STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2002047904 vs. 7 . O27 0164 MARINER HEALTH PROPERTIES VI, LTD., d/b/a MARINER HEALTH OF TITUSVILLE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against MARINER HEALTH PROPERTIES VI, LTD., d/b/a MARINER HEALTH OF TITUSVILLE (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Sixty Five Thousand Dollars ($65,000) and a survey fee in the amount of Six Thousand Dollars ($6,000) for a total of Seventy One Thousand Dollars pursuant to Sections 400.102 (1) (a) and (d), 400.19(3), 400.121(1), and 400.23(8) (a) and (b), Florida Statutes. 2. The Respondent was cited for the deficiencies during the annual survey conducted on or about September 27, 2002. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Brevard County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28-106.207, Florida Administrative Code. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 2225 Knox McRae Drive, Titusville, Florida 32780. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO NOTIFY PHYSICIANS OR FAMILY OF SIGNIFICANT CHANGES IN THE BLOOD SUGAR LEVELS OF DIABETIC RESIDENTS. VIOLATING RULE 59A-4.1288, Florida Administrative Code INCORPORATING BY REFERENCE 42 CFR 483.10(b) (11); §400.022 (1) (1) Fl. Stat. (2002) CLASS I DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about September 27, 2002 an annual survey was conducted at the facility. 9. On that date, based on record review and interview, the facility failed to notify physicians or family of significant changes in the blood sugar levels of Diabetic residents for 5 of 38 sampled residents. 10. A Class I deficiency was cited against Respondent based on the findings below: 10.1 Review of clinical record for resident #13 documented six days where blood sugar levels were below acceptable levels. 9/09/02: 11:30 AM: 55, 9/11/02: 11:30 AM: 53, 4:30 PM: 57, 9/13/02: 6:30 AM: 58, 9/14/02: 6:30 AM: 56, AM: 100, 9/16/02: 11:30 AM: 63, 9/20/02: 11:30 AM: 61. No documentation of notification to the physician were in the Interdisciplinary progress notes except for 9/17/02 when blood sugar levels were documented as: 6:30 AM: 34, 11:30 AM: 55, 4:30 PM: 66. Information was faxed to physician on 9/17/02 but no response was noted. The Hospice nurse visited the resident on 9/11/02. No documentation was in the clinical record notifying the Hospice nurse of the blood sugar irregularities. Interview with family member on 9/25/02, at approximately 8:00 PM, revealed that the facility did tell him/her when the resident is having problems. When asked specifically about the fluctuation in blood sugar levels from 9/11/02 to 9/20/02, the family member could not recall if the facility had informed him/her of the concern. 10.2 Review of clinical record for resident #25 documented low blood sugar levels with accucheck on 9/02/02 at 4:30 PM: 67, 9/03/02 at 6:30 AM: 50 rechecked 85, 9/05/02 4:30 PM: 50, 9/08/02 4:30 PM: 64, 9/10/02 6:30 AM: 68, 11:30 AM: 61, 4:30 PM: 66, 9/11/02: 11:30 AM: 58, 9/12/02: 6:30 AM: 56, 9:00 PM: 63, 9/13/02: 6:30 AM: 66, 9/15/02: 11:30 AM: 35, 9:00 PM: 63, 9/17/02: 6:30 AM: 63, 9/21/02: 6:30 AM: 66. Interdisciplinary Progress Notes dated from 8/22/02 to 09/22/02 had no documentation related to low blood glucose levels or any notification to physician or family. 10.3 Review of clinical record for resident #26 documented a low blood sugar level on 9/13/02 at 6:30 AM: 53, and on 9/25/02: 63. No documentation of notification to the physician was in the Interdisciplinary progress notes. 10.4 Review of resident #24's chart revealed that the resident received accuchecks at 6:30 AM and 4:30 PM each day due to abnormal blood sugars. On 9/17/02 6:30 AM the resident's blood sugar was measured at 55. A review of the resident's chart revealed that there were no nurses' notes recorded on this date documenting the low blood sugar reading and subsequent action taken by the facility staff. The nurses' notes did not indicate that either the physician or the family were called about the resident's change in condition. Interview with the physician and facility staff at 10:30 PM on 9/25/02 in the conference room revealed that the physician had not been called about the resident's low blood sugar reading on 9/17/02. 10.5 Clinical record review revealed resident #28 was on daily insulin injection and was ordered for daily accuchecks before meals and at bedtime. There was no documentation for blood sugar/accucheck on 9/20/02 at 4:30 PM and on 9/24/02 at 6:30 AM. On 9/25/02 at 6:30 AM, results of the fingerstick blood sugar test was 33. There was no documentation from the nurses' notes that revealed the physician was notified of the resident's change of condition. Interview with the unit manager on 9/25/02 at approximately 10:30 P.M. confirmed that the facility nurse failed to document pertinent information after the blood sugar of the resident dropped to 33. 11. The above actions or inactiong constitute a violation of: (1) Section 400.23 (8) (a) Fl. Stat. (2002) which defines a Class I deficiency as one in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, a serious injury, harm, impairment or death of a resident receiving care in a facility; (2) Section 400.022 (1) (1) Fl. Stat. (2002) which requires that residents have the right to receive adequate and appropriate health care consistent with the resident care plan and with established and recognized practice standards within the community, and with the rules as adopted by the agency; (3) 42 CFR 483.10 (b) (11) which requires, in pertinent part, a facility must immediately consult with the resident’s physician or interested family member when there is a significant change in the residents physical, mental or psychosocial status (i.e. deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) or a need to alter treatment significantly or to commence a new form of treatment. 12. The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which a fine of Twelve Thousand Five Hundred Dollars ($12,500) is authorized pursuant to Sections 400.23(8) (a) and 400.121(1), Florida Statutes. COUNT ITI RESPONDENT FAILED TO ESTABLISH PARAMETERS FOR MONITORING EPISODES OF HYPOGLYCEMIA FOR INSULIN DEPENDENTS DIABETES MELLITUS RESIDENTS. VIOLATING RULE 59A-4.1288, Florida Administrative Code, INCORPORATING BY REFERENCE 42 CFR 483.20(k) (3) (i); §$400.022 (1) (1) Fl. Stat. (2002) CLASS I DEFICIENCY 13. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 14. On or about September 27, 2002 an annual survey was conducted at the facility. 15. On that date, based on record review, policy review, and interview, the facility failed to establish parameters for monitoring episodes of hypoglycemia for Insulin Dependent Diabetes Mellitus residents. 16. A Class I deficiency was cited against Respondent based on the findings below: 16.1 Review of the monthly physician order sheets for residents #2,5,13,20,24,25,26,27,28,29,30 and 33, did not have any written orders identifying parameters for withholding insulin for a resident assessed with low blood sugar levels (hypoglycemia) . 16.2 Interview with the nurse and unit manager was done on the afternoon of 9/25/02. Resident #13 was documented having fluctuating hypoglycemic blood sugar levels from 9/11-9/17/02. No documentation was present in the Interdisciplinary notes as to the actions taken when hypoglycemic episodes occurred or that a repeat level was taken. When interviewed as to when the physician or family was informed, the nurse stated that on 9/17/02 when 6:30 AM accucheck was 34, and 11:30 AM accucheck was 55, the physician was faxed the information. No follow-up was documented that the physician responded or the facility reassessed and implemented treatment for hypoglycemic blood sugar level other than withholding insulin injections. 16.3 Interview with the unit manager, on 9/25/02 at approximately 10:30 P.M., confirmed that facility nurse failed to document pertinent information after the blood sugar of resident #28 was 33 on the 6:30 AM accucheck of 9/25/02. 16.4 The facility protocol for Hypoglycemia (RC1 0105.00) was reviewed. A summary of the policy is: Purpose: To provide information for identifying hypoglycemia and specifying appropriate response. Fundamental information identifies signs and symptoms of Hypoglycemia. Procedure: 1. When resident complains or shows signs of insulin shock, report it to the nurse. 2. The nurse will: a. test the resident's blood glucose with a blood glucose monitoring device. b. record the results. 3. and 4. Implement treatments to elevate blood glucose levels 5. Stay with the resident to ensure all the food is eaten and resident does not fall back asleep. Feed resident if he/she is disoriented or lethargic. 6. Call the physician for further orders. a. follow orders. b. repeat blood glucose. 7. Call physician if the resident has not improved within 20 minutes of initial treatment. 8. Based on physician order use instant glucose or I.M. glucagon. 9. Notify family or responsible party. Documentation: Record in the progress notes: 1. Resident's signs and symptoms, frequency and results of blood testing, any change in medication administration, type time and amount of oral intake, resident's response to treatment, and notification of physician, family or responsible party. 2. Record blood glucose level in the treatment record. 3. In the Care Plan, record intervention and approaches to minimize hypoglycemic episodes. Contrary to the facility protocol, the physicians were not notified of the changing blood glucose levels for the residents, therefore the physicians were not included in the management of the abnormalities of the blood glucose levels until they had reached a critical level. 16.5 Interview with the unit manager on 9/25/02 at 10:30 PM confirmed the fact that resident #24 had a blood sugar of 55 at 6:30 PM on 9/17/02. The interview also revealed that the facility nurse failed to document the course of action taken by the facility at the time of this incident. References for Type I diabetes practice guidelines included: "Staged diabetes management: a systematic approach." MN: Matrex, International Diabetes Center,2000. p.133-71, and Department of Veterans Affairs Veterans Health Administration Office of Quality and Performance: "Management of patients with Diabetes mellitus in the primary care setting". Released May 2000. 17. The above actions or inactions constitute a violation of: (1) Section 400.23(8) (a) Fl. Stat. (2002) which defines a Class I deficiency as one in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, a serious injury, harm, impairment or death of a resident receiving care in a facility; (2) Section 400.022 (1) (1) Fl. Stat. (2002) which requires that residents have the right to receive adequate and appropriate health care consistent with the resident care plan and with established and recognized practice standards within the community, and with the rules as adopted by the agency; (3) 42 CFR 483.20(k) (3) (i) which requires that the services provided or arranged by the facility must meet professional standards of quality. 18. The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which a fine of Twelve Thousand Five Hundred Dollars ($12,500) is authorized pursuant to Sections 400.23(8) (a) and 400.121(1), Florida Statutes. COUNT III RESPONDENT FAILED TO MONITOR AND DOCUMENT CARE FOR 7 OF 39 SAMPLED RESIDENTS.VIOLATING RULE 59A-4.1288, Florida Administrative Code, INCORPORATING BY REFERENCE 42 CFR 483.25; § 400.022 (1) (1) Fl. Stat. (2002) CLASS I DEFICIENCY 19. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 20. On or about September 27, 2002 an annual survey was conducted at the facility. 21. On that date, based on observation, interview, and record review, the facility failed to monitor and document care for 7 of 39 sampled residents (#3,10,13,24,25,26, and 28). 22. A Class I deficiency was cited against Respondent based on the findings below: 22.1 Resident #13 was initially admitted to the facility on 2/18/97. The clinical record revealed a physician's note, dated 10/25/01: "family requesting hospice. Sugars out of control pt not eating. Will d/c (discontinue) P.O. (by mouth) oral agents do regular insulin sq (sub cutaneous)." Review of the Minimum Data Set (MDS) Annual assessment, dated 6/17/02, coded the resident as totally dependent for all daily living activities including transferring, dressing, and eating. Cognitive awareness was documented as short and long term memory loss with severe cognitive impairment. No behavioral concerns were noted. The resident usually understands directions. A Quarterly Assessment, completed on 9/16/02, remained consistent with the Annual Assessment. The clinical record documented that the resident had symptoms of a Urinary Tract Infection (UTI) on 8/06 and a urine culture confirmed a UTI. The resident was administered an antibiotic, Levaquin 500 milligrams (mg.) by mouth for five (5) days. On 8/14/02, the medication was changed to the antibiotic, Bactrim DS two times a day for ten (10) days. On 8/14/02, the physician increased the insulin order from 6:30 AM Novolin 70/30 Insulin to 65 units to 70 units, added at 4:30 PM Novolin 70/30 Insulin 40 units, and changed the sliding scale Humalog insulin for coverage. Blood sugar accucheck monitoring was changed from three times a day to four times a day: 6:30 AM, 11:30 AM, 4:30 PM, and 9:00 PM. Review of the blood sugar accucheck monitoring for 9/11/02 documented 6:30 AM: 83 mg/dL, 11:30 AM: 63 mg/dL, 4:30 PM: 57 mg/dL and 9:00 PM: 95 mg/dL. No documentation of reassessment of low blood sugar levels were noted on MAR or in the Interdisciplinary progress notes. No documentation was noted if any action was taken in regards to the low levels at 11:30 AM. Insulin was held at 4:30 PM per the Medication Administration Record (MAR). No documentation was noted to explain the rationale for withholding the insulin. The physician and family were not notified. Further review of clinical record and MAR revealed the following blood sugars/mg/dL: 9/09/02: 6:30 AM: 109, 11:30 AM: 55, 4:30 PM: 99, 9 PM: 166 9/10/02: 6:30 AM: 110, 11:30 AM: 138, 4:30 PM: 117, 9 PM: 108 9/11/02: 6:30 AM: 83, 11:30 AM: 53, 4:30 PM: 57, 9 PM: 95 9/12/02: 6:30 AM: 74, 11:30 AM: 123, 4:30 PM: 278, 9 PM: 197 9/13/02: 6:30 AM: 58, 11:30 AM: 147, 4:30 PM: 142, 9 PM: 18 9/14/02: 6:30 AM: 56, 11:30 AM: 188, 4:30 PM: 175, 9 PM: 338 9/15/02: 6:30 AM: 114, 11:30 AM: 129, 4:30 PM: 112, 9 PM: 110 9/16/02: 6:30 AM: 100, 11:30 AM: 63, 4:30 PM: 127, 9 PM: 162 9/17/02: 6:30 AM: 34, 11:30 AM: 55, 4:30 PM: 66, 9 PM: 146 9/18/02: 6:30 AM: 141, 11:30 AM: 134, 4:30 PM: 76, 9 PM: 221 9/19/02: 6:30 AM: 115, 11:30 AM: 193, 4:30 PM: 101, 9 PM: 131 9/20/02: 6:30 AM: 223, 11:30 AM: 61, 4:30 PM: 143, 9 PM: 129 9/21/02: 6:30 AM: 99, 11:30 AM: 151, 4:30 PM: 136, 9 PM: 130 9/22/02: 6:30 AM: 89, 11:30 AM: 158, 4:30 PM: 188, 9 PM: 146 The 6:30 AM dose of Novolin 70/30 was held on 9/12-13/02, and 14/02. Clinical record documentation failed to reveal documentation of neither nursing staff addressing and reassessing the blood sugar abnormalities nor any additional treatment or intervention by the nursing staff other than holding insulin. The 4:30 PM dose of Novolin 70/30 was held on 9/09,10,11, 15,17,18,19,20,22/02. No documentation was noted as to the rationale for holding these doses for these days either on the MAR or the Interdisciplinary Progress Notes (IPN). IPN dated 9/11/02 (no time indicated) by Hospice revealed: "Pt has eyes open most of visit. No smiling. Some eye response. Tried to give verbal response x 1. Lungs clear and throughout. States no pain. Abd. Firm. Daughter states pt is less responsive to her." No documentation was present in response to the decreasing blood sugar levels or further evaluation by the Hospice nurse. IPN dated 9/15/02 documented the physician visit with no concern stated in regards to low blood sugar levels on 9/11,12,13,14. Plan: "continue same plan; Interdisciplinary progress notes dated 9/17/02:12 n Faxed MD re: low BS (blood sugar). 12:15 n Res. Alert no signs or symptoms of distress BS 67 gave nip. On 9/17/02 1 p BS 102." No documentation was noted if the physician responded. No new orders were received. IPN, dated 9/23/02, documented: "change of order to discontinue PM insulin - use sliding scale only at 4:30 PM." Further review including 24 Hour Report/Change of Condition Report for the month of September 2002 did not note any information pertaining to resident #13. Interview with the nurse responsible for resident #13, in the afternoon on 9/25/02, stated that he/she takes care of the residents and that he/she forgot to document the care and treatment rendered to this resident. Review of the MAR for September 2002 documented that resident received Ativan 0.5 mg, on 9/11/02 at 6:00 AM. Review of the Behavior/Intervention Monitoring record note on 9/11/02, 6:00 AM revealed: "agitation, one to one intervention, no change, 9/11/02, 6:00 AM agitation, med given, outcome, better." Further review of the Controlled Drug Record documented Ativan was again given to the resident on 9/15/02. Interview with the nurse responsible for resident #13 was conducted in the afternoon on 9/25/02. The nurse stated that he/she did not document information on the MAR or the behavioral flow sheet. Review of the facility policy: Resident Care 1: Basic resident Care "Hypoglycemia (Insulin Shock)" Effective 3/00 Purpose: To provide information for identifying hypoglycemia and specifying appropriate response. Under fundamental information signs and symptoms of Hypoglycemia included: nervousness, irritability, or changes in the personality also noted was resident not able to wake up or appears to be in a coma, unconscious, or partially unconscious (stupor). Changes in the resident's agitation were viewed as behaviors and not correlated to low blood sugar levels. The Hospice nurse did not correlate the resident's daughter's concern of the resident being less responsive to a low blood sugar level on 9/11/02. Interview with the Medical Director/resident's physician, on 9/25/02 at approximately 5:30 PM, was conducted. When questioned in regards to the Glucose levels the physician stated there was no documentation of monitoring Glucose. He/she could not clarify when Ativan was given. He/she would have to talk to nurse who administered the medication to verify the times the Ativan was given. The physician stated that some time ago, the resident was sick one morning at 3 AM and sent to hospital (not recently). He/she stated that the resident can't communicate. The unit manager nurse had cared for him/her a long time. When asked how staff would know how to monitor hypoglycemia no information was available on the unit, i.e. signs and symptoms of hypoglycemia. The physician reviewed the IPN and stated that there were no nurses' notes documenting low blood sugar levels. He/she also stated that the resident presented signs of agitation with low blood sugar, but that it didn't indicate low blood sugar. When asked how he/she would know of the low blood sugar, he/she stated that the nurses should keep doctors informed of low blood sugar. 22.2 Resident #25's clinical record revealed that the resident was readmitted to the facility on 3/04/02 with diagnoses of Cerebral Vascular Accident, Dysphagia, Insulin Dependent Diabetes Mellitus and Hypertension. The resident required total care from staff. The resident received a puree diet with one can of Glucerna, bolus, at 6:30 AM and 10:30 PM and one can at 10:30 AM, 2:30 PM and 6:30 PM if the resident consumed less than 75% of the previous meal. The resident received Novolin N Insulin 100 U/ML 15 units at 6:30 AM and 7 units every evening 4:30 PM as well as a sliding scale regimen for blood sugar greater than 200 mg/dL. Review of the MAR documented accucheck blood sugars/mg/dL as follows: (times with two numbers indicates a recheck) 9/02/02: 6:30 AM: 95, 11:30 AM: 90, 4:30 PM: 67, 9 PM: 121 9/03/02: 6:30 AM: 50/85, 11:30 AM: 85, 4:30 PM: 77,9 PM: 111 9/04/02: 6:30 AM: 100,11:30 AM: 136, 4:30 PM: 114, 9 PM: 121 9/05/02: 6:30 AM: 80, 11:30 AM: 200, 4:30 PM: 50, 9 PM: 69 9/06/02: 6:30 AM: 92, 11:30 AM: 132, 4:30 PM: 69, 9 PM: 110 9/08/02: 6:30 AM: 112,11:30 AM: 72, 4:30 PM: 64, 9 PM: 115 9/10/02: 6:30 AM: 68, 1:30 AM: 61, 4:30 PM: 66, 9 PM: 97 9/11/02: 6:30 AM: 139,11:30 AM: 58, 4:30 PM: 98, 9 PM: 70 9/12/02: 6:30 AM: 56, 11:30 AM: 189, 4:30 PM: 104, 9 PM: 63 9/13/02: 6:30 AM: 66, 11:30 AM: 70, 4:30 PM: 107, 9 PM: 137 9/15/02: 6:30 AM: 159,11:30 AM: 35, 4:30 PM: 92, 9 PM: 63 9/17/02: 6:30 AM: 63, 11:30 AM: 89, 4:30 PM: 98, 9 PM: 107 9/21/02: 6:30 AM: 66, 11:30 AM: 131, 4:30 PM: 96, 9 PM: no documentation On 9/08/02 at 4:30 PM, the MAR was blank with no notes on the back of the MAR or in the IPN. According to the MAR, on 9/10/02 at 4:30 PM, Insulin was administered. On 9/12/02 at 6:30 AM Insulin was administered on 9/17/02 Insulin was administered. There was no documentation noted if the blood sugar was reassessed in either the MAR or the IPN. The physician's note, dated 9/11/02, documented: "Plan of care: continue same management." On 9/25/02 at 9:45 PM, the Director of Nursing, Nurse Unit Managers and Administrator were interviewed in regards to parameters for low blood sugar levels. Nurses stated that Insulin would be held at around 60 dependent on the tolerance of the resident. When asked how agency nurses would know when to hold insulin, the nurses agreed that if there were no parameters were established, the nurse working with the resident would have to use professional judgement. Accucheck machines were calibrated every night for accuracy. The nurse working with the resident should notify the physician if no specific physician orders or parameters were established for low blood sugar levels. 22.3 Resident #28 was admitted to the facility on 9/16/02 with diagnoses of insulin dependent diabetes mellitus, morbid obesity, ulceration of vulva, peripheral vascular disease, hypertension, and chronic kidney disease. Clinical record review revealed the resident was on daily insulin injection and was ordered for daily accuchecks before meals and at bedtime. On 9/25/02 at 6:30 AM, results of the fingerstick blood sugar test was 33. There was no documentation as to whether insulin was administered since a blank space was left on the MAR. There was no documentation in the nurses' notes that revealed the physician was notified. Also, nursing staff failed to document what measures was done to bring blood sugar levels back to normal. On 9/20/02, the accucheck for 4:30 P.M. was also left blank, and no documentation could be found as to whether insulin was administered or not. Interview with the unit manager on 9/25/02 at approximately 10:30 P.M. confirmed that the nurse failed to document pertinent information after the blood sugar of the resident dropped to 33. 22.4 Resident #26 was admitted to the facility on 10/18/00 with diagnoses of Cerebral Vascular Accident, Chronic Atrial Fibrillation and Non Insulin Dependent Diabetes Mellitus. Physician's Orders revealed change of diagnoses to Insulin Dependent Diabetes Mellitus. Review of the MAR revealed two days where the resident's blood sugar level was below 68 mg/dL. On 9/13/02 at 6:30 AM, the accucheck was 53 and a recheck was 96. On 9/25/02 at 6:30 AM, the accucheck was 63 and the recheck was 128. Review of the IPN and the back of the MAR failed to reveal neither documented interventions implemented to increase low blood sugars on these dates nor documentation that the physician was notified. 22.5 Resident #24 had diagnoses of diabetes, gastrointestinal bleed, cellulitis and cirrhosis of the liver. A review of the resident's MAR revealed that on 9/17/02, the 6:30 AM accucheck for blood sugar level was 55. A review of the nurses! notes on 9/17/02 revealed no documentation existed in the chart detailing the course of action taken by the nurse at this time. Nurses' notes did not reveal whether the doctor or family was called on this date (refer to F-157). Interview with staff in the conference room on 9/25/02 at 9 PM revealed that neither the family nor the doctor was called on 9/17/02 when the resident's blood sugar was 55. Also, documentation concerning the course of action taken by nursing staff on 9/17/02 did not exist according to interview with staff at this time on 9/25/02. 22.6 Resident #3 had diagnoses of severe rheumatoid arthritis and atrial flutter. A review of the resident's chart revealed that he/she wore a Lido-derm patch on the posterior neck due to discomfort. Interview with the cognitively aware resident on 9/25/02 at 3:15 PM revealed that the neck patch had been worn for two weeks but had not been effective in relieving the pain. The resident stated that he/she still had pain in the neck. A review of the MAR revealed that the resident had been using the Lido-derm patch since 9/8/02. An interview took place with the resident's nurse at 11 AM at the East Wing nurses' station on 9/26/02. The nurse was asked if the resident was being assessed for pain using a pain assessment form or any other type of assessment tool. The nursing staff person stated: "no assessment form was in the chart. The only time we would use a form is if he/she is having pain." When asked if the neck pain was being monitored anywhere else in the resident's chart, the nursing staff responded that it was not. 22.7 Resident #10 had diagnoses of cardiopulmonary disease, Parkinson's disease and osteoporosis. Observation of the resident's left foot revealed an open area on the second toe of the left foot. A review of nurses' notes in the resident's chart revealed that the open area on the second toe was first noted on 8/13/02. The open area was diagnosed with cellulitis on 8/13/02 and was being treated with mycolog cream at this time. Both feet were being left open to the air. A review of the treatment book revealed a photograph of the resident in his/her wheelchair. A statement beside a picture of the resident in the wheelchair stated: "keep legs apart-- not touching, keep heels off foot pedals." On 9/24/02 at 12:10 PM, the resident was observed sitting his/her room in his/her wheelchair with both bare feet together. Later that day at 3:30 PM, a staff person was observed wheeling the resident down the hall in his/her wheelchair. Again, the resident's bare feet were observed to be positioned together. On 9/25/02 at 8:45 AM, the resident was observed sitting in his/her room. Again, both feet were observed to be touching one another in the toe area. Resident #10 was also supposed to have a small foam rubber cover attached to his/her wheelchair on the left side near the thigh area. The foam rubber padding was attached to the metal part of his/her wheelchair and was called an armrest cover according to the photograph in the treatment book. This photograph in the treatment book for resident #10 represented the plan of care for the resident. According to interview with staff at 9:05 on 9/26/02 at the East Wing nurses! station, no other documentation about the wheelchair attachments and set-up existed for the resident. Observation of the resident in his/her wheelchair throughout the survey revealed that the foam armrest was never observed to be attached to the left side of the resident's wheelchair as pictured in the photographs. During this interview, it was revealed that no one had been putting the foam padding armrest on the resident's wheelchair. 23. The above actions or inactions constitute a violation of: (1) Section 400.23 (8) (a) Fl. Stat. (2002) which defines a Class I deficiency ag one in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, a serious injury, harm, impairment or death of a resident receiving care in a facility; (2) Section 400.022 (1) (1) Fl. Stat. (2002) which requires that residents have the right to receive adequate and appropriate health care consistent with the resident care plan and with established and recognized practice standards within the community, and with the rules as adopted by the agency; (3) 42 CFR 483.25 which requires that each resident receive 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. 24. The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which a fine of Twelve Thousand Five Hundred Dollars ($12,500) is authorized pursuant to Sections 400.23(8) (a) and 400.121(1), Florida Statutes. COUNT IV RESPONDENT FAILED TO SUPERVISE NURSING SERVICES AND TREATMENTS TO INSULIN DEPENDENT DIABETICS FOR 5 OF 39 SAMPLED RESIDENTS TO ENSURE THAT THE HIGHEST PRACTICABLE LEVEL OF CARE AND WELL BEING WAS MAINTAINED. VIOLATING RULE 59A-4.1288, Florida Administrative Code, INCORPORATING BY REFERENCE 42 CFR 483.30(a) (1)&(2); § 400.022 (1) (1) Fl. Stat. (2002) CLASS I DEFICIENCY 25. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 26. On or about September 27, 2002 an annual survey was conducted at the facility. 27. On that date, based on record review and interview, the facility failed to supervise nursing services and treatments to Insulin Dependent Diabetics for 5 of 39 sampled residents (#13,24,25,26 and 28), to ensure that the highest practicable level of care and well being was maintained. 28. A Class I deficiency was cited against Respondent based on the findings below: 28.1 Review of clinical records for residents #13,24 25,26, and 28 revealed insufficient documentation of monitoring of hypoglycemia or low blood sugar levels. Interview conducted at 9:45 PM on 9/25/02 with the Unit managers and the director of nursing, could not explain why or identify the reason for lack of documentation as to why the low blood sugars were neither reviewed nor addressed. Review of the September 2002, Daily 24 Hour Reports did not document low blood sugar levels for the residents involved. The Unit managers and the Director of Nursing explained the procedure that should have been followed but could not provide written documentation for actions completed by the nurses. Review of the nurses' competency tests, for both the agency and facility nurses, documented knowledge of the correct procedures for low blood sugar levels. (Refer to F 281, F 309) 29. The above actions or inactions constitute a violation of: (1) Section 400.23 (8) (a) Fl. Stat. (2002) which defines a Class I deficiency as one in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, a serious injury, harm, impairment or death of a resident receiving care in a facility; (2) Section 400.022 (1) (1) Fl. Stat. (2002) which requires that residents have the right to receive adequate and appropriate health care consistent with the resident care plan and with established and recognized practice standards within the community, and with the rules as adopted by the agency; (3) Section 42 CFR 483.30(a) (1)&(2) which requires that a facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well- being of each resident as determined by resident assessment and individual plans of care. 30. The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which a fine of Twelve Thousand Five Hundred Dollars ($12,500) is authorized pursuant to Sections 400.23(8) (a) and 400.121(1), Florida Statutes. COUNT V RESPONDENT FAILED TO IMPLEMENT AND MONITOR POLICIES/PROTOCOLS OR MONITOR STAFF COMPETENCY, TO ENSURE THAT EACH RESIDENT WITH DIAGNOSES OF DIABETES MELLITUS WAS TREATED IN A MANNER TO ENSURE THE WELL BEING OF 1 OF 39 SAMPLED RESIDENTS. VIOLATING RULE 59A- 4.1288, Florida Administrative Code, AND INCORPORATING BY REFERENCE 42 CFR 483.75 CLASS I DEFICIENCY 31. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 32. On or about September 27, 2002 an annual survey was conducted at the facility. 33. On that date, based on record review and interview, the facility failed to implement and monitor policies/protocols or monitor staff competency, to ensure that each resident with a diagnoses of Diabetes Mellitus was treated in a manner to maintain and ensure the well being of 1 of 39 sampled residents (#13). 34. A Class I deficiency was cited against Respondent based on the findings below: Interview with the Medical Director on 9/25/02 at approximately 5:00 PM revealed that he/she was unaware that his/her resident (#13) had repeated episodes of low blood sugars from 9/11-17/02. When questioned as to why there was no documentation if he/she was contacted, he/she stated "I have a sign on the unit with my page number". He/she stated that the resident was difficult to control" and when asked specifically about what action was taken when glucose level drops below normal, physician stated, "I don't want the resident to wait." No evidence of action pertaining to the glucose levels was present in the clinical record. The physician stated that he/she was not aware of the low blood sugar levels. The facility operations policy #OP2 0102.00 was reviewed. A summary of the policy is: Policy: The facility designates a physician to serve as medical director. Fundamental Information: The medical director provides medical direction and coordination of medical care in the facility. Coordination of medical care includes, but is not limited to: -Liaison with attending physicians to assure that they are in compliance with standards of practice. ~Periodic evaluation of the adequacy and appropriateness of health professionals and support staff and services; (refer to F 309, F 353). -Implementation of resident care policies (refer to F 281). -Period review of medical records to assure that the care is in accordance with the appropriate standards and that the documentation is adequate; (refer to F 281, F 309, F 353). Procedures: 2. The Medical Director coordinates the medical care in the facility to ensure the adequacy and appropriateness of the medical services provided. 4. The Medical Director review and approves standardized procedures that registered nurses may use in performing resident care services. 20 35. The above actions or inactions constitute a violation of: (1) Section 400.23(8) (a) Fl. Stat.(2002) which defines a Class I deficiency as one in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, a serious injury, harm, impairment or death of a resident receiving care in a facility; (2) Section 400.022 (1) (1) Fl. Stat.(2002) which requires that residents have the right to receive adequate and appropriate health care consistent with the resident care plan and with established and recognized practice standards within the community, and with the rules as adopted by the agency; (3) Section 42 CFR 483.75 which requires that a facility be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. 36. The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which a fine of Twelve Thousand Five Hundred Dollars ($12,500) is authorized pursuant to Sections 400.23(8) (a) and 400.121(1), Florida Statutes. COUNT VI RESPONDENT FAILED TO PROVIDE THE NECESSARY TREATMENT AND SERVICES TO PROMOTE THE HEALING OF EXISTING PRESSURE ULCER, TO PREVENT INFECTION, AND PREVENT A NEW AVOIDABLE HOUSE ACQUIRED PRESSURE ULCER FROM DEVELOPING FOR ONE OF 39 SAMPLED RESIDENTS. 21 VIOLATING RULE 59A-4.1288, Florida Administrative Code, AND INCORPORATING BY REFERENCE 42 CFR 483.25(c) CLASS II DEFICIENCY 37. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 38. On or about September 27, 2002 an annual survey was conducted at the facility. 39. On that date, based on observations, staff interviews, and clinical record reviews the facility failed to provide the necessary treatment and services to promote the healing of existing pressure ulcer, to prevent infection, and prevent a new avoidable house acquired pressure ulcer from developing for one of thirty nine sampled residents (#1). 40. A Class II deficiency was cited against Respondent based on the findings below: 40.1 Resident #1 was identified on the initial tour, 9/23/02 at 1:25 PM, as having a Stage II House Acquired Pressure Ulcer on the coccyx. The resident was observed positioned on their back throughout the tour. Further observations during random tours and times on 9/24/02, at 9:00 AM, 10:30 AM, 11:15 AM and again at 12 Noon, for the three (3) hours the resident was observed lying on his/her back in the same position. During perineal care observation, on 9/25/02 at 9:20 AM, the resident was observed lying on an incontinence pad, saturated with urine. The CNA/Mentor was observed using the same washcloth to cleanse the pressure ulcer on coccyx after using it to cleanse the resident's feet. Further observations of the student in training assisting with the resident's perineal care revealed he/she wiped the resident's perianal area from back to front and then front to back motion, cleaning the pressure ulcer site at the 22 same time. The washcloth was observed to have dark brown feces-like material on it. The resident was also observed to have a new Stage II pressure ulcer on the left side of the coccyx at that time. 40.2 Interview with nurse was conducted on 9/25/02 at 3:15 PM regarding pressure ulcer treatment and the facility's knowledge of a new Stage II pressure ulcer on coccyx. The nurse stated: "I feel very bad, the CNA/Mentor reported to me of the new house acquired pressure ulcer after the resident's AM and perineal care." During a pressure ulcer treatment observation, on 9/25/02 at 3:15 PM, resident #1 was observed lying on an incontinence pad, with moderate Saturation of urine. The incontinence pad was rolled under the resident and no incontinent care was provided before the nurse started measuring the pressure ulcers. Observations confirmed the presence of a House Acquired Stage II Pressure Ulcer on the coccyx. The ulcer measured 3.4 x 2.3 centimeters (cm) and a second, new House Acquired Pressure Ulcer Stage II on the Left Sacral area, measured 2.0 x 2.0 com. The facility failed to identify the stage II pressure ulcer until 9/25/02, during observations of perineal and wound care, when the ulcer was already opened. Further, observations of the pressure ulcer treatment on 09-25-02 at 3:15 p.m., revealed the nurse failed to wash his/her hands and change gloves after pressure ulcer measurements. The treatment nurse failed to cleanse the pressure areas after rolling the resident onto the incontinence pad, further placing the resident at risk for further wound contamination. He/she proceeded to apply a treatment of Calmoseptine cream to both pressure ulcers. After the nurse finished the treatment, he/she proceeded to notify the physician on 9/25/02 at 4:10 PM of the new stage II pressure ulcer on the left perianal area for treatment orders. The physician gave orders for Calmoseptine cream every shift and as needed. Also at the same time and date, the facility requested from physician clarification for the resident to have a Hospice consult. 40.3 Medical record review documented resident #1 was admitted to the facility on 9/3/02 with a diagnosis of Alzheimer's disease, with dementia. Review of the admission MDS dated 9/7/02 coded 0 under pressure ulcers, meaning the resident entered the facility without pressure 23 ulcers. The first stage II house acquired pressure ulcer was dated 9/15/02, 12 days after admission to the facility and the second stage II house acquired pressure ulcer was dated 9/25/02, 22 days after the resident's admission to the facility. The resident was coded as severely impaired for cognitive skill/decision making and total care, and dependant on staff for all activities of daily living. 40.4 Interview with the Director of Nursing, Unit Manager, CNA/Mentor, and wound nurse on 9/25/02 at 2:00 PM, and again on 9/27/02 at approximately 7:00 PM with the Administrator also present, was conducted. Staff confirmed the facility failed to properly monitor the care and services provided to resident #1, who the facility stated entered the facility in a declining condition and developed two stage II pressure ulcers after admission to the facility. 41. The above actions or inactions constitute a violation of: (1) Section 400.23(8) (b) Fl. Stat.(2002) which defines a Class II deficiency as one which has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as determined by an accurate and comprehensive resident assessment, plan of care, and provision of services.;(2) Section 400.022 (1) (1) Fl. Stat. (2002) which requires that residents have the right to receive adequate and appropriate health care consistent with the resident care plan and with established and recognized practice standards within the community, and with the rules as adopted by the agency; (3) Section 42 CFR 483.25 (c) which requires that a facility must ensure that a resident who enters a facility without pressure sores does not develop pressure sores unless the individuals clinical condition demonstrates that they were 24 unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent sores from developing. 42. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of Two Thousand Five Hundred Dollars ($2,500) is authorized pursuant to Sections 400.23(8) (b) and 400.121(1), Florida Statutes. COUNT VII RESPONDENT FALSIFIED THE MEDICATION ADMINSTRATION RECORD FOR ONE RESIDENT VIOLATING §400.1415 Fl. Stat. (2002) CLASS II DEFICIENCY AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 43. On or about September 27, 2002 an annual survey was conducted at the facility. 44. On that date, based on record review, a medication administration record was falsified for resident #26. 45. A Class II deficiency was cited against Respondent based on the findings below: Resident #26 medication administration record (MAR) was copied by the survey team on 9/25/02 at approximately 10:00 PM. Survey team identified abnormal blood sugar levels on 9/13/02 at 6:30 AM: 53/96 and 9/25/02 at 6:30 AM: at 63/128. It was verified on 9/25/02 that the physician was not contacted. On 9/27/02 the facility was asked to copy clinical records of residents related to the immediate jeopardy and to identify the nurses involved that performed the accuchecks. Upon a review of copies of clinical records provided to the survey team by the facility on 9/27/02, the record of resident #26 had a note from facility stating no abnormal accuchecks. Review of the MAR in the facility 25 file reflected altered information on the MAR documentation of the blood sugar levels on 9/13/02 and 9/25/02. The copy of the MAR in the file copy provided by the facility to the survey team reflected the following information. On 9/13/03 6:30 AM "153/ (unidentifiable initials)". On 9/25/02 6:30 AM the 63 value was marked out/128 remained. 46. The above actions or inactions constitute a violation of: (1) Section 400.23(8) (b) Fl. Stat. (2002) which defines a Class II deficiency as one which has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as determined by an accurate and comprehensive resident assessment, plan of care, and provision of services; (2) §400.1415 Fl. Stat. (2002) states that any person who fraudulently alters, defaces, or falsifies any medical record commits a second degree misdemeanor. 47. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of Two Thousand Five Hundred Dollars ($2,500) is authorized pursuant to Sections 400.23(8) (b) and 400.121(1), Florida Statutes. ADDITIONAL FEE UNDER §400.19(3), FLORIDA STATUTES 48. The Respondent has been cited for Five Class I deficiencies and Two Class II deficiencies therefore is subject to a survey fee of $6,000 pursuant to Section 400.19(3), Florida Statutes. 26 49, Notice was provided in writing to the Respondent of each of the above violation(s) and the time frame for correction. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Counts I through VII; B. Recommend administrative fines and fees be imposed against the Respondent as follows: 1. Twelve Thousand Five Hundred Dollars ($12,5000) on Count I; 2. Twelve Thousand Five Hundred Dollars ($12,5000) on Count II; 3. Twelve Thousand Five Hundred Dollars ($12,5000) on Count III; 4. Twelve Thousand Five Hundred Dollars ($12,5000) on Count IV; 5. Twelve Thousand Five Hundred Dollars ($12,5000) on Count V; 6. Two Thousand Five Hundred Dollars ($2,500) on Count VI; 7. Two Thousand Five Hundred Dollars ($2,500) on Count VII; 8. Six Thousand Dollars ($6000) Survey Fee. Cc. Assess costs related to the investigation and prosecution of this case pursuant to § 400.121 (10) Fl. Stat. (2002) and D. All other general and equitable relief allowed by law. 27 NOTICE MARINER HEALTH PROPERTIES VI, LTD., d/b/a MARINER HEALTH OF TITUSVILLE is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Drive, North, Sebring Building, Suite 330D, St. Petersburg, Florida 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 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. Esquire 525 Mirror Lake”Drive, North Sebring Building, Suite 330D St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (FAX) 28 I HEREBY CERTIFY that a copy hereof has been furnished to C T Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324, by U.S. Certified Mail Return Receipt No. 7002 Titusville, 2225 Knox McRa Drive U.S. Mail, on December 7 2002. Copies furnished to: C T Corporation System Registered Agent for Mariner Health of Titusville 1200 South Pine Island Road Plantation, Florida 33324 (U.S. Certified Mail) Administrator Mariner Health of Titusville 2225 Knox McRae Drive Titusville, Florida 32780 (U.S. Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS 43 Tallahassee, FL 32308 (Interoffice Mail) Molly McKinstry Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O’Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 29

Docket for Case No: 03-000169