59A-4.106, Fla. Admin. Code (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) 7. PETITIONER re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 8. On or about February 21, 2002, PETITIONER conducted a survey at Respondent's facility. An isolated class II deficiency was cited based on the following findings: Based on observations, record reviews and staff interviews, the facility failed to maintain the highest practicable level of physical well being of 1 (Resident #9) Resident from a sample of 12 residents reviewed. This is evidenced by: 1) The facility failed to completely and accurately assess the physical needs of Resident #9, who is at risk for incident and/or accident. 2) The facility failed to develop an adequate plan of care to prevent Resident #9 from being involved in an accident which resulted in a laceration on his head. The findings include: 1. During the initial tour on 2/19/02 at approximately 10:00 A.M., the facility staff stated that Resident #9 was newly admitted to the facility. The staff stated that Resident #9 fell within 24 hours after his admission. Observation of the resident during the initial tour revealed he has steri-strips (tape used to hold cuts/incision) on the top of his head. 2. Clinical record review revealed that Resident #9 was admitted from another nursing facility on 2/15/02. The interdisciplinary discharge summary from the facility states, "Alert and oriented times 3 with episodes of confusion and forgetfulness requires face to face contact due to Hard of Hearing. Able to voice most needs without difficulty. Ambulatory unsteady gait. At risk for falls. Personal alarm in use. Requires set-up for ADL's...." 3. During the review of the initial nursing assessment dated 2/15/02, it stated the resident is "very angry and refusing to cooperate." The nurse ended her assessment with, "will observe and supervise closely." Further review of the resident's clinical record revealed no documentation to indicate that the resident was assessed adequately, including his risk for falls. There is no documentation in the resident's clinical record to indicate that the resident was "supervised closely." There is no documentation in the clinical record to indicate that a plan of care was developed to address his risk for falls, as stated in the transfer/discharge summary, from the transferring facility. There is no documentation in the resident's clinical record to indicate that the facility attempted to prevent an incident and/or accident involving the resident. Review of the nurse’s notes, dated 2/16/02, stated that the resident refused all ADL (Activities of Daily Living) care and vitals. It further stated, "very angry this am, yelling at staff.” Further review of the nurse’s notes, dated 2/16/02 revealed, "Resident found lying on left side on floor in room 139 in front of chair. Back of head with 3 cm laceration, bleeding moderate amount." 4. Review of the acute care plan, dated 2/16/02, revealed no documentation to indicate that the resident's risk for incident/accident was addressed. The only concern addressed in his plan of care was "alteration in thought process.” The plan of care did not include measures to provide safety for the resident to prevent an incident and/or accident. 5. During an interview with the Clinical Coordinator on 2/22/02 at 1:30 P.M., she stated that she had a "nurse to nurse" report from the transferring facility on 2/15/02. The nurse, from the transferring facility, informed her that the resident has Dementia. She stated this was the only concern. Further investigation revealed that the Clinical Coordinator did not review the interdisciplinary discharge summary completed by the transferring facility on 2/15/02. She stated that she "would have added" a written plan of care for falls and hearing if she had seen this interdisciplinary discharge summary. 9. Based on all of the foregoing, Respondent violated 42 CFR § 483.25, and/or Chapter 400.022 Fla.Stat. (2001) by failing to maintain the highest practicable level of physical well being of a resident (resident #9) by failing to completely and accurately assess the physical needs of Resident #9 who fs at risk for incident and/or accident. Further, The facility failed to develop an adequate plan of care to prevent Resident #9 from an accident which resulted in a laceration on his head. 42 CFR § 483.25 states in pertinent part as follows: Sec. 483.25 Quality of care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. (a) Activities of daily living. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable, This includes the resident's ability to-- (i) Bathe, dress, and groom; (ii) Transfer and ambulate; ii) Toilet; (iv) Eat; and (v) Use speech, language, or other functional communication systems. (2) A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section; and (3) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. (b) Vision and hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-- (1) In making appointments, and (2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. (c) Pressure sores. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. (d) Urinary Incontinence. Based on the resident's comprehensive assessment, the facility must ensure that-- (1) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and (2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. (e) Range of motion. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and (2) A resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (f) Mental and Psychosocial functioning. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem, and (2) A resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that such a pattern was unavoidable. (g) Naso-gastric tubes. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident's Clinical condition demonstrates that use of a naso-gastric tube was unavoidable; and (2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills. (h) Accidents. The facility must ensure that-- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (i) Nutrition. Based on a resident's comprehensive assessment, the facility must ensure that a resident-- (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem. (j) Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. (k) Special needs. The facility must ensure that residents receive proper treatment and care for the following special services: (1) Injections; (2) Parenteral and enteral fluids; (3) Colostomy, ureterostomy, or ileostomy care; (4) Tracheostomy care; (5) Tracheal suctioning; (6) Respiratory care; (7) Foot care; and (8) Prostheses. (1) Unnecessary drugs--(1) General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (i) In excessive dose (including duplicate drug therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above. (2) Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. (m) Medication Errors. The facility must ensure that-- (1) It is free of medication error rates of five percent or greater; and (2) Residents are free of any significant medication errors. (42 CFR 483.25-in pertinent part) 59A-4,106 Facility Policies. (1) Admission, retention, transfer, and discharge policies: (a) Each resident will receive, at the time of admission and as changes are being made and upon request, ina language the resident or his representative understands: 1. A copy of the residents’ bill of rights conforming to the requirements in Section 400.022, F.S.; 2. A copy of the facility’s admission and discharge policies; and 3. Information regarding advance directives. (b) Each resident admitted to the facility shall have a contract in accordance with Section 400,151, F.S., which covers: 1. A list of services and supplies, complete with a list of standard charges, available to the resident, but not covered by the facility’s per diem or by Title XVIII and Title XIX of the Social Security Act and the bed reservation and refund policies of the facility. 2, When a resident is in a facility offering continuing care, and is transferred from independent living or assisted living to the nursing home section, a new contract need not be executed; an addendum shall be attached to describe any additional services, supplies or costs not included in the most recent contract that is in effect. (59A-4.1 06 Fla Admin Code Facility Policies.-in pertinent part) 10. Pursuant to Section 400.23(8), Florida Statutes, the foregoing constitutes an isolated class II deficiency. This deficiency is defined in this statute in pertinent part as follows: (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations, A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more thana very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of deficiencies as follows: (b) A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. (Section 400.23(8), Fla.Stat. 2001-in pertinent part), 11. Pursuant to Section 400.23(8), Florida Statutes, PETITIONER is may assess a fine against Respondent for this deficiency. CLAIM FOR RELIEF WHEREFORE, PETITIONER respectfully requests the following relief: 1) enter findings confirming the allegations delineated hereinabove; 2) Impose a $2500 fine against Respondent; 3) Grant any other general and equitable relief as deemed necessary in the furtherance of justice COUNT II Respondent failed to maintain the highest practicable level of physical status of a resident (resident #5) who was admitted to the facility continent and declined to frequent incontinence from a sample of 12 residents. The facility failed to provide appropriate treatment and services for Resident #5 to restore as much bladder function as possible. 42 CFR §483.25 (2001) Section 400.022 Fla.Stat. (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) 12. PETITIONER re-alleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 13. Onor about February 21, 2002, PETITIONER conducted a survey at Respondent’s facility. A class II deficiency was cited based on the following findings: Based on observation, review of the clinical record and CNA Flow Sheets and resident and nursing staff interviews the facility failed to maintain or attain the highest practicable physical status for 1 (Resident #5) resident who was admitted to the facility continent and declined to frequent incontinence, from a sample of 12 residents. The facility failed to provide appropriate treatment and services for Resident #5 to restore as much normal bladder function as possible. This is evidenced by: 1) Lack of assessment of the cause of the incontinence, 2) Lack of reassessment of the resident when incontinence developed. 2) Lack ofa care plan to address the resident's incontinence and lack of a bladder retraining program. The findings include: 1. Review of the nurse's notes completed at admission, dated 09/13/01, revealed that the resident was alert and oriented X 3 and continent of bowel and bladder. Review of nurse's notes from 9/14/01 through 9/16/01, indicated that the resident continued to be continent. Review of Resident #5's admission Minimum Data Set (MDS) assessment completed on 09/25/01, revealed that the resident was coded a "0" - indicating totally continent. Review of the care plan dated 09/28/01, indicated that the resident was at risk for decline in Activities of Daily Living (ADL) function due to recent change in environment and visual impairment. The goal was to maintain highest level of functioning such as toileting self with stand by assistance through next review date of 12/18/01. Further review of the nurse's notes dated 10/14/01 at 6:45 P.M., revealed that the resident had fallen in his room by the bathroom door. It was documented that he was weak from an upper respiratory infection and failed to put the call light on. Documentation in the nurse's notes dated 10/20/01 at 0600 revealed, "Fell in bathroom. I slipped on my urine." Also stated, "I hit my head...” Review of Incontinence Monitoring Record, completed from 12/01/01 through 12/03/01, indicated that the resident was incontinent 1 to 2 times a day on each day monitored. Review of the Bowel & Bladder Assessment, completed on 12/17/01, indicated that the resident was alert with awareness of need to void and motivated to be continent. The assessment also indicated that the resident needed assistance with toileting. The assessment stated that the resident was occasionally incontinent (2 or more times per week, but not daily). The potential factors contributing to incontinence were: Diabetes, psychoactive medications, macular degencration and mild to moderate Dementia. The summary statement that determined the outcome of the bladder assessment was not completed and the form did not include documentation on how the facility would proceed to address the resident's incontinence. Review of the MDS quarterly assessment dated 12/1 8/01, indicated that the resident needed assistance with toileting and had declined to a "3" - frequently incontinent of bladder (incontinent daily, but some control present). The MDS indicated that the resident was on a scheduled toileting plan with no bladder retraining program. Review of the resident's care plan updated 12/20/01, revealed no documentation of a care plan to address the resident's incontinence. The ADL Care Plan indicated that it was reviewed, with next review date documented as 03/20/02. There were no changes to the goals or approaches to address the resident's decline in continence. Review of the Care Plan Conference Summary dated 12/28/01, revealed no documentation that the resident's incontinence was discussed. Further review of the nurse's notes dated 01/1 8/02, indicated that the resident was sent to the hospital with an expected return. Documentation in the nurse's notes dated 01/25/02 at 3:40 P.M., revealed that the resident returned from the hospital with an indwelling catheter. Review of the Admission Nursing Assessment dated 01/25/02, revealed that the catheter had been discontinued on 01/25/02 and that the resident uses the toilet. Under the bladder habits section both "yes" and "no" were circled to answer the question regarding continence. "Yes" was circled as the answer to the question regarding dribbles. Restorative programs checked did not include scheduled toileting or bladder retraining, Further review of the clinical record revealed that a Bowel and Bladder Assessment was not completed after the catheter was discontinued. Further review of the nurse's notes revealed: 02/02/02 11-7 "Incontinent of urine X 2." 02/11/02 11-7 "Incontinent of urine X 2....Needs assistance with ADL's. Unsteady gait. Needs assistance with ambulation and transfer from bed to chair. Lower extremity weakness." 02/12/01 "Inc. (incontinent) of urine X 2. ...Assistance provided with ADL's. Unable to stand or transfer ss (without) assistance of two." 02/19/02 8:15 A.M., "Pt. (patient) found on floor in his room on R (right) side. No apparent injuries noted.” Review of the CNA (Certified Nursing Assistant) Flow Sheet for February 2002, revealed that the resident required one person assistance with toileting. It was documented from 02/01/02 through 02/20/02, that the resident was incontinent on all shifts every day except for three days on the day shift when he was toileted and remained dry. Review of the readmission 5 day Medicare MDS dated 02/04/02 and the 14 day assessment dated 02/08/02, revealed that the resident remained coded as a "3" - frequently incontinent. Scheduled toileting plan was and checked and no bladder retraining was blank. 10 Interview with the Assistant Director of Nursing (ADON), who completed the MDS's, on 02/21/02 at 12:20 P.M., revealed that she uses the nursing assessment and the CNA Flow Sheets to document level of continence when completing the MDS. She stated that she had determined that the resident was frequently incontinent in 12/01, based on the information from the 12/01 flow sheet. She further stated that she used the 2/02 CNA Flow Sheet to determine that the resident was frequently incontinent when she completed her 02/04/02 and 02/08/02, MDS's. Regarding the discontinued catheter, the ADON stated that a new bladder assessment should have been completed after the catheter was discontinued and she did not know why the staff did not complete the assessment. Further interview with the ADON on 02/21/02 at 1:50 P.M., confirmed that the resident was continent on admission and now was incontinent. She stated that she did not know why the resident had a decline and why it was not addressed in the care plan. Review of the care plan on 02/21/02, revealed that it had not been updated since 12/28/01 and contained no care plan to address the resident's continued incontinence. 14. Based on all of the foregoing, Respondent violated 42 CFR § 483.25, and/or Chapter 400.022 Fla.Stat.(2001) by failing to maintain the highest practicable level of physical status for Resident #5 who was admitted to the facility continent and declined to frequent incontinence as the facility failed to provide appropriate treatment and services for Resident #5 to restore as much normal bladder function as possible in violation of Title 42 CFR § 483.25 which states in Pertinent part as follows: Sec. 483.25 Quality of care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, (a) Activities of daily living. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to-- (i) Bathe, dress, and groom; (ii) Transfer and ambulate; (iii) Toilet; (iv) Eat; and (v) Use speech, language, or other functional communication systems, 1] (2) A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section; and (3) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. (b) Vision and hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-- (1) In making appointments, and (2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. (c) Pressure sores. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and (2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. (d} Urinary Incontinence. Based on the resident's comprehensive assessment, the facility must ensure that-- (1) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and (2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. (e) Range of motion. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who enters the facility without a limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and (2) A resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. (f) Mental and Psychosocial functioning. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem, and (2) A resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, untess the resident's clinical condition demonstrates that such a pattern was unavoidable. (g) Naso-gastric tubes. Based on the comprehensive assessment of a resident, the facility must ensure that-- (1) A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident's clinical condition demonstrates that use of a naso-gastric tube was unavoidable; and (2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills, (h) Accidents. The facility must ensure that-- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (i) Nutrition. Based on a resident's comprehensive assessment, the facility must ensure that a resident-- (1) Maintains acceptable Parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem. (j) Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. (k) Special needs. The facility must ensure that residents receive Proper treatment and care for the following special services: (1) Injections; (2) Parenteral and enteral fluids; (3) Colostomy, ureterostomy, or ileostomy care; (4) Tracheostomy care; (5) Tracheal suctioning; (6) Respiratory care; (7) Foot care; and (8) Prostheses. (1) Unnecessary drugs--(1) General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: (i) In excessive dose (including duplicate drug therapy); or (ii) For excessive duration; or (iii) Without adequate monitoring; or (iv) Without adequate indications for its use; or (v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (vi) Any combinations of the reasons above, (2) Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and (ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. (m) Medication Errors. The facility must ensure that-- (1) It is free of medication error rates of five percent or greater; and 13 (2) Residents are free of any significant medication errors. (42 CFR 483.25-in pertinent part) 59A-4,106 Facility Policies. (1) Admission, retention, transfer, and discharge policies: (a) Each resident will receive, at the time of admission and as changes are being made and upon request, in a language the resident or his representative understands: 1. A copy of the residents’ bill of rights conforming to the requirements in Section 400.022, F.S.; 2. A copy of the facility’s admission and discharge policies; and 3. Information regarding advance directives, (b) Each resident admitted to the facility shall have a contract in accordance with Section 400.151, F.S,, which covers: 1. A list of services and su by the facility’s per diem or by Title XVIII and Title XI X of the Social Security Act and the bed reservation and refund policies of the facility. 2. When a resident is ina facility offering continuing care, and is transferred from independent living or assisted living to the nursing home section, a new contract need not be executed; an addendum shall be attached to describe any additional services, supplies or costs not included in the most recent contract that is in effect. (59A-4.106 Fla Admin Code Facility Policies.-in pertinent part) 15. Pursuant to Section 400.23(8), Florida Statutes, the foregoing constitutes an isolated class II deficiency. This deficiency is defined in this statute in pertinent part as follows: (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be Classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems Causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility’s residents. The agency shall indicate the classification on the face of the notice of deficiencies as follows: (b) A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of pplies, complete with a list of standard charges, available to the resident, but not covered correction of the deficiency. (Section 400.23(8), Fla.Stat. 2001-in pertinent part). 16. Pursuant to Section 400.23(8), Florida Statutes, PETITIONER is may assess a fine against Respondent for this deficiency. CLAIM FOR RELIEF WHEREFORE, PETITIONER respectfully requests the following relief: 1) enter findings confirming the allegations delineated hereinabove, 2) Impose a $2500 fine against Respondent; 3) Grant any other general and equitable relief as deemed necessary in the furtherance of justice 4) Agency for Health Care Administration 4y Kichard Jasegh Salle Richard Joseph Saliba, Esquire, As Senior Attorney Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5865 (office): (850) 921-0158 fax

Docket for Case No: 02-004746