STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2002006431 Division of Administrative Hearings FIL! OX 1502 vs. DESOTO HEALTH & REHABILITATION, L.L.C., DESOTO HEALTH AND REHABILITATION 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 DESOTO HEALTH & REHABILITATION, L.L.C., d/b/a DESOTO HEALTH AND REHABILITATION (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) pursuant to Sections 400.102(1) (a) and (d), 400.121(1), and 400.23(8)(b), Florida Statutes. 2. The Respondent was cited for the deficiencies set forth below as a result of a Complaint Survey conducted on or about January 14-17, 2002. JURISDICTION 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Desoto County, Division of Administrative Hearings, pursuant to Section 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 1002 North Brevard Avenue, Arcadia, Florida 34266. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO PREVENT RESIDENT-TO-RESIDENT ABUSE; VIOLATING 59A-4.1288, F.A.C. INCORPORATING BY REFERENCE 42 CFR 483.13 (c) (1) (i). CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. A Complaint survey was conducted on or about January 14-17, 2002. 9. On that date, based on observation based on clinical record review and interview with facility staff including nursing, administration and medical records personnel, the facility failed to prevent resident-to-resident abuse by 3 residents (Residents #2, #11 and #15 from extended survey). This is evidenced by: 1. Failing to identify, investigate and correct witnessed and/or documented resident- to-resident abuse by 3 residents. 2. Failure of the facility to monitor effectiveness of abuse and neglect training as evidenced by lack of incident reporting after resident-to-resident abuse. 3. Failure of the facility to adequately supervise staff personnel as evidenced by the lack of Director of Nursing from 11/12/01 through 1/7/02 and lack of Social Worker from 12/19/01 through 1/7/02. 4. Failure of the facility to care plan residents and monitor residents who have documented or witnessed behaviors of resident to resident aggressiveness or abuse. 10. A Class II deficiency was cited against Respondent based on the findings below: 1. Resident #2 was admitted to the facility on 4/6/01 with multiple diagnoses including but not limited to Dementia. Resident #2 was discharged to a local hospital on 9/21/01 and did not return to the facility. This is a closed record review. The admission MDS (Minimum Data Set) dated 4/19/01 reveals: B 4. Cognitive status was 1 - Modified independence - some difficulty in new situations only. B 5. Indicators of delirium. c. Episodes of disorganized speech = 1.- Episodes of restlessness = 1. i Rh f. Mental function varies over the course of the day 1 = Behavior present, not of recent onset. E 1. Verbal expressions of distress c. = 1 Sleep cycle issues k. = 1 1 = Indicator of this type exhibited up to five days a week. E 4. Behavioral symptoms b. = 1/1 Verbally abusive Behavioral symptoms c. = 1/1 Physically abusive behavioral symptoms. d. = 1/1 Socially inappropriate/disruptive behavioral symptoms. e. = 1/1 Resist Care. 1/1 = Behavior of this type occurred 1-3 days in last 7 days and behavior was not easily altered. The Quarterly MDS dated 7/18/01, reads that Resident #2's cognition is now a 2 = moderately impaired - decisions poor, cues/supervision required. E 1. has additions of, a. Resident made negative statements, d. persistent anger with self or others, and 1. crying and tearful. Behavioral symptoms unchanged. 2. Clinical record review of the nurses notes reveal the following: 4/26/01, "Resident becomes aggressive towards staff and residents hitting & yelling obscenities, throwing furniture & anything --- can get --- hands on, then walks the halls & threatens to hit someone whoever gets in --- way." The Director of Nursing was called and instructed the staff to call the MD for "Help." The resident's room was changed. The resident was given Haldol 1 mg. stat for agitation. On 5/2/01, nurse’s notes indicate that the resident is wandering in and out of other residents' rooms. Nurse’s notes for the month of May 2001, indicate that the resident cannot sleep. On 5/19/01, the physician orders Trazodone 50 mg. at bedtime for insomnia. Nurse’s notes dated 5/22/01, reveal that the resident is verbally abusive but does not indicate to whom he/she directs the abuse. On 7/1/01, nurse’s notes indicate that the resident is becoming combative with staff. The resident was given Haldol 1 mg. IM and a psych consult was ordered. Nurse’s notes on 8/21/01, reveal resident was found in the room yelling at roommate. The note reads that the resident is agitated and verbal intervention has little effect. Nurses notes, late entry, 8/24/01 reads, "Resident & and Roommate was fighting in middle of hallway." The resident was moved. On 8/31/01, nurses notes timed at 9:30 A.M. read, "Very distressed & combative, cursing & being abusive to other pts (Patients)." The physician was notified and Haldol .5 mg. IM was given. On 9/4/01, nurses notes timed at 11:00 P.M. read, "Resident up in wheelchair. ~----- verbal abusive to staff, acting out, went into others room, given redirection as need with some effect..." On 9/6/01 at 4:00 P.M., the nurse’s note reads, "Resident yelling, cursing at other residents and staff, also combative toward residents, running into them with wheelchair - also combative toward staff. Dr. --- was beeped and returned call with orders to give Haldol IM .5 mg. Dr. ---- also stated that this would be the last time he would order a chemical restraint, he stated he ordered a psych consult and wants that done before he orders anything else." The physician then cancelled the Haldol order. Nurses notes on 9/9/01 read, "Resident with aggressive behavior toward other residents smacking, pinching. Removed from stimuli." On 9/13/01 at 6:00 A.M., a nurses note reveal that the resident, "Ran wheelchair into a resident sitting in hallway, smacking at him and pushed med cart into entrance of nursing station. Continues to ram med cart and pushing it at this time. Wheels locked on med cart. Resident removed from area, given coffee." At 9:30 P.M., the resident is again upset and climbing into other residents' beds. Nursing staff writes that resident is extremely agitated and aggressive with staff. Resident again transferred to another room. Resident #2's care plan does not note the resident's abusive behavior and subsequent needed interventions. Review of the facility incident and accident report for this period of time reveals documentation of several falls for this resident. However, there is no documentation in regards to the resident-to-resident abuse situations. Interviews with a staff nurse on the West Wing of the facility and a medical records employee revealed that several residents on the West Wing hit other residents. The charts for Resident #11, #14, and #15 were given to the writer. Review of the facility's incident and accident log does not reveal any incident reports were written for any resident-to-resident abuse issues regarding the above residents. 3. Interview with the acting Director of Nursing on 1/16/01, revealed that he was aware that residents were hitting other residents and actually offered information regarding Resident #15. The DON confirmed that he did not initiate an investigation, document the incident as an incident report, or report it as an adverse incident. Clinical record review of nursing notes for Resident #15 shows that on 12/25/01 at 3:25 P.M., this resident "kicked another resident without provocation "x2 in the past 10 minutes." Residents were separated and isolated from each other." The following nurses note documented the same date (12/25/01) at 4 P.M. shows, "Again attempting to assault another resident in the hallway. Yelling appears very agitated. Again separated & isolated from each other." Upon request the facility provided the QI incident report. Attached to this report was the investigation report Part I, which is not signed and dated. This report continues on a 3rd. page, which is section II and is to be completed in 24 hours. The investigative report shows, "In review of nurses notes & speaking to staff I felt he was not actually or deliberately trying to harm another resident. Cannot substantiate that he actually made contact. Will ask for psych follow up." Section III (review within 48 hours) shows a follow up of "No bruising on resident noted will continue to monitor resident's behavior and follow up with psych." There is no indication that this incident was submitted as an adverse event 4. Clinical record review for Resident #11 shows that on 12/25/01 at 4:00 P.M., the resident was kicked by another resident with no red areas noted, small area tender to touch. Documentation shows the wife was notified and the resident was monitored for injury by nursing staff. On 12/26/01 at 1:30 P.M., it is documented that Rt. Upper lower leg was tender to touch. On 12/27/01 at 1:30 P.M., the resident did not show signs of redness, bruising, swelling of Rt. Leg, no complaints of tenderness. Review of the facility incident and accident reports for this time period does not include a record of this incident. No adverse incident report was generated for this incident of resident-to- resident abuse. 5. Clinical record review for Resident #11 shows: 1. She has been assessed as being verbally and physically abusive and resistive to care. 2. Her care plan, dated 08/23/2001, shows "Resident has poor cognitive skills R/T (related to) DX (diagnosis) Dementia-At times can be verbally and physically abusive towards staff and other residents." 3. The goal is: Resident will accept care without resistance or unacceptable behaviors through next review. This resident has documentation in the clinical record that shows the following. 1. On 10/15/01, nurse's notes include, "some verbal abuse to other residents nearby, "shut-up, get the hell away." Can be redirected one on one." 2. On 01/07/02, the resident came within range of another resident in the dayroom and she scraped the resident's head with her fingernails. Did not break the skin. Interview with a staff on the West Wing at 9:40 A.M. on 01/17/02, shows that this resident is resistive to care and strikes out at staff a lot, also that she will self-propel herself in her wheelchair and will reach out to other residents if they are nearby. The resident's care plan, reviewed and updated on 03/12/02, does not address resident-to-resident abuse. The facility was unable to provide incident reports or show that an investigation was initiated on the resident-to-resident abuse incidents. The facility did not initiate an Adverse Incident report. Interview on 01/15/02 at 4:50 P.M., Incident Report logs and Abuse/Neglect investigations were requested from the QA/Risk Manager. The surveyor was told that the former Social Worker took the Incident Report log with her when she left and that the former Director of Nurses only had one investigation from October, 2001. The Risk Manager said that she did not know if there were more, or where the paperwork would be located. The Risk Manager said that the former DON did not return to the facility at the Administrator's request to show staff where the reports were. 11. The above actions or inactions constitute a violation of (1) Section 400.23 (8) (d) Fl. Stat. (2001), which defines a Class II deficiency that 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. (2) Chapter 59A-4.1288 Fl. Admin. Code. R. incorporating by reference 42 CFR 483.13(c) (1) (i) which requires the facility to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 12. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Five Thousand Dollars ($5,000) is authorized under §400.022(3), $400.102(1) (a) (a), §$400.121({1), and §400.23(8) (b), Florida Statutes. COUNT ITI RESPONDENT FAILED TO INITIATE THE POLICIES AND PROCEDURES TO PREVENT RESIDENT TO RESIDENT ABUSE BY THREE RESIDENTS; VIOLATING 59A-4.1288 F.A.C. INCORPORATING BY REFERENCE 42 CFR 483.13 (C) (1) (i). CLASS II DEFICIENCY 13. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 14. A Complaint survey was conducted on or about January 14-17, 2002. 15. On that date, based on clinical record review, and interview with facility staff including nursing, administration and medical records personnel, the facility failed to initiate the policies and procedures to prevent resident-to-resident abuse by 3 residents (Residents #2, #11 and #15 from extended survey). This is evidenced by: 1. Failing to identify, investigate and correct witnessed and/or documented resident-to-resident abuse by 3 residents. 2. Failure of the facility to monitor effectiveness of abuse and neglect training as evidenced by lack of incident reporting after resident-to-resident abuse. 3. Failure of the facility to adequately supervise staff personnel as evidenced by the lack of Director of Nursing from 11/12/01 through 1/7/02 and lack of Social Worker from 12/19/01 through 1/7/02. 16. A Class II deficiency was cited against Respondent based on the findings below: 1. Resident #2 was admitted to the facility on 4/6/01 with multiple diagnoses including but not limited to Dementia. Resident #2 was discharged to a local hospital on 9/21/01 and did not return to the facility. This is a closed record review. The admission MDS (Minimum Data Set) dated 4/19/01 reveals: B 4. Cognitive status was 1 - Modified independence - some difficulty in new situations only. B 5. Indicators of delirium - c. Episodes of disorganized speech = 1 d. Episodes of restlessness = 1. £. Mental function varies over the course of the day = 1. 1 = Behavior present, not of recent onset. E 1. Verbal expressions of distress c. = 1 Sleep cycle issues k. = 1 1 = Indicator of this type exhibited up to five days a week. E 4. Behavioral symptoms b. = 1/1 Verbally Abusive Behavioral symptoms. c. = 1/1 Physically abusive behavioral symptoms. d. = 1/1 Socially inappropriate/disruptive behavioral symptoms. e. = 1/1 Resists Care. 1/1 = Behavior of this type occurred 1-3 days in last 7 days and behavior was not easily altered. The Quarterly MDS dated 7/18/01, reads that Resident #2's cognition is now a 2 = moderately impaired - decisions poor, cues/supervision required. E 1. has additions of, a. Resident made negative statements, d. persistent anger with self or others, and 1. crying and tearful. Behavioral symptoms unchanged. Clinical record review of the nurses notes reveal the following: 4/26/01, “Resident becomes aggressive towards staff and residents hitting & yelling obscenities, throwing furniture & anything --- can get --- hands on, then walks the halls & threatens to hit someone whoever gets in --- way." The Director of Nursing was called and instructed the staff to call the MD for "Help." The resident's room was changed. The resident was given Haldol 1 mg. stat for agitation. On 5/2/01, nurse’s notes indicate that the resident is wandering in and out of other residents' rooms. Nurse’s notes for the month of May 2001, indicate that the resident cannot sleep. On 5/19/01, the physician orders Trazodone 50 mq. at bedtime for insomnia. Nurse’s notes dated 5/22/01, reveal that the resident is verbally abusive but does not indicate to whom he/she directs the abuse. On 7/1/01, nurse’s notes indicate that the resident is becoming combative with staff. The resident was given Haldol 1 mg. IM and a psych consult was ordered. Nurse’s notes on 8/21/01, reveal resident was found in the room yelling at roommate. The note reads that the resident is agitated and verbal intervention has little effect. Nurses notes, late entry, 8/24/01 reads, "Resident & and Roommate was fighting in middle of hallway." The resident was moved. On 8/31/01, nurses notes timed at 9:30 A.M. read, "Very distressed & combative, cursing & being abusive to other pts (Patients)." The physician was notified and Haldol .5 mg. IM was given. On 9/4/01, nurses notes timed at 11:00 P.M. read, "Resident up in wheelchair. ------ verbal abusive to staff, acting out, went into others room, given redirection as need with some effect..." On 9/6/01 at 4:00 P.M., the nurse’s note reads, "Resident yelling, cursing at other residents and staff, also combative toward residents, running into them with wheelchair - also combative toward staff. Dr. --- was beeped and returned call with orders to give Haldol IM .5 mg. Dr. ---- also stated that this would be the last time he would order a chemical restraint, he stated he ordered a psych consult and wants that done before he orders anything else." The physician then cancelled the Haldol order. 13 Nurses notes on 9/9/01 read, "Resident with aggressive behavior toward other Residents smacking, pinching. Removed from stimuli." On 9/13/01 at 6:00 A.M., a nurses note reveal that the resident, "Ran wheelchair into a resident sitting in hallway, smacking at him and pushed med cart into entrance of nursing station. Continues to ram med cart and pushing it at this time. Wheels locked on med cart. Resident removed from area, given coffee." At 9:30 P.M., the resident is again upset and climbing into other residents' beds. Nursing staff writes that resident is extremely agitated and aggressive with staff. Resident again transferred to another room. Resident #2's care plan does not note the resident’s abusive behavior and subsequent needed interventions. Review of the facility incident and accident report for this period of time reveals documentation of several falls for this resident. However, there is no documentation in regards to the resident-to-resident abuse situations. Interviews with a staff nurse on the West Wing of the facility and a medical records employee revealed that several residents on the West Wing hit other residents. The charts for Residents #11, #14, and #15 were given to the writer. Review of the facility's incident and accident log does not reveal any incident reports were written for any resident-to-resident abuse issues regarding the above residents. 2. Interview with the acting Director of Nursing on 1/16/01, revealed that he was aware that residents were hitting other residents and actually offered information regarding Resident #15. The DON 14 confirmed that he did not initiate an investigation, document the incident as an incident report, or report it as an adverse incident. Clinical record review of nursing notes for Resident #15 shows that on 12/25/01 at 3:25 P.M., this resident "kicked another resident without provocation "x2 in the past 10 minutes." Residents were separated and isolated from each other." The following nurses note documented the same date (12/25/01) at 4 P.M. shows, "Again attempting to assault another resident in the hallway. Yelling appears very agitated. Again separated & isolated from each other." Upon request the facility provided the QI incident report. Attached to this report was the investigation report Part I, which is not signed and dated. This report continues on a 3rd. page which is section II and is to be completed in 24 hours. The investigative report shows, "In review of nurses notes & speaking to staff I felt he was not actually or deliberately trying to harm another resident. Cannot substantiate that he actually made contact." "Will ask for psych follow up." Section III (review within 48 hours) shows a follow up of, "No bruising on resident noted will continue to monitor resident's behavior and follow up with psych." There is no indication that this incident was submitted as an adverse event 3. Clinical record review for Resident #11 shows that on 12/25/01, at 4:00 P.M., the resident was kicked by another resident with no red areas noted, small area tender to touch. Documentation 15 shows the wife was notified and the resident was monitored for injury by nursing staff. On 12/26/01 at 1:30 P.M., it is documented that Rt. Upper lower leg was tender to touch. On 12/27/01 at 1:30 P.M., the resident did not show signs of redness, bruising, swelling of Rt. Leg, no complaints of tenderness. Review of the facility incident and accident reports for this time period does not include a record of this incident. No adverse incident report was generated for this incident of resident-to- resident abuse. Clinical record review for Resident #11 shows: 1. She has been assessed as being verbally and physically abusive and resistive to care. 2. Her care plan, dated 08/23/2001, shows "Resident has poor cognitive skills R/T (related to) DX (diagnosis) Dementia-At times can be verbally and physically abusive towards staff and other residents." 3. The goal is: Resident will accept care without resistance or unacceptable behaviors through next review. This resident has documentation in the clinical record that shows the following. 1. On 10/15/01, nurse's notes include, "some verbal abuse to other residents nearby, "shut-up, get the hell away." Can be redirected one on one." 2. On 01/07/02, the resident came within range of another resident in the dayroom and she scraped the resident's head with her fingernails. Did not break the skin. Interview with a staff on the West Wing at 9:40 A.M. on 01/17/02, shows that this resident is resistive to care and strikes out at staff a lot, also that she will self-propel herself in her wheelchair and will reach out to other residents if they are nearby. The resident's care plan, reviewed and updated on 03/12/02, does not address resident-to-resident abuse. The facility was unable to provide incident reports or show that an investigation was initiated on the resident-to-resident abuse incidents. The facility did not initiate an Adverse Incident report. Interview on 01/15/02 at 4:50 P.M., Incident Report logs and Abuse/Neglect investigations were requested from the QA/Risk Manager. The surveyor was told that the former Social Worker took the Incident Report log with her when she left and, that the former Director of Nurses only had one investigation from October, 2001. The Risk Manager said that she did not know if there were more, or where the paperwork would be located. The Risk Manager said that the former DON did not return to the facility at the Administrator's request to show staff where the reports were. 17. The above actions or inactions constitute a violation of (1) Section 400.23 (8) (d) Fl. Stat. (2001), which defines a Class II deficiency that has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial 17 well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. (2) Chapter 59A-4.1288 Fl. Admin. Code. R. Incorporating by reference 42 CFR 483.13(C) (1) (i) which requires the facility to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 18. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Seven Thousand Five Hundred Dollars ($7,500) is authorized under §400.022(3) $400.102(1) (a,d), §400.121(1), and §400.23(8) (b), Florida Statutes. COUNT III RESPONDENT FAILED TO HAVE A DESIGNATED REGISTERED NURSE TO SERVE AS THE DIRECTOR OF NURSES FROM 11/12/01 UNTIL 01/07/02. VIOLATING 59A-4.1288 F.A.C. INCORPORATING BY REFERENCE 42 CFR 483.30 (b) (1) (3). CLASS II DEFICIENCY 19. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 20. A Complaint survey was conducted on or about January 14-17, 2002. 21. On that date, based on staff interviews, the facility did not have a designated registered nurse to serve as the Director of Nurses from 11/12/01 until 01/07/02. 22. A Class II deficiency was cited against Respondent based on the findings below: 1. The facility has been found to have deficiencies in the 18 areas of Abuse/Neglect (refer to F224 and F226), Services meeting Profession Standards of Quality (refer to F281), and Staffing to meet the needs of residents (refer to F353). The deficient practice identified for F224, F226, F281 and F353 includes staff behavior and practice that is monitored and supervised by the Director of Nurses position. 2. On 1/14/02, upon surveyors entrance to the facility at 9:00 A.M., surveyors requested to speak to the Administrator and the Director of Nurses (DON). Surveyors were told that the Administrator had not arrived yet and that there was no Director of Nurses at the present time that the former DON had quit and a new one will be starting. 3. On 1/15/01, interview with administrative staff shows that a staff Registered Nurse was appointed interim DON on 01/07/02. This nurse was observed on 1/15/02, second shift and on 01/16/02, first shift, to be working as a floor nurse in the facility's East Wing. 4. On 01/17/01 at 10:00 A.M., when asked by a surveyor if there was a DON now, a nurse replied that she had been so busy that she hadn't had time to find out what was going on. 5. Clinical record review for Resident #13 shows that from the dates 12/20/01 to 1/09/02 there are 8 telephone orders from the physician. Eight of 8 orders have no physician signature. The facility policy states that telephone orders are signed in a timely manner. 19 23. The above actions or inactions constitute a violation of (1) Section 400.23 (8) (d) Fl. Stat. (2001), which defines a Class II deficiency that 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. (2) Chapter 59A-4.1288 Fl. Admin. Code. R. incorporating by reference 42 CFR 483.30(b) (1)-(3) which requires the facility to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. 24. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Seven Thousand Five Hundred Dollars ($7,500) is authorized under §400.022 (3) §400.102(1) (a,d), §$400.121(1), and §400.23(8) (b), Florida Statutes. COUNT IV RESPONDENTS’ ADMINISTRATOR FAILED TO MONITOR STAFF AND DID NOT ASSURE THAT THE DAY-TO-DAY ADMINISTRATION WAS IMPLEMENTED IN A MANNER THAT PROTECTED THE RESIDENTS RIGHTS AND ENSURED QUALITY OF CARE. VIOLATING 59A-4.1288 F.A.C. INCORPORATING BY REFERENCE 42 CFR 483.75. CLASS II DEFICIENCY 25. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 26. A Complaint survey was conducted on or about January 14-17, 2002. 27. On that date, based on observation of residents and staff 20 throughout the facility, clinical record reviews, interviews with residents on an individual basis and in the Resident Group Council Meeting, family interview, interviews with the Administrator, Risk Manager, and nursing staff the Administrator failed to monitor staff and did not assure that the day to day administration was implemented in a manner that protected the resident rights and ensured quality of care. This is evidenced by: 1. Patterned resident abuse (see F224). 2. Lack of implementation of policies and procedures to prevent resident-to-resident abuse (see F226 widespread deficiency). 3. Failure to clean and maintain the environment for all residents (see F253 widespread, substandard) . 4. Failure to provide the facility with a DON (F354 widespread). 28. A Class II deficiency was cited against Respondent based on the findings below: 1. During the initial tour of the facility on 01/14/02 and subsequent facility observations on 01/15/01, 01/16/02 and 01/17/02, it was determined that the facility was not maintained in a clean and homelike environment. Refer to F253 and F469. 2. Surveyor observation, clinical record review and staff interview shows that the facility failed to provided services to residents in accordance with professional standards of quality. Refer to F281. 3. Interview with individual residents and 18 of 18 residents in the Resident Council meeting shows that the facility failed to follow through with grievances. Refer to F166, F368 and F364. 21 4. Failure to provide supervision as evidence by lack of DON in the facility from 12/17/01 to 01/07/02. Refer to F354. 5. Failure to protect residents from abuse. Refer to F224 and 226. 29, The above actions or inactions constitute a violation of (1) Section 400.23 (8) (d) Fl. Stat. (2001), which defines a Class II deficiency that 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. (2) Chapter 59A-4.1288 Fl. Admin. Code. R. incorporating by reference 42 CFR 483.75 which requires that a facility must 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. 30. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Seven Thousand Five Hundred Dollars ($7,500) is authorized under §400.022 (3) $400.102(1) (a,d), §400.121(1), and §400.23(8) (b), Florida Statutes. COUNT V RESPONDENT FAILED TO IMPLEMENT THEIR PROCEDURE FOR REPORTING INCIDENTS AND ACCIDENTS TO THE RISK MANAGER OR DESIGNEE WITHIN THREE BUSINESS DAYS AFTER THE OCCURRENCE VIOLATING §400.147(1) (d) F.S. CLASS II DEFICIENCY 31. AHCA re-alleges and incorporates (1) through (6) as if 22 fully set forth herein. 32. A Complaint survey was conducted on or about January 14-17, 2002. 33. On that date, based on clinical record review and interview with facility staff including nursing and administration, the facility failed to implement their procedure for reporting incidents and accidents to the Risk Manager or designee within 3 business days after the occurrence. 34. A Class II deficiency was cited against Respondent based on the findings below: Clinical record review and interview with facility staff including nursing, administration and medical records personnel, shows that the facility failed to initiate the policies and procedures to prevent resident to resident abuse by 3 residents (Residents #2, #11 and #15 from extended survey). On 01/15/02 at 4:50 P.M., Incident Report logs and Abuse/Neglect investigations were requested from the QA/Risk Manager. The surveyor was told that the former Social Worker took the Incident Report log with her when she left and, that the former Director of Nurses only had one investigation from October, 2001. The Risk Manager said that she did not know if there were more, or where the paperwork would be located. The Risk Manager said that the former DON did not return to the facility at the Administrator's request to show staff where the reports were. 35. The above actions or inactions constitute a violation of (1) 23 Section 400.23 (8) (d) Fl. Stat. (2001), which defines a Class II deficiency that 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. (2) Section 400.147(1) (d) Fl. Stat (2001) which requires the development and implementation of an incident reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. 36. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Seven Thousand Five Hundred Dollars ($7,500) is authorized under §400.022(3) §400.102(1) (a,d), §400.121(1), and §400.23(8) (b), Florida Statutes COUNT VI RESPONDENT FAILED TO MINIMIZE THE RISK OF ADVERSE INCIDENTS TO RESIDENTS AS EVIDENCED BY LACK OF FACILITY INVESTIGATION INTO ISSUES OF RESIDENT TO RESIDENT ABUSE; VIOLATING §400.147(1) (e) F.S. CLASS II DEFECIENCY 37. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 38. A Complaint survey was conducted on or about January 14-17, 2002. 39. On that date, based on clinical record review and interview 24 with facility personnel including nursing and administration, the facility failed to minimize the risk of adverse incidents to residents as evidenced by lack of facility investigation into issues of resident-to-resident abuse. 40. A Class II deficiency was cited against Respondent based on the findings below: Clinical record review and interview with facility staff including nursing, administration and medical records personnel, shows that the facility failed to initiate an Adverse Incident Report for Residents #2, #11 and #15 who had documented episodes of resident to resident abuse. The facility provided surveyors with one adverse incident from October 2001. On 01/15/02, 1/16/02 and 1/17/02, adverse incidents and any type of investigation initiated for the above residents were requested from the Unit Manager/Administration and QA/Risk Manager. The surveyors were told that the former Social Worker took the Incident Report log with her when she left and that the former Director of Nurses only had one investigation from October, 2001. The Risk Manager said that she did not know if there were more, or where the paperwork would be located. The Risk Manager said that the former DON did not return to the facility at the Administrator's request to show staff where the reports were. 25 Interview with acting DON, revealed that he was aware of incidents of resident-to-resident abuse but did not initiate and adverse incident investigation. Interview with nursing staff and a medical record person on the West Wing, revealed that the staff were aware of resident to resident abuse however, the facility was unable to locate any investigation into these incidents including adverse incident reporting. 41. The above actions or inactions constitute a violation of (1) Section 400.23 (8) (d) Fl. Stat. (2001), which defines a Class II deficiency that 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. (2) Section 400.147(1) (e) Fl. Stat (2001) which requires the development of appropriate measures to minimize the risk of adverse incidents to residents, including, but not limited to, education and training in risk management and risk prevention for all non physician personnel. 42. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Seven Thousand Five Hundred Dollars ($7,500) is authorized under §400.022(3) §400.102(1) (a,d), §400.121(1), and §400.23(8) (b), Florida Statutes COUNT VII RESPONDENT FAILED TO INITIATE ADVERSE INCIDENT REPORTING POLICY AND PROCEDURES; VIOLATING §400.147(5) F.S. 26 CLASS II DEFICIENCY 43. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 44. A Complaint survey was conducted on or about January 14-17, 2002. 45. On that date, based on clinical record review of adverse incident logs and interview with facility staff in administration, the facility failed to initiate adverse incident reporting policy and procedure. 46. A Class II deficiency was cited against Respondent based on the findings below: Clinical record review and interview with facility staff including nursing, administration and medical records personnel, shows that the facility failed to initiate an adverse incident report for Residents #2, #11 and #15 who had documented episodes of resident to resident abuse. The facility provided surveyors with one adverse incident from October 2001, which did not correlate to any of the above incidents... On 01/15/02, 1/16/02 and 1/17/02, adverse incidents and any type of investigation initiated for the above residents were requested from the Unit Manager/Administration and QA/Risk Manager. The surveyors were told that the former Social Worker took the Incident Report log with her when she left and that the former Director of Nurses only had one investigation from October, 2001. The Risk Manager said that she 27 did not know if there were more, or where the paperwork would be located. The Risk Manager said that the former DON did not return to the facility at the Administrator's request to show staff where the reports were. 47. The above actions or inactions constitute a violation of (1) Section 400.23 (8)(d) Fl. Stat. (2001), which defines a Class II deficiency that 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. (2) Section 400.147(5) Fl. Stat (2001) which for purposes of reporting to the Agency under this section, the term “adverse incident” means: An event over which the facility personnel could exercise control and which is associated in whole or in part with the facility’s intervention, rather than the condition for which such intervention occurred, and which results in one of the following: 1. Death; 2. Brain or spinal damage; 3. Permanent disfigurement ; 4. Fracture or dislocation of bones or joints; 5. A limitation of neurological, physical, or sensory function. 48. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Seven Thousand Five Hundred Dollars ($7,500) is authorized under §400.022 (3) 28 $400.102(1) (a,d), §400.121(1), and §400.23(8) (b), Florida Statutes COUNT VIII RESPONDENT FAILED TO INITIATE ADVERSE INCIDENT ONE DAY REPORTING POLICY AND PROCEDURE; VIOLATING §400.147(7) F.s. CLASS II DEFICIENCY 49. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 50. A Complaint survey was conducted on or about January 14-17, 2002. 51. On that date, based on clinical record review of adverse incident logs and interview with facility staff in administration, the facility failed to initiate adverse incident 1 day reporting policy and procedure. 52. A Class II deficiency was cited against Respondent based on the findings below: Clinical record review and interview with facility staff including nursing, administration and medical records personnel, shows that the facility failed to initiate an adverse incident report for Residents #2, #11 and #15 who had documented episodes of resident to resident abuse. The facility provided surveyors with one adverse incident from October 2001, which did not correlate to any of the above incidents. On 01/15/02, 1/16/02 and 1/17/02, adverse incidents and any type of investigation initiated for the above residents were requested from the Unit Manager/Administration and QA/Risk Manager. The surveyors 29 were told that the former Social Worker took the Incident Report log with her when she left and that the former Director of Nurses only had one investigation from October, 2001. The Risk Manager said that she did not know if there were more, or where the paperwork would be located. The Risk Manager said that the former DON did not return to the facility at the Administrator's request to show staff where the reports were. 53. The above actions or inactions constitute a violation of (1) Section 400.23 (8) (d) Fl. Stat. (2001), which defines a Class II deficiency that 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. (2) Section 400.147(7) Fl. Stat (2001) which requires the facility to initiate an investigation and shall notify the agency within one business day after the risk manager or his designee has received a report. 54. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Seven Thousand Five Hundred Dollars ($7,500) is authorized under §400.022 (3) $400.102(1) (a,d), §400.121(1), and §400.23(8) (b), Florida Statutes COUNT IX RESPONDENT FAILED TO COMPLETE ADVERSE INCIDENT 15 DAY REPORTING POLICY AND PROCEDURE; VIOLATING §400.147(8) F.S. CLASS II DEFICIENCY 30 55. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 56. A Complaint survey was conducted on or about January 14-17, 2002. 57. On that date, based on clinical record review of adverse incident logs and interview with facility staff in administration, the facility failed to complete adverse incident 15 day reporting policy and procedure. 58. A Class II deficiency was cited against Respondent based on the findings below: Clinical record review and interview with facility staff including nursing, administration and medical records personnel, shows that the facility failed to initiate an adverse incident report for Residents #2, #11 and #15 who had documented episodes of resident to resident abuse. The facility provided surveyors with one adverse incident from October 2001, which did not correlate to any of the above incidents.. On 01/15/02, 1/16/02 and 1/17/02, adverse incidents and any type of investigation initiated for the above residents were requested from the Unit Manager/Administration and QA/Risk Manager. The surveyors were told that the former Social Worker took the Incident Report log with her when she left and that the former Director of Nurses only had one investigation from October, 2001. The Risk Manager said that she did not know if there were more, or where the paperwork would be 31 located. The Risk Manager said that the former DON did not return to the facility at the Administrator's request to show staff where the reports were. 59. The above actions or inactions constitute a violation of (1) Section 400.23 (8) (d) Fl. Stat. (2001), which defines a Class II deficiency that 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. (2) Section 400.147(8) Fl. Stat (2001) requires each facility to complete an investigation and submit an adverse incident report to the agency for each adverse incident within 15 calendar days after its occurrence. 60. The above referenced violations constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Seven Thousand Five Hundred Dollars ($7,500) is authorized under §400.022 (3) $400.102(1) (a,d), §400.121(1), and §400.23(8) (b), Florida Statutes 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 Ix; B. Impose a total fine of Sixty Five Thousand Dollars ($65,000) for the violations cited in Counts I through IX, against the 32 Respondent under §400.102(1) (a) and (d), 400.121(1), and 400.23(8) (b), Florida Statutes; Cc. Assess costs related to the investigation and prosecution of this case pursuant to § 400.121 (2) Fl. Stat. (2001) and; D. All other general and equitable relief allowed by law. NOTICE DESOTO HEALTH & REHABILITATION, L.L.C., d/b/a DESOTO HEALTH AND REHABILITATION 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. Eileen O’Hara Garcia, Esquire AHCA - Senior Attorney 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (FAX) 33 I HEREBY CERTIFY that a copy hereof has been furnished to Philip Castleberg, Registered Agent for Desoto Health & Rehabilitation, L.L.C., 1002 North Brevard Avenue, Arcadia, Florida 34266, by U.S. Mail and Administrator, Desoto Health and Rehabilitation, 1002 North Brevard Avenue, Arcadia, Florida 34266 by U.S. Certified Mail, Return Receipt No.7002 2030 0007 8499 0186 on March yA Gh. Eileen O’Hara Gafcia, Esquire Copies furnished to: Philip Castleberg Registered Agent for Desoto Health and Rehabilitation, 1002 North Brevard Avenue Arcadia, Florida 34266 (U.S. Mail) Administrator Desoto Health and Rehabilitation, 1002 North Brevard Avenue Arcadia, Florida 34266 (U.S. Certified Mail) Eileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 (Interoffice) 34

Docket for Case No: 03-001502