CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION o Y ee STATE OF FLORIDA, AGENCY FOR HEALTH - CARE ADMINISTRATION, ee Zs Zo _— Sy rae) od Petitioner, ae. VS. AHCA NO: 200201381 {5 PD -“ MARINER HEALTH CARE OF NASHVILLE, INC. d/b/a MARINER HEALTH CARE OF PORT CHARLOTTE, 740 4575 1294 2050 D224 SENDERS RECORD |: Certified Article Number: ; 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 CARE OF NASHVILLE, INC. d/b/a MARINER HEALTH CARE OF PORT CHARLOTTE, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1) This is an action to impose an administrative fine in the amount of FIVE THOUSAND DOLLARS ($5,000) pursuant to Sections 400.022(1)(0), 400.022(3), 400.102(1)(a), 400.102(2), 400.121(1), and 400.23(8)(b), Florida Statutes and Florida Administrative Code Rule 59A-4.1288. 2) The Respondent was cited for the deficiencies set forth below as a result of an Annual Health Licensure and Re-certification Survey conducted on or about 2/11/02 through 2/14/02. JURISDICTION 3) The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4) Venue lies in Charlotte County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Florida Administrative Code Rule 28-106.207. . Page 1 of 25 EXHIBIT A CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 PARTIES 5) AHCA is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part Il, Florida Statutes and Chapter 59A-4, Florida Administrative Code. 6) Respondent is a skilled nursing facility located at 25325 RAMPART BLVD., PORT CHARLOTTE, Florida 33983. The facility is licensed under Chapter 400, Part I, Florida Statutes and Chapter 59A- 4, Florida Administrative Code. Its license number is 14260961 effective through 12/31/2003. COUNT I THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF AN AVOIDABLE IN-HOUSE ACQUIRED PRESSURE SORE AND FAILED TO ENSURE THAT RESIDENTS WHO HAD PRESSURE SORES RECEIVED NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT INFECTION AND PREVENT NEW SORES FROM DEVELOPING. 400.022, 400.102(1)(a), 400.121, and 400.23(8)(b), FLA. ADMIN. CODE R. 59A-4.1288 (INCORPORATING BY REFERENCE 42 CFR § 483.25) CLASS Il DEFICIENCY 7) AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8) Based on observations, clinical record reviews and staff interviews, the facility failed to provide care and treatment to prevent the development of new pressure sores for 3 (Residents #2, #7 and #15) of 8, from a sample of 15 active sampled residents reviewed for pressure sores/ulcers. 9) This is evidenced by: a) The facility was unable to demonstrate that Resident #7's right heel pressure sore was unavoidable. The facility protocol for pressure ulcer prevention was not followed for this resident. b) Resident #2 did not receive the necessary care to prevent the development of new pressure sores. The facility did not follow the resident's Care Plan and their protocol to prevent the development of pressure sores. c) The facility failed to adequately assess and develop an appropriate plan of care to prevent Resident #15 from developing new pressure sores. 10) The findings include: Page 2 of 25 a) b) c) d) ¢) 8) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 Observation of Resident #7 on 02/11/02 at 2:50 P.M., revealed that the resident was sitting in a geri-chair with her feet resting on the footrest of the chair. The resident had bilateral heel protectors on. Her right leg was contracted and her foot was resting on the heel. The resident's heel was not off loaded. Observation of the resident at 5:30 P.M. on 02/11/02, revealed that the resident was seated in the chair in the same position as observed at 2:50 P.M. Observation of the resident on 02/12/02 at 10:50 A.M., revealed that the resident was seated in a geri-chair with the heel protectors on and her right leg pulled up towards her chest with the boot resting on her heel. The foot was not off loaded from the chair. The resident was observed again at 1:25 P.M., in the same position. Observation of the resident on 02/13/02 at 10:00 A.M., revealed the resident was in bed. The resident was observed being transferred to the geri-chair with the use of a lift. The resident had bilateral heel protectors on with her heels resting on the footrest of the chair. The resident's heels were not off loaded with pillows. The aide confirmed that the resident had a pressure sore on her right heel. Observation of the resident on 02/13/02 at 11:00 A.M., revealed that the resident was seated in a geri-chair with her feet in heel protectors and her right leg bent at the knee with her right foot resting on the heel. Her left leg was hanging off the end of the chair with her heel resting on the edge of the chair. Interview with a nurse's aide working on the floor revealed that the resident's aide was on her lunch break. No other aide was observed entering the room to reposition the resident. Interview with the resident's aide at 11:30 A.M. on 02/13/02, revealed that she places the heel protectors on the resident's feet to protect her heels. When questioned why the heels were not elevated off the footrest, the aide stated that she was never told to do this. The aide then left the unit to assist in the dining room. Page 3 of 25 h) k) ») CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 Continuous observation of the resident from 11:30 A.M. until noon on 02/13/02, revealed that the resident remained in the chair in the same position. No staff was observed entering the room to reposition the resident. Observation of the resident at 12:02 P.M. on 02/13/02, revealed that the right heel was in the same position and the left heel was now hanging off the side of the chair. Observation at 12:30 P.M., revealed that the resident was in the same position. Observation of the resident at 1:05 P.M. on 02/13/02, revealed that the resident's aide was still off the floor and the resident remained in the same position in the chair. At 1:20 P.M. on 02/13/02, the aide was observed back on the unit assisting other residents. At 1:25 P.M., she entered Resident #7's room and put her back into her bed. Observation of the resident in the bed revealed that she was positioned towards her right side with a folded blanket under her left side. The resident's right leg was bent and her heel was resting on the bed. Interview with the resident's aide confirmed that the resident had been seated in the geri-chair from 10:00 A.M. until 1:25 P.M. m) Interview with the Restorative Certified Nurses Aide (CNA) on 02/13/02 at 1:45 P.M., confirmed n) 0) that the resident's legs were contracted and that the resident cannot move herself. Review of Resident #7's February 2002, physician's orders revealed an order for bilateral heel protectors in bed. Review of the Interdisciplinary Progress Notes dated 02/11/02, completed by nursing, revealed that the Restorative CNA had noted an open area on the resident's heel. The nurse documented that she located the area on the right heel and measured it as 2 cm. X 3 cm. X 0.01 depth, superficial opening, wound bed reddened and dark pink. The area was documented as dry with no drainage. It was also documented that the Advanced Registered Nurse Practitioner (ARNP) would be in today and the nurse would have her assess the resident and provide wound care orders. The nurse further documented that she applied a temporary dressing. Page 4 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 p) Review of the resident's Care Plan dated 11/16/01, revealed that the resident was at risk for 1) 8) t) u) v) pressure sore development. The approaches included tum and reposition every 2 hours and as needed; skin checks with moming and evening care and notify nurses of any open areas or discolored skin; pressure reduction mattress and bilateral heel protectors at all times. The Care Plan was updated 02/11/02, for "right heel Stage I." Approaches included wound treatment as ordered; weekly wound rounds; monitor for effectiveness of treatment and RD (Registered Dietitian) consult. Review of the Weekly Skin Integrity Checks for January 2002, revealed that the skin was intact through 01/30/02. Skin check completed on 02/06/02, indicated a new wound. Review of the Weekly Pressure Ulcer Healing Assessment dated 02/11/02, noted that this was a new Stage II pressure sore on the right heel with date of onset of 02/11/02. There was no documentation of the condition of the wound when it was found on 02/06/02. Review of the physician's telephone orders revealed an order dated 02/11/02, for the wound treatment. There was no documentation of an order for treatment from 02/06/02 through 02/10/02. Review of the Treatment Record for 02/02, revealed a treatment dated 02/06/02 for "skin prep to b/l (bilateral) heels BID (twice a day).". The Treatment Record indicated that this was started on 02/08/02. The next treatment was documented on 02/11/02, for right heel Stage II open area. Interview with the Director of Nursing (DON) on 02/13/02 at 1:50 P.M., revealed that "bunny boots” (heel protectors) were adequate to relieve pressure if the resident was able to move, however, she confirmed that if the resident was totally dependent on staff to move and couldn't move herself, then the CNA should be off loading the heels with a pillow. She stated that the facility had no written policy on this. Observation of the wound by 2 nurse surveyors with the Physical Therapy (PT) Director and the Unit Nurse Manager on 02/13/02 at 3:45 P.M., revealed that the right heel wound was 2 X 2.5 cm. Page 5 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1284 2050 0224 with a small amount of drainage and no odor. The tissue was pinkish-reddish. There was positive hyper granulation. The PT Director stated that the "tissue appears clean and beefy.". The Unit Manger stated, "It's at Stage II." They both agreed that subcutaneous tissue was exposed, which would be indicative of a Stage III pressure ulcer. w) Interview with the Director of Nursing and Unit Manager on 02/14/02, confirmed that the Unit x) Nurse had found the resident's heel with "peeling skin" on 02/06/02. They further confirmed that the nurse had started the skin prep without a written physician's order. The Unit Nurse Manager stated that she had spoken to the 11 P.M. to 7 A.M. nurse who worked Sunday night, 2/10/02. The nurse told the Unit Manager that she had done the skin prep treatment to the heel and found no open area, They further stated that the skin prep had "toughened" the skin on the heel and "friction" of the heel rubbing in the heel protector had rubbed the skin off. Further review of the clinical record revealed no documentation of the open area being caused by friction, but rather staged as a pressure ulcer. 11) The findings also included the following: a) b) c) Resident #2 was admitted to the facility on 10/3/01 with diagnoses that include Diabetes, Lymphedema - both lower extremities, Agitated Psychotic Behavior, Major Depression and Hypertension. He has a history of chronic renal failure. During an observation of the resident on 2/11/02 at 11:40 A.M., it revealed he was in his room, in bed, wearing a hospital gown and incontinent brief. The resident was asleep and lying on his back. Observation of the resident's lower extremities revealed no signs or symptoms of edema. He was wearing bilateral heel pads and had dressings on both heels. During an observation of the resident on 2/11/02 at 1:15 P.M., he remained in his room, in bed, awake, alert but slightly drowsy. He was dressed in a hospital gown and had incontinent briefs on. His head was elevated at 90 degrees while he ate his lunch. The resident was calm and smiled when spoken to. Page 6 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 d) During an observation of the resident on 2/12/02 from 9:03 A.M. through 9:40 A.M., he was in his e) g) room, in bed, lying on his back, and wearing a hospital gown. His head was elevated at 90 degrees. His breakfast meal was in front of him on an overbed table. The resident hardly ate his breakfast. He was falling asleep off and on. No one was observed assisting the resident to eat. Observation of the resident at 10:00 A.M., revealed he remained on his back. He was asleep. At 10:35 A.M., observation of the resident's heels revealed an ulcer on the right, measuring approximately 5.0 cm x 5.0 cm and on the left heel measuring 3.5-4.0 cm x 4.5-5.0 cm. Both ulcers were reddish in color with some necrotic tissue. It had some yellowish drainage. Interview with the nurse at 10:45 A.M., revealed foul smelling odor from the ulcers. She also confirmed the resident did not have edema on both lower extremities. Observations of the resident's coccyx revealed an in house acquired Stage III pressure ulcer measuring approximately 2.0 cm x 3.0 cm. The tissue exposed was pinkish to reddish with some serosanguineous drain. The resident was observed in his room, in bed, lying on his back until 11:30 A.M. He was not repositioned for almost 2 1/2 hours. During an observation of the resident on 2/12/02 from 12:15 P.M. through 12:25 P.M., he was in his room, in bed, lying on his back. He was sleeping. At 1:05 P.M. through 1:20 P.M., the resident was in his room eating his lunch meal. His head was elevated at 90 degrees and his meal was in front of him on an overbed table. He was alert, calm, and slightly drowsy. No one was observed assisting the resident to eat. At 2:30 P.M., the resident was in his room, in bed, lying on his back. At 2:45 P.M., the resident was transferred to a recliner chair. He was placed in the hallway, outside his room. His head was elevated at 45 degrees, putting pressure on his coccyx. The resident was falling asleep off and on. He was calm. He remained in the recliner chair, outside his room until 3:00 P.M. At 3:05 P.M., a staff member took the resident and left him in front of the nurses’ station. Shortly after, the resident was taken by the activities staff in front of the A Wing dining room. The resident remained on his back and his head elevated at 45 degrees. Page 7 of 25 h) dD CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 The resident remained in the recliner, in the same position, in front of the A Wing dining room until 4:00 P.M. He was drowsy and falling asleep off and on. After a few minutes, the resident was taken by the activities staff outside for activities. At 4:30 P.M., the resident was observed still in the recliner chair, on his back. The resident was not repositioned. During observations of the resident on 2/13/02 throughout the moming from 8:00 A.M. through 10:30 A.M., he was in his room in bed, lying on his back. He was not repositioned for 2 1/2 hours. The resident's head was elevated at 90 degrees, putting pressure on his coccyx, while he ate his breakfast from 8:20 A.M. until 8:35 A.M. The resident remained in this position until 9:10 A.M. The restorative CNA weighed the resident, per surveyor request, at 9:15 A.M. and placed the resident back in bed, on his back, with his head elevated at 30 degrees. Observation of the resident during the breakfast meal revealed staff did not assist him after set-up. The resident was falling asleep in front of his meal. From 9:15 A.M. through 10:15 A.M., the resident remained lying on his back. At approximately 10:30 A.M., after his morning care, the resident was transferred to the recliner chair. He was dressed, awake, alert but slightly drowsy. His head was elevated approximately 30 degrees. He remained on his back. Further observation revealed the resident was uncomfortable. He was attempting to move but was unable to and had facial grimaces. He complained that his back was "hurting." The resident remained in this position until 11:30 A.M. The resident was on his back for 3 1/2 hours (since 8:00 A.M.). At 11:45 A.M., the resident summoned the surveyor while passing by his room. The resident was still in the recliner chair with his head elevated at 30 degrees. He complained that his back was hurting. Review of the initial MDS (Minimum Data Set) completed on 10/15/01, revealed the resident required extensive assistance to transfer and toilet, limited assistance to ambulate, and supervision for bed mobility. He was frequently incontinent of bladder but continent of bowel. He was able to feed himself. He is 68 inches tall and weighed 295 Ibs. Further review revealed the resident Page 8 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 had behavioral problems. The MDS also revealed he had two Stage 4 stasis ulcers. Clinical record review revealed these stasis ulcers are due to poor circulation in both lower extremities. k a Review of the significant change MDS completed on 1/7/02, revealed the resident declined in all areas of his Activities of Daily Living (ADL's). He now requires total assistance to transfer, toilet, and total assistance with bed mobility. He now requires assistance to eat. He is totally incontinent of both bowel and bladder. He remains to have behavioral problems. The MDS also revealed he weighs 256 lbs. 1) During the review of the physician's orders for the month of February 2002, revealed orders for Lasix (diuretic - for edema on both lower extremities), Risperdal (antipsychotic - for agitated psychotic behavior), and Celexa (antidepressant - for diagnosis of Major Depression). Review of the MAR (Medication Administration Record) confirmed the resident is receiving these drugs. m) During the review of the resident's Resident Assessment Protocol (RAP) Summary completed on "1/8/02" revealed he triggered for Pressure Ulcers. The Protocol Review Report stated, “Care Plan Decision: Proceed; Care Plan Type: Continuation." It further stated, "Has non stageable stasis necrotic wounds on heels. Interventions in place for wound healing. ABT (antibiotic) as ordered. Bedrest. Turned and repositioned by staff. Turns self at times. Risk for injury R/T (related to) falls. Have severe PVD (Peripheral Vascular Disease), Vascular Dementia, Wt (weight) Loss and End Stage Renal Failure. Will continue current care plan to promote healing and prevent further breakdown." The resident is on a pressure reduction mattress. n) Review of the resident's Care Plan developed on 10/19/01 and updated on 1/14/02, revealed the following problems and/or needs include: i) “Strict bed rest R/T (related to) poor circulation on lower extremities and multiple wounds to lower extremities and Edematous Bilat (bilateral) lower legs." ii) "Electrolyte imbalance.” iii) "Self care deficit.” Page 9 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 iv) “Neurogenic Bladder - At risk for impaired Skin Integrity R/T incontinent episodes of Bladder." vy) "Psychotropic Drug use; receives psychoactive medications daily with risk of side effects." vi) "Res (resident) wt 295 above IBW (ideal body weight); 10/19/01 - wishes not to lose wt; Res with high blood sugar." vii)"11/26/01 - Res not eating well - 50% or less R/T infection and antibiotics; Res declined to D/C (discontinue) Large Portions for diet; wt 277# (pounds) loss 7.6%." viii) "12/17/01 - wt down to 255 Ibs." o) Further review of the Care Plan revealed the following approaches include, "Bedrest with BR (bathroom) privileges as ordered by MD. May be OOB (out of bed) daily for short periods in geri- chair; 12/19/01, Resident may be up in recliner chair once per day for short duration as tolerated; toilet q (every) 2 hrs (hours) & enc. (encourage) resident to allow incontinence care to be rendered p (after) each episode - urinal at bedside." 12) Review of the facility's guidelines for Wound Healing revealed under "Prevention" includes the following: "2. Minimize exposure to moisture. 4. Reposition every 2 hours. 8. Address nutritional aspects (labs, 1&0 (intake and output), weight, supplements)." 13) During an interview with the DON and Unit Manager on 2/13/02 at 3:00 P.M., they stated that the resident “would not stay off his back." There is no Care Plan to address this concern. There is no documentation that alternative interventions were attempted to address this concem. On 2/14/02, the DON and Unit Manager stated that the resident's pressure reduction mattress was changed to an air mattress the evening of 2/13/02. 14) Interview with the Dietitian on 2/14/02 at approximately 11:00 A.M., revealed the resident's protein and caloric intake have not been assessed since the 2 pressure ulcers on his coccyx and right buttock were noted on 2/1/02. There has been no assessment to determine if the resident's protein and calorie needs are being met to assist in wound healing. It also confirmed that the resident's intake of meals Page 10 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 and supplements are poor since his admission on 10/3/01. Review of the resident's meal consumption for the months of January and February 2002, revealed his average intake was less than 50% and he often refused to drink Glucerna Shake (nutritional supplement). Review of the laboratory results dated 1/30/02, revealed abnormal values. The resident's Hemoglobin and Hematocrit levels are low. 15) During the review of the Weekly Pressure Ulcer Healing Assessment, it revealed the two Stage II pressure ulcers were noted on his right buttock and coccyx on 2/1/02. The coccyx pressure ulcer measured 1.5 cm x 1.5 cm x 0.01 cm in depth. There was scant amount of serosanguineous exudates (drainage). Tissue was red and the surrounding skin was pink. The right buttock pressure ulcer was 1.0 em x 1.0 cm by 0.01 cm in depth. There was scant amount of serosanguineous exudates. The tissue was red and the surrounding skin was pink. Further review of the weekly assessments revealed the coccyx pressure ulcer has worsened. 16) On 2/7/01, the coccyx pressure ulcer measured 3.0 cm x 2.0 cm x 0.01 cm in depth. It was at Stage II. During an observation of the coccyx pressure ulcer on 2/13/02, at 3:55 P.M., the wound was measured by the PT (Physical Therapy) Director with the Unit Manager. The ulcer measured 3.1 cm x 2.7 cm. It had yellow slough (dead tissue; about 25%). The rest of the tissue exposed was pinkish. The Unit Manager stated that the pressure ulcer was at Stage II. Both PT Director and Unit Manager agreed that subcutaneous tissue is exposed, indicating that the pressure ulcer is at Stage III. 0 17) The findings also included the following: a) Resident #15 was admitted to the facility on 1/15/02 with diagnoses that include, but not limited to Diabetes Mellitus, Diabetic Neuropathy, CHF (Congestive Heart Disease), Dementia, Degenerative Joint Disease, and Contusion of left knee that required immobilization of left leg while out of bed. b) Clinical record review revealed the resident is a vegetarian with dietary orders for meats 3 (three) times per week and NCS (No Concentrated Sweets) diet. Further review of the clinical record revealed, "Meal intake varies: fair to good consuming 25% - 50%." The dietary recommendation Page 11 of 25 c) d) e) g) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 was for 1 can of Glucerna (nutritional supplement) "if p.o. intake less than 75%." The order for this was obtained. On 1/30/02, after dietary consults, related to additional decubiti (pressure ulcers), the order was changed to 1 can of Glucerna TID (three times a day). There was no documentation to indicate that the resident's protein intake was assessed to determine if his needs were being met to assist in wound healing. Review of the resident's tray ticket revealed that he is to receive meat on 2/12/02. During an observation of the supper meal on 2/12/02 the resident did not have meat. The Resident Data Set completed on admission revealed, "resident with bilateral heel decubiti, (left heel ulcer unstageable, right heel stage II), reddened buttocks.” It assessed him as being at risk for pressure ulcers citing activity level as chair fast; mobility as very limited requiring two or more person physical assist. Pain assessment revealed, "shooting pain left knee with movement, relieved with pain medication” and “everything makes the pain worse." The MDS (Minimum Data Set) assessment reference dates (ARD) 1/22/02 and 1/30/02, identified the resident as needing total assist with bed mobility and total assist of 2+ persons to transfers. Further review of the MDS/ARD completed on 1/22/02, revealed the resident has two (2) pressure ulcers (one Stage I and one Stage IV). The MDS/ARD completed on 1/30/02, revealed the resident has four (4) pressure ulcers (one Stage I, two Stage II, and 1 Stage IV). The nurse's note on 1/27/02, revealed 3 new pressure areas: 2 newly opened areas on his R (right) buttocks, measuring 2.0 cm x 1.5 cm and on his L (left) buttocks measuring 1.5 cm x 1.8 em. The nurse's stated, "...reported blisters earlier, now open, purple center.. R (right) calf, indentation around it, as if seated on hard object. Area approx. (approximately) 0.5 cm diameter, center yellow slough." Review of the Weekly Pressure Ulcer Healing Assessment revealed, on 1/27/02, two additional Stage II pressure areas on the resident's right lower calf was noted. The first pressure ulcer measured 1.1 cm x 1.0cm. On 1/29/02, this pressure area had a depth of 0.1 cm. On 1/31/02, the Page 12 of 25 h) k) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 pressure sore increased to 1.4 cm x 1.0 cm, having smal! amount of purulent yellow exudates (drainage). The second right lower calf pressure area measured 0.6 cm x 0.5 cm. On 1/29/02, it had a depth of 0.1 cm. On 1/31/02, this pressure area increased to 1.1 cm x 1.0 cm x 0.1 cm in depth with small amount of purulent yellow exudates. A Stage I pressure ulcer on the resident's left calf was noted on 1/31/02. The pressure ulcer measured 3.0 cm x 3.0 cm x 0.2 cm in depth with scant black purulent exudates. Interviews with the DON and Unit Manager on 2/13/02 at approximately 3:00 P.M. and 2/14/02 at approximately 10:30 A.M., confirmed that the resident acquired additional pressure ulcers (calf area) since his admission to the facility on 1/15/02. They stated that propping pillows to offload the resident's heels caused these additional pressure ulcers. During the interview with the Administrator on 2/14/02 at approximately 11:00 A.M., she stated that she was unaware that pillows could cause pressure ulcers. When she addressed this to the Medical Director, “he said it was possible." She said that at one point in the morning meeting, the team explored intervention of turning and repositioning resident every hour versus two hours. However, she stated this intervention was not implemented. During the review of the nurses’ notes for the month of January 2002, it revealed the knee immobilizer on the resident's left leg was applied when he is out of bed, his heels are off loaded and his lower extremities are propped on pillows. The resident's plan of care dated 1/15/02, included medicating him as indicated to alleviate pain. Review of the admission orders 1/15/02, revealed an order for Darvocet N-100 (narcotic analgesic) every 4-6 hour as needed for pain. Review of the MAR for the month of January 2002, revealed the resident did not receive this drug. This order was discontinued on 1/16/02 and Oxycodone (narcotic analgesic) Suppository was ordered every 4 hrs for pain, The order stated Oxycodone 5 mg. every 4 hours as need for pain. Review of the MAR for the month of January 2002, revealed the resident did not receive this drug Page 13 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 until 1/18/02. On 1/21/02, the order for Oxycodone changed to be given at 9:30 A.M. and half hour before physical therapy. After the resident refused to continue physical therapy, the order for Oxycodone was changed to a routine AM and PM dose. m) Review of the Resident's plan of care dated 1/17/02, revealed the following approaches for impaired skin integrity (heels): Wound care as ordered. Off load heels. Monitor heels on weekly basis with wound care team. Skin to be kept clean and dry. Frequent position changes. n) During the review of the "Interim Plan of Care" (this is used to communicate resident needs to har CNA's who are providing direct care) dated 1/15/02, it listed under Special Equipment: left immobilizer. It stated, "above needed due to..." .This section was not completed. No weight bearing status was checked (the resident is non weight bearing on his left leg). o) During an observation on 2/12/02 at 2:25 P.M., it confirmed the resident has pressure ulcers on the outer aspect of his left lower leg, and right lower leg above the heel, and on both heels. p) The resident developed 6 in house acquired pressure ulcers since his admission to the facility on 1/15/02. There is no documentation of adequate assessment of the resident's pain, which can limit his mobility, and no adequate assessment of the resident's response to the pain medication. 18) Based upon the foregoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which required the Respondent, based upon a comprehensive assessment of a resident, to ensure that 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. That rule incorporates by reference 42 CFR § 483.25(c)(1). 19) Based upon the forgoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which required the Respondent to ensure that residents who had pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. That rule incorporates by reference 42 CFR § 483.25(c)(2). Page 14 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 20) The foregoing also constitutes a violation of § 400.022, Fla. Stat., which requires the Respondent to ensure the residents’ right to receive adequate and appropriate health care and protective and support services. 21) The foregoing also constitutes an intentional or negligent act materially affecting the health or safety of residents of the facility as defined by § 400.102 (1)(a), Fla. Stat. and is subject to a fine under § 400.121 Fla. Stat. 22) The foregoing constitutes a Class II deficiency as defined by § 400.23(8)(b) Fla. Stat. as follows: 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 I] 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 shal] be doubled for each deficiency if the facility was previously cited for one or more class I or class I 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. 23) AHCA assigned a mandatory correction date of March 16, 2002. 24) 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 under § 400.23(8), Fla, Stat. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of AHCA on Count I, B. Impose a fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) for the violation cited in Count I against the Respondent under §§ 400.022, 400.102(1)(a), 400.121(1), and 400.23(8)(b), Fla. Stat. and Fla. Admin. Code R. 59A-4.1288 (incorporating by reference 42 CFR § 483.25). Page 15 of 25 CERTIFIED ARTICLE NUMBER 7106 4675 1294 2050 0224 COUNT I THE FACILITY FAILED TO ENSURE THAT A RESIDENT MAINTAINED ACCEPTABLE PARAMETERS OF NUTRITIONAL STATUS, SUCH AS BODY WEIGHT AND PROTEIN LEVELS, UNLESS THE RESIDENT'S CLINICAL CONDITION DEMONSTRATED THAT THIS IS NOT POSSIBLE 400.022, 400.102(1)(A), 400.121, AND 400.23(8)(B), FLA. ADMIN. CODE R. 59A-4.1288 (INCORPORATING BY REFERENCE 42 CFR § 483.25) CLASS Il DEFICIENCY 25) AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 26) Based on observations, record reviews and staff interviews, the facility failed to adequately assess, develop an appropriate Care Plan and interventions to prevent a significant weight loss and/or maintain acceptable parameters of nutritional status for 1 (Resident #2) of 5 from a sample of 15 active residents reviewed for weight loss and nutritional concerns. 27) This is evidenced by: a) The facility did not adequately assess Resident #2's nutritional status after the resident loss a significant amount of weight of 7.16% in 8 weeks and developed 2 pressure areas. b) The facility did not develop a Care Plan to ensure that the resident would maintain acceptable parameters of nutritional status while he is on a planned weight loss. c) There is no assessment of the resident's abnormal laboratory nutritional levels and no assessment of his protein and caloric intake based on his current needs. 28) The findings include: a) Resident #2 was admitted to the facility on 10/3/01. His diagnosis included, Diabetes Mellitus, Lymphedema, Hypertension, Major Depression, and Agitated Psychotic Behavior. His medical history included Chronic Renal Insufficiency. The resident had a darkened area (eschar) on his left heel. b) On 10/18/01, 15 days after his admission, an area on his right heel was noted. Both areas were documented unstageable. Page 16 of 25 c) d) e) 8) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 During an interview with facility staff, during the initial tour on 2/11/02, it revealed that these areas located on the resident's heels were stasis ulcers. Review of the resident's initial Minimum Data Set (MDS) completed on 10/15/01, revealed he required "extensive" assistance with Activities of Daily Living (ADL) which include transferring, hygiene, dressing, bathing, and toileting. He is able to feed himself. He was frequently incontinent of bladder and continent of bowel. He is 68" (inches) tall and weighs 295 Ibs (pounds). During the review of the significant change MDS completed on 1/7/02, it revealed the resident requires "total" assistance with most ADL’s that include transferring, hygiene, bathing, dressing, toilet use and bed mobility. He is totally incontinent of bowel and bladder. He requires assistance of 1 person to eat. His weight was 256 lbs. which indicates a severe weight loss of 13.22% in 2 1/2 months. Further review of the resident's clinical record revealed he was well over his body weight. His usual body weight (UBW) was 300+ lbs. Further review also revealed that the resident has 3+ edema on both lower extremities when he was admitted on 10/3/02. The physician ordered Lasix (diuretic) for the resident's edema. Review of the physician's order for the month of February 2002, revealed an order for Lasix 40 mg. by mouth twice a day. The laboratory tests completed while he was at the hospital revealed low Hemoglobin and Hematocrit levels. His BUN (Blood Urea Nitrogen - reference range - 6-28 mg/dL) was high at 51 mg/dL. Further review of the resident's clinical record also revealed that his appetite was poor. He was receiving No Concentrated Sweets (NCS) double portions diet. He is receiving Humulin 70/30 8 units subcutaneously everyday at 6:30 A.M., for his diabetes. Further clinical record review revealed he had behavioral problems such as agitation, yelling, delusions and paranoia. He is currently receiving Risperdal (antipsychotic) 1 mg. every moming, 0.5 mg everyday at 4:00 P.M., and 0.5 mg. at bedtime. He is receiving Celexa 40 mg. everyday for depression. Further review Page 17 of 25 h) D k) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 of the resident's clinical record also revealed he was given an intravenous infusion of 1/2 NS (normal saline) at 100 cc per hour on 11/28/01 and discontinued on 12/4/01 due to electrolyte imbalance. During an interview with the Unit Manager on 2/14/02 at approximately 1:30 P.M., revealed that the resident's lower extremities were no longer edematous on 11/29/01. The nurse's notes dated 11/29/01, confirmed there was "no edema” noted on the resident's lower extremities. The resident's weight at that time was 277 lbs. During the interview with the Unit Manager and Director of Nursing (DON) on 2/14/02 at approximately 11:00 A.M., it revealed that the resident's significant weight loss in December 2001 was due to the diuretic used to decrease the resident's edema. Review of the resident's weight record revealed he weighed 275 Ibs. in 12/2/01 and 265 Ibs. in 12/10/01, indicating a weight loss of 10 Ibs. in one week. Review of the nutritional note dated 12/14/01 stated, "Rt (resident) does not want to lose anymore wt (weight). Rt. states that he simply has no appetite. No desire to eat at all." The Dietitian recommended Mighty Shake twice a day. She also recommended a short-term appetite stimulant. The clinical record review also revealed the resident was receiving antibiotic therapy for infected heel ulcers. Review of the resident's weight record revealed he weighed 255 lbs. on 12/17/01. This indicates a severe weight loss of 20 Ibs. from 12/2/01, or a severe weight loss of 7.2% in 2 weeks. m) The physician's telephone order dated 12/17/01, revealed Sugar Free (SF) Mighty Shakes 4 times a day was ordered. Review of the Medication Administration Record (MAR) for the month of December 2001, revealed the resident often refused to take the SF Mighty Shake. There is no documentation of the percentage of his intake of the Mighty Shake except for 3 occasions. His average meal intake for the month of December 2001, was approximately 20% for breakfast, 26% for lunch and 33% for dinner. Page 18 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 n) During the review of the Dietitian's progress notes dated 12/27/01, she stated that the resident's 0) P. ~S Hemoglobin and Hematocrit levels are low at "10.7 gm/dL and 31.6%." She also stated that the resident's albumin level in 10/01 was low at 3.2 mg./dL. She further stated, "BS (blood sugar) are unstable & require SSC (sliding scale). Res (resident) increased needs secondary to wound, infection, significant weight loss, though res (resident) remains above IBW (ideal body weight), but wt (weight) loss undesirable at current wt. Current intake does not meet est. (estimated) needs, res with moderately impaired cognitive status, feeds self, Res cont (continue) with c/o (complained of) no appetite, rec (recommend) appetite stimulant x 30 days, cont wkly (weekly) wts (weights), Promod (protein powder) 2 sc (scoops) TID (three times a day) in applesauce or juice, rec (recommend) to restart Vit. C 500 mg. & ZnSO4 (Zinc Sulfate) unless this are stasis ulcers then Vit. C & Zn is not warranted." During an interview with the DON, Unit Manager, RD (Registered Dietitian) and facility Administrator on 2/14/02 at approximately 11:00 A.M., they stated that the resident's physician refused to order the Vit. C, Zinc, and Promod. They stated that on 12/18/01, during their focus meeting, the physician wanted the resident to lose weight. The goal weight was 180 Ibs. They stated that the resident's healthcare surrogate was informed and agreed with the physician's plan. The resident was started on a planned weight loss on 12/18/01. There is no documentation to indicate what alternative measures will be implemented to meet the protein needs of the resident which is needed for wound healing and infection, after the physician refused to order the protein powder. There is no documentation in the resident's clinical record to indicate that the resident’s protein intake was monitored. During the review of the Care Plan for planned weight loss developed on 12/18/01, it stated under RAP/PROBLEM/NEED, "Planned weight loss program per MD to slow wt loss til (until) achieves wt 180. *Rapid wt loss with poor po (oral) intakes; cog (cognitively) impaired." The goal stated, "1) Will lose 3-5 pounds per week to achieve wt of 180 (per MD) thru 1/18/02. 2) Will show no Page 19 of 25 q) 1) s = CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 s/s (signs and symptoms) dehydration abnormal labs, skin turgid thru 1/18/02. 3) Will consume 50% of meals snacks offered thru 1/18/02." The following approaches were listed: i) Provide diet NCS large as ordered. ii) 1/2 sandwich/milk at HS (at bed time). iii) Monitor wts and food %. iv) Monitor blood sugars. v) Monitor labs. vi) Encourage intakes of diet & fluids offered. vii) Milk shake (sugar free) QID (4 times a day).\ viii) Refer to RD (Registered Dietitian) prn (as needed). ix) Assist with meals as needed. On 1/9/02, the resident weighed 258 Ibs, and on 2/5/02 he weighed 246 lbs. This indicates a weight loss of 12 Ibs. in 4 weeks. It also indicates that the resident had a severe weight loss of 19 Ibs. or 7.16% since 12/10/01 (8 weeks). There is no documentation in the resident's clinica] record to indicate that the resident's nutritional status was assessed. There is no documentation to indicate that the planned weight loss was still meeting its goals while providing the resident with a well balanced diet to prevent physical complications. There is no documentation to indicate that the resident's protein and caloric intake were assessed to determine if he was meeting his nutritional needs with consideration to his medical conditions including existing wounds. There are no revisions to the resident's Care Plan to address the severe weight loss. On 2/1/02, two new pressure sores were noted on the resident's coccyx and right buttock. The coccyx pressure sore was 1.5 cm X 1.5 cm at stage II. The right buttock pressure sore was 1 cm X 1 cm at Stage IT. Review of the physician's telephone orders and MAR revealed that the SF Mighty Shake was decreased to twice a day on 1/13/02. This was discontinued on 1/28/02 and Glucema Shake one Page 20 of 25 t) u) v) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 can between meals three times a day was started. Review of the resident's intake of the SF Shake 4 times a day, from 1/1/02 through 1/13/02, revealed an average intake of 19% at 9:00 A.M., 15% at 1:00 P.M., 5:00 P.M. 100% and 69% at 9:00 P.M. After the SF Shake was changed to twice a day on 1/13/02, review of the MAR revealed the resident did not drink the morning shake from 1/4/02 through 1/28/02 except on 2 occasions. His average intake of the afternoon SF Shake from 1/4/02 through 1/28/02, was approximately 35%. From 1/29/02 through 1/31/02, the resident's average intake of the Glucerna Shake was approximately 40% at 9:00 A.M., 15% at 1:00 P.M. and 50% at 6:00 P.M. Review of the residents meal consumption for the month of January 2002, revealed his intake was approximately 58% for breakfast, 38% for lunch, and 58% for supper. On 2/13/02, the resident was weighed per surveyor request. The resident weighed 239.7 Ibs. This indicates a severe weight loss of 18.3 Ibs. since 1/9/02 or 7% in 5 weeks. The resident's average meal consumption for the month of February 2002, from 2/1/02 through 2/12/02: breakfast - 37.5%; lunch - 31%; supper - 37%. The resident has been refusing his Glucerna Shake at 9:00 A.M. and 1:00 P.M. His average intake of Glucerna Shake at 6:00 P.M. is 35%. There is no documentation to indicate that the resident was receiving his HS snacks, nor was there documentation to indicate that this was offered. On 2/14/02, the dietitian provided documentation completed by the CNA for 2/12/02 and 2/13/02. Review of this documentation revealed the resident was offered juice and sandwich on 2/12/02. The resident refused the sandwich. On 2/13/02, the resident was offered juice. w) Review of the laboratory result dated 1/30/02, revealed the following abnormal values: i) BUN (blood urea nitrogen) - 53 H (high) (expected values - 6-28 mg/dL). ii) Glucose - 158 H (expected values - 60-115 mg/dL) iii) Glycohemoglobin (HAIC) - 8 (Intermittently well-controlled - 7.0%-9.0%). iv) RBC (red blood cells) - 3.25 L (low) (expected value - 4.5-5.9 mill/cmm). Page 21 of 25 x na y) 2) CERTIFIED ARTICLE NUMBER 7106 4675 1294 2050 0224 v) Hemoglobin - 9.5 L (expected value - 14-18 gm/dL). vi) Hematocrit - 28.4 L (expected value - 40-54%). There is no documentation in the resident's clinical record to indicate that these laboratory values were assessed. During an observation of the resident on 2/12/02 from 12:55 P.M. through 1:15 P.M., revealed he was in his room, in bed, awake, alert, oriented to person and situation. He was wearing a hospital gown and he appeared pale. He was observed falling asleep on and off in front of his meal and the staff did not provide any assistance while he ate. Further observation of his lunch meal revealed he ate less than 25% of the baked beans and 75% of the applesauce. He drank 2 small glasses of juice (240 cc). He did not eat the potato salad, barbecued beef with sauce and any of the soup. He did not drink the milk (236 ml). His meal was not double portion. Observation of the resident on 2/13/02 at 8:20 A.M., revealed he was in his room, in bed. Awake, alert but drowsy, oriented to person and place. A CNA was setting him up for breakfast. Further observation of the resident until 8:30 A.M., revealed he was falling asleep in front of his breakfast meal. He appeared pale. There was no staff assisting the resident. Observation of the resident's breakfast tray at 8:35 A.M., revealed he ate less than 25% of the cereal and scrambled egg, and 25% of the banana. He did not eat the sausage and the 2 slices of wheat toast. He drank 50% of the whole milk (120 cc) and drank 25% of the orange juice (40 cc). He did not drink the Glucerna Shake and prune juice. His meal was not double portion. Interview with the CNA revealed that the resident refused to eat anymore. aa) During an observation of the resident's stasis ulcers on his heels on 2/12/02 at 10:35 A.M., the left heel ulcer measured approximately 3.5-4.0 cm x 4.0-5.0 cm. The right heel ulcer measured approximately 5.0 cm x 5.0 cm. The tissue exposed was pinkish-reddish with some necrotic areas. The nurse confirmed the presence of a foul odor from the ulcers after the dressing was removed. Observation of the resident's new pressure ulcer on his right buttock and coccyx on 2/12/02 at Page 22 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 10:55 A.M., revealed that his coccyx pressure sore has worsened. Observation revealed it measured approximately 2.0 cm x 3.0 cm. There is yellowish drainage without odor and the subcutaneous tissue was exposed indicating the presence of a Stage III pressure sore. The resident did not have edema. bb) During the interview with the Dietitian, DON, and Unit Manager on 2/14/02 at 11:00 A.M., they confirmed that the resident's protein and caloric intake have not been assessed since he developed new pressure sores. 29) Based upon the forgoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which required the Respondent to ensure that a resident 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. That rule incorporates by reference 42 CFR § 483.25(i)(1). 30) AHCA assigned a mandatory correction date of March 16, 2002. 31) The foregoing also constitutes a violation of § 400.022, Fla. Stat., which requires the Respondent to ensure the residents’ right to receive adequate and appropriate health care and protective and support services. 32) The foregoing also constitutes an intentional or negligent act materially affecting the health or safety of residents of the facility as defined by § 400.102 (1)(a), Fla. Stat. and is subject to a fine under § 400.121 Fla. Stat. 33) The foregoing constitutes a Class II deficiency as defined by § 400.23(8)(b) Fla. Stat. as follows: 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 ispection. A fine shall be levied notwithstanding the correction of the deficiency. Page 23 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 34) 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 under § 400.23(8), Fla. Stat. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of AHCA on Count II, B. Impose a fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) for the violation cited in Count I against the Respondent under §§ 400.022, 400.102(1)(a), 400.121(1), and 400.23(8)(b), Fla. Stat. and Fla. Admin. Code R. 59A-4.1288 (incorporating by reference 42 CFR § 483.25). NOTICE The Respondent 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 Joanna Daniels, Assistant General Counsel, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, FL 32308. 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. Respectfully submitted, Joanna Daniels FL Bar #0118321 Assistant General Counsel Agency for Health Care Administration 2727 Mahan Dr., MS #3 Tallahassee, FL 32308 (850) 922-5873 Fax (850) 413-9313 Page 24 of 25 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0224 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Administrator, MARINER HEALTH CARE OF PORT CHARLOTTE, 25325 RAMPART Oe PORT CHARLOTTE, Florida 33983 Return Receipt No. 7106 4575 1294 2050 0224 on January\, ' Pe ourac danske Joanna Daniels Assistant General Counsel Copies furnished to: Wendy Adams Joanna Daniels Agency for Health Care Administration Agency for Health Care Administration 2727 Mahan Drive, MS #3 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 Tallahassee, FL 32308 (Interoffice Mail) (Interoffice Mail) JD/ghm Page 25 of 25

Docket for Case No: 03-000938