STATE OF FLORIDA 03 W015 FM. 05 AGENCY FOR HEALTH CARE ADMINISTRATION | m AGENCY FOR HEALTH CARE SALT EEE > ie ADMINISTRATION, : rere, Petitioner, AHCA No.: 2003001544 AHCA No.: 2003001253 Vv. Return Receipt Requested: 7000 1670 0011 4849 5788 FLORIDA DEPARTMENT OF VETERANS 7000 1670 0011 4849 5795 AFFAIRS d/b/a ALEXANDER ~ vna7 tf NININGER STATE VETERANS’ O2> pe) SOY NURSING HOME, 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 Florida Department of Veterans Affairs d/b/a Alexander Nininger State Veterans’ Nursing Home (hereinafter “Alexander Nininger State Veterans’ Nursing Home”) pursuant to Section 28-106.111, Florida Administrative Code and Chapter 120, Florida Statutes hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine in the amount of $5,000.00 pursuant to Section 400.23(8), Florida Statutes [AHCA No.: 2003001253]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7)(b), Florida Statutes [AHCA No. 2003001544). JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4, Venue lies in Broward County pursuant to Section 120.57 and Section 121(1) (e), Florida Statutes and Chapter 28- 106.207, Florida Administrative Code. PARTIES 5. AHCA is the enforcing authority with regard to nursing home licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Alexander Nininger State Veterans’ Nursing Home is a skilled nursing facility located at 8401 W. Cypress Drive, Pembroke Pines, Florida 33025 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I ALEXANDER NININGER STATE VETERANS’ NURSING HOME FAILED TO MEET NUTRITION PARAMETERS CONCERNING WEIGHT LOSS FOR 3 OF 18 SAMPLED RESIDENTS. TITLE 42 SECTION 483.25(i) (1), CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS II 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Alexander Nininger State Veterans’ Nursing Home participates in Title XVIII or XIX it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. An unannounced re-certification and licensure survey was conducted from 2/3/03 through 2/5/03 at Alexander Nininger State Veterans Nursing Home. The facility was determined not to be in compliance with 42 Code of Federal Regulation 483, Subpart B, Requirements for Long Term Care. The following is a description of the noncompliance. 10. Based on record review, observation and interview, it was determined that the facility did not ensure that 3 of 18 sampled residents (#15, #9, and #10) maintained acceptable parameters of nutritional status. The findings include the following. is) RESIDENT #15 11. During the initial tour of the facility on 02/3/03, the RN Supervisor indicated that resident #15 was a new resident and had experienced weight loss since admission to the facility. Observation of the resident's lunch tray on 02/4/03, revealed that the resident had had grilled cheese sandwich, steamed broccoli spears, carrot raisin salad, diced pears, two thickened juices and coffee brought to him for lunch. 50 percent of the coffee had been consumed and the rest of the meal was left on the tray. 12. Resident #15 was admitted to the facility on 1/16/03 with diagnoses including CVA, Left Hemiparesis, HTN, A.Fib and CAF. The admission height and weight of the resident were documented as 6'2" and 223 pounds respectively. 13. A review of the record revealed no completed MDS for the resident, no initial dietary assessment, and an initial care plan that only addressed adjustment to the facility and a risk for depression. 14. Review of the weekly weight record revealed that the resident weighed 223 pounds on week one, 214 pounds on week two and 206 pounds on week three. 15. Further review of the record revealed physicians orders for a mechanical soft applesauce consistency diet and PT/OT/Speech evaluation and treatment on 1/16/03. Review of the record been conducted. 16, interview with the During an Manager on 02/4/03 at 2:35 pm, the therapist stated, revealed no documentation that an evaluation had Therapy Department that the resident had come to the facility with a thickened liquids order and they had given the resident a screening. PT/OT/ speech When asked if there was a difference between a speech screening and evaluation, the therapist replied "ves". She stated that an evaluation is a more in depth and comprehensive process than a screening. When asked why the resident had received only a screening and not as ordered by the physician, the therapist resident has an HMO as a payor source and the the evaluation replied," the facility could not treat him because he was not a Medicare patient. She said the resident had to be referred to his primary care physician for treatment. The therapist was made aware of the resident's current weight status and loss. When asked if the resident could have benefited from the speech evaluation she replied She stated that the resident had a need for thickened "ves" . liquids and needed treatment. Further review of the record revealed no documentation that an appointment for the resident to see his primary care physician had been made. 17. During an interview with the dietary consultant on 02/4/03 at 2:55 pm, the consultant stated, "no initial dietary a assessment had been completed for this resident". She also said she had not been made aware of the resident's weight loss. She stated there is a protocol for informing the Cletician of weight loss and that no one had communicated to her that the resident had lost weight. The dietician provided the surveyors with a copy of this protocol. 18. On 01/20/03, a physician’s order for thickened liquid to nectar consistency was written. An order for dysphagia treatment 3X per week for 4 weeks to increase efficacy of swallow was also written on 01/20/03. There was no documentation in the record to indicate that the treatment had been given as ordered. 19. On 01/27/03, a physician’s order for a dietary consult for food preferences was written. There was no documentation in the record to indicate the consult had been done. 20. On 02/5/03, the facility was asked to weigh the resident. His weight was now 200 pounds. This represented a 23-pound weight loss in 20 days for this resident, which is a 10.38 significant loss in less than 30 days. The facility had failed to provide assessments, ordered treatments, ordered consultations, a care plan to address problems with swallowing or weight loss, and any assistance in order for the resident to receive treatment, which ultimately led to a significant weight loss. 21. On 02/5/03, after surveyor intervention, a dietary assessment and consult for preference were completed. The dietician's recommendations included: to increase an Ensure supplement to 1 can 4 times per day, ProMod 2 scoops twice a day, an appetite stimulant and continued weekly weights. It was documented that the physician approved all of the dietician's recommendations, except for the appetite stimulant. RESIDENT #9 22. Resident #2 was admitted to the facility on 6/7/02 and re-admitted on 10/14/02 with multiple diagnoses, which included Dementia, Hypertension, Chronic Obstructive Pulmonary Disease. Review of the clinical record revealed the resident had a Comprehensive Assessment dated 10/31/02 with a recorded weight of 132 pounds. The resident was coded on the Minimum Data Set as being an extensive assist with meals. Review of the weight records documented the resident's weight on 11/30/02 to be at 128 pounds for a loss of 4 pounds in a month, and a weight documented for 12/27/02 to be 118 pounds, indicating the resident had sustained a significant weight loss of 7.5% in one month. Further review of the clinical record revealed the physician had not been notified of the residents weight loss and there were no dietary interventions or recommendations since admission of 6/7/02. The last documentation noted was on 1/31/03 (2 months after the weight loss was noted.) Interview with the facility staff including, tae Unit Charge Nurse, the Dietary Manager and the Consultant Registered Dietician revealed, the resident was not assessed for the weight loss, and there were no interventions or recommendations made until 1/31/03. RESIDENT #10 23. During the review of the clinical record of resident #10 on 02/04/03, it was noted that a physician's telephone oxder dated 01/29/02 requested the following: (1) Dietary evaluation, (2) 3 Day Calorie Count, and (3) refer for peg tube placement if resident fails calorie count. A review of the calorie count work sheet revealed that all foods were documented by nursing staff on 01/30/03 through 02/01/03, however there were no totals for each day. A review of the Nutritional Assessment note dated 01/30/03 documented that the calorie count would be completed on 02/01/03 and the dietary manager would document the nutrition intake totals and provide the totals to the registered dietitian for evaluation. An interview with the facility registered dietitian on 02/04/03 revealed that she had instructed the dietary manager tc calculate the daily intake, however the manager failed to perform this activity. 24. Based on the foregoing, Alexander Nininger State Veterans’ Nursing Home violated 483.25(i) (1), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23 (7) (b), Florida Statutes. COUNT II ALEXANDER NININGER STATE VETERANS’ NURSING HOME PROVIDED EXCESSIVE DOSES OF PYSCHOACTIVE MEDICATIONS RESULTING IN ADVERSE CONSEQUENCES. 483.25(1), CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS II 25. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. An unannounced re-certification and licensure survey was conducted from 2/3/03 through 2/5/03 at Alexander Nininger State Veterans Nursing Home. The facility was determined not tc be compliance with 42 Code of Federal Regulation 483, Subpart B, Requirements for Long Term Care. The following is a description of the noncompliance. 27. Based on observation, record review and interview it was determined that the drug regimen of 1 of 18 residents (Resident #3) was not free from unnecessary drugs. The findings include the following. 28. While making observations on the Delta wing at 8:30 AM on 2-5-2003, a surveyor noted that it took staff forty minutes to arouse Resident #3 from sleep to serve him/her breakfast and administer his/her medications. Previous observations of the resident by the surveyor over the course of the survey and staff interviews further established that Resident #3 had not been out of bed for 2 days. 29. On reviewing the clinical record, it was determined Resident #3 had been admitted 9-4-2002 and by the time of the survey had been diagnosed with Dementia with Psychosis among other health conditions. Closer review of Resident #3's c.inical record revealed that the resident was receiving four medications, which had a side effect of inducing weakness or sedation. The four drugs are: Ativan 0.5mg (every 8 hours); Zyprexa 20mg (daily at 5:00 PM); Nitroglycerin 2% Ointment (1 inch at 9 AM daily); and Buspar (10mg twice a day). 30. Review of Resident #3's clinical record, revealed that: (1) a Nurse's Note dated 2-4-2003 10:15 AM documents that Resident #3 refused to get out of bed and demanded to be left alone (2) a Nurse's Note dated 2-3-2003 at 10:00 PM 10 documents that the resident slept soundly most of the shift and was lethargic when awake; (3) An entry on the February 2003 medication administration record documents that at 10 PM on 2-3-2003 the resident did not receive his/her dose of Ativan as he/she was lethargic; (4) a Nurse's Note dated 1-30- 2003 documents that Resident #3 told staff at 8:30 AM on 1-30- 2903 that "I want to sleep"; 31. Following the surveyor's discussion of this issue with staff, an order was received at 10:40 AM on 2-5-2003 to reduce Resident #3's Ativan to 0.5mg twice a day at 9 AM and 3 PM (from Ativan 0.5mg every eight hours daily); and to reduce Resident #3's Zyprexa to 15mg at 5:00 PM daily (from Zyprexa 20mg at 5:00 PM daily). 32. As Resident #3 was receiving drugs in the presence of adverse consequences (lethargy and over sedation) and as staff did net recognize the significance of these clinical symptors (l.e., Resident #3 was not being adequately monitored) it was determined Resident #3 was receiving unnecessary drugs. 33. Based on the foregoing, Alexander Nininger State Veterans’ Nursing Home Nursing violated 483.25(1), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries pay an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statute. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Alexander Nininger State Veterans’ Nursing Home shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit “A” 12 EXHIBIT “A” Conditional License License # SNF 130471019; Certificate No.: Effective date: 02/05/2003 Expiration date: 06/10/2003 10104 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Counts I and II. 2. Assess against Alexander Nininger State Veterans Nursing Home an administrative fine of $5,000.00 for the two (2) Class II violations on Counts I and II as cited above. 3. Assess against Alexander Nininger State Veterans Nursing Home a conditional license in accordance with Section 490.23(7), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if applicable. 5. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, 14 Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. aw M. oe g i - Assistant General Counsel Agency for Health Care Administration 8355 NW 53™ Street Miami, Florida 33166 Copies furnished to: Diane Reiland Fleld Office Manager Agency for Health Care Administration Manchester Building 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Charles T. Bringle, Administrator, Alexander Nininger State Veterans’ Nursing Home, 8401 wW. Cypress Drive, Pembroke Pines, Florida 33025; Florida Department of Veterans Affairs, 9500 Bay Pines Blvd., St. Petersburg, Florida 33708 on this anol day of May, 2003 Alba M. tn Ne a fi 16

Docket for Case No: 03-002564