STATE OF FLORIDA , my AGENCY FOR HEALTH CARE ADMINISTRATION | : CS py , AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2003001394 O-> 357] vs. VENICE REHAB AND HEALTH CENTER, Respondent. / ADMINISTRATIVE COMPLAINT ens BADIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION ("“AHCA"), by and through its undersigned counsel, and files this Administrative Complaint against VENICE REHAB AND HEALTH CENTER (“VENICE REHAB"), pursuant to Section 120.569, and 120.57, Florida Statutes (2002), and alleges: NATURE OF THE ACTION ee The ACTION 1. This is an action to assign a conditional license to VENICE REHAB, pursuant to Section 400.23(7)(b), Florida Statutes (2002), and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002). A copy of the original conditional license is attached hereto as Exhibit “A” and incorporated herein by reference. JURISDICTION AND VENUE HIV N AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). 3. AHCA has jurisdiction pursuant to Chapter 400, Part Il, Florida Statutes (2002). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2002). PARTIES 5. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. VENICE REHAB AND HEALTH CENTER is a Florida corporation with a principal address of 437 South Nokomis Avenue, Venice, Florida 34285. 7. VENICE REHAB is a 178-bed skilled nursing facility located at 437 South Nokomis Avenue, Venice, Florida 34285. VENICE REHAB is licensed by AHCA as a skilled nursing facility having been issued license number SNF 1570096, certificate number 9814, with an effective date of February 14, 2003 and an expiration date of June 27, 2003. 8. VENICE REHAB is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part I!, Florida Statutes and Chapter 59A-4, Florida Administrative Code, respectively. COUNT I EFFECTIVE JANUARY 31, 2003, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO VENICE REHAB AND HEALTH CENTER BASED UPON THE DETERMINATION THAT VENICE REHAB AND HEALTH CENTER WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF THREE (3) CLASS | DEFICIENCIES AT THE MOST RECENT OFF-HOURS ANNUAL HEALTH LICENSURE AND RECERTIFICATION SURVEY OF FEBRUARY 9-14, 2003. § 400.23(7)(b) and (8)(a) and 400.022(1) Florida Statutes Rule 59A-4.1288; Rule 59-A4.123(1) and Rule 59A-106(4)(f),(r) and (aa), F.A.C., 42 CFR 483.13(c)(1)(i); 483.20(k)(3)(i) and 483.25 9. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. The regulatory provisions of the Florida Statutes, Code of Federal Regulations and Florida Administrative Code that are pertinent to these alleged violations read as follows: 400.23 Rules, evaluation and deficiencies; licensure status. — (7) The agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established miles adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shall assign a licensure status of standard or conditional to each nursing home. (b) A conditional licensure status means that a facility, due to the presence of one or more class | or class Ii deficiencies, or class Ii! deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class |, class || or class III deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred oniy occasionaliy or in a very iirnited numver of iocations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of the deficiencies as follows: (a) A class | deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class | violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class | deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, 412,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class | or class |! deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. 400.022 Residents’ Rights. (1) All licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: (17) Notify a licensed physician when a resident exhibits signs of dementia or cognitive impairment or has a change of condition in order to rule out the presence of an underlying physiological condition that may be contributing to such dementia or impairment. The notification must occur within 30 days after the acknowledgment of such signs by facility staff. If an underlying condition is determined to exist, the facility shall arrange, with the appropriate health care provider, the necessary care and services to treat the condition. 483.13 Resident behavior and facility practices. (c) Staff treatment of residents. The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. (1) The facility must-- (i) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 483.20 Resident assessment. (k}) Comprehensive care plans. as (3) The services provided or arranged by the facility must— (i) Meet professional standards of quality. § 483.25 Quality of care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care. (h) Accidents. The facility must ensure that- (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 59A-4.106 Facility Policies. (4) Each facility shall maintain policies and procedures in the following areas: ({v) Resident care planning; (aa) Specialized rehabilitative and restorative services. 59A-4.1288 Exception. Nursing homes that participate in Title XVI or XIX must follow certification rules and regulations found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference. Non-certified facilities must follow the contents of this rule and the standards contained in the Conditions of Participation found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference with respect to social services, dental services, infection control, dietary and the therapies. FIRST CLASS | DEFICIENCY 11. On or about February 9-14, 2003, AHCA conducted an off-hours annual health licensure and recertification survey at VENICE REHAB AND HEALTH CENTER. On or about February 9-14, 2003, based upon observation, interview and record review the AHCA survey team determined that the facility jeopardized the health, life and safety of 3 of 21 active sampled residents [Residents #12, #18 and #19] from a total sample of 24 residents and an extended sample of 5 residerits with 3 additional closed records reviewed in conjunction with a complaint investigation for a total sample of 32 charts reviewed. The facility neglected and jeopardized Resident #12 by its failure to implement uniform policies and procedure within the facility for staff to follow regarding resident falls and the reporting thereof to the attending physician and supervisory personnel; its failure to notify the attending physician of a resident’s [Resident #12] injuries following two consecutive falls on two consecutive days; its failure to follow facility policies and procedures by notifying the Registered Nurse in charge of care following the injury of a resident-[Resident #12]; its failure to.update the resident’s care plan with progressive intervention for a resident {Resident #12] with a long history of falls who was also known to have seizure activity; and its failure to adequately review and investigate falls which were reported and implement safety measures to alleviate falls. The facility neglected and jeopardized Resident #18, who was admitted to the facility with short bowel syndrome requiring total parenteral nutrition, by its failure to provide the total parenteral nutrition formulation prescribed by the physician for a 3-week period, resulting in the resident receiving less than estimated caloric and protein needs and experiencing weight loss [After a 3-week period the facility obtained a metabolic profile that indicated some abnormal laboratory results/findings]; its failure to obtain laboratory data to monitor the total parenteral nutrition as prescribed by the physician on January 27, 2003 and February 3, 2003; the failure of the nursing staff to notify or to document notification by the nursing staff to the physician of the resident having experienced 2 episodes of hypoglycemia; its failure to ensure that the total parenteral nutrition of Resident #18 was brought into compliance with the physician’s orders at the time of the survey team’s exit on February 14, 2003; and the lack of coordination demonstrated by the facility between the physician, pharmacy, nursing staff, registered dietician and consultant pharmacist with relation to the provision and monitoring of the total parenteral nutrition for Resident #18, who was known to be at high risk for malnutrition and complications relating to the administration of the total parenteral nutrition. The facility neglected and endangered by its failure adequately monit6or laboratory biood values for a resident [Resident #19] on coumadin therapy, resulting in a highiy elevated, 54.9 PT [Prothrombin Time] and 4.5 INR [International Normalization Ratio] and leaving the resident exposed to life-threatening harm as is evidenced by the facility's failure to obtain orders for laboratory tests to monitor the resident's blood values since admission; the failure of the facility's staff to monitor side effects and drug-to-drug interactions for concurrent use of coumadin and oxandrin; and the failure of the facility's nursing staff to monitor and identify potential serious drug interactions and side effects. On that basis, the AHCA survey team cited VENICE REHAB AND HEALTH CENTER with a Class | deficiency, supported by the following findings: 11.1. Resident #12 was originally admitted in September 2002. On September 12, 2002 at approximately 7:00 a.m. the resident fell to the floor with jerky movements and all-body movement with seizure-like activity lasting approximately 15 seconds. When he/she fell, the patient hit his/her head and sustained abrasions to his/her head, back and arm. The resident was transferred to a local hospital and admitted following this incident. The resident was readmitted to the facility on September 16, 2002. 11.2. On September 27, 2002 a nurse's note at 7:00 a.m. reveals that Resident #12 fell on his/her face at 5:50 a.m., having sustained a resultant laceration to his/her left eyebrow. The laceration was described in the nurse’s note as deep with moderate bleeding and the note indicates that ice and a pressure dressing were applied to the The note further indicates that the resident was sent to the hospital laceration. emergency room for evaluation and stitches. A nursing note at 7:30 a.m. that day indicated that the resident had required 3 stitches at the hospital emergency room and was returning to the facility. 11.3. On October 2, 2002 a care plan meeting was held with all disciplines and the wife of Resident #12 in attendance. The documentation reflects that the resident has multiple care plans for this time frame. One, which was developed on September 14, 2002 contains a note under the heading “Problems and Strengths” ‘that indicates that Resident #12 wanders independently in ambulation pursuant to a physical therapy evaluation performed on September 27, 2002 and instructs staff to assist the resident when he/she is fatigued. The stated goal was to prevent any injury from falls through the next review. The enunciated approach was to keep the floor clear of clothes, ensure that the resident's shoes and socks are on when he/she is up; to observe the resident for signs of fatigue and assist him/her as needed, to offer the resident rest periods on an as needed basis and to monitor the resident closely and offer him/her rest periods at least twice a day. 11.4. Another care plan for Resident #12 that was developed on September 23, 2002 for Activities of Daily Living notes under the heading “Problems and Strengths” that the resident requires supervision with bed mobility, transfers, ambulation and locomotion and further notes that the resident has a diagnosis of Alzheimer's, dementia, depression and anxiety and further that the resident has a history of falls. The note further reflects that the resident suffers from unsteady gait at times and that the resident receives daily antidepressant and anti-anxiety medications and observes that the resident has the potential for future falls. The goals enunciated in this care plan include a goal that the resident would not sustain any fall-related injuries through the next review date, with the approach identified as supervision of ambulation daily and assistance with ambulation as needed for unsteady gait. 11.5. On November 23, 2002 Resident #12 was Baker-Acted to the local hospital emergency room for evaluation. The resident returned to the facility on November 26, 2002. 11.6.On November 27, 2002 Resident #12 was noted to be ambulating in the hallway of the facility, appearing disoriented and demonstrating signs of confusion and fatigue. 11.7. On November 28, 2002 at 4:30 a.m. Resident #12 was noted to have been ambulating all night throughout the units of the facility with an unsteady gait with the observation that he/she kept lying or sitting on the floor. At 10:10 a.m. a nurse’s note indicates that Resident #12 had seizure activity at 10:00 a.m., lasting % minute. 11.8.On December 1, 2002 at 2:30 p.m. the resident {#12} was noted to have been ambulating in the hallway with an unsteady gait. At 5:00 p.m. on that date the resident was noted to have been very unsteady on his/her feet. The note records that when staff attempted to assist the resident, he/she knelt, and then required assistance in getting to his/her feet. The note further indicates that the resident was then placed in a chair for a period of one hour, during which he/she appeared to have what was described in the note as “body shakes”. 11.9.0n December 3, 2002 at 3:30 a.m., the resident [#12] was noted to be wandering in the hallway with an unsteady gait. 11.10. On December 14, 2002 a nurse’s note indicates that Resident #12 fell out of his/her chair, head first and hit his/her head. A small red bump was reportedly observed on the resident's head, with the notation that the swelling appeared to have gone down to some degree. Pursuant to the nursing notes, the attending physician's answering service was notified. 11.11. On December 16, 2002 a nurse’s note at 4:30 a.m. indicates that the resident [#12] fell face down, resulting in a bruised area on the left forehead. At 2:30 p.m. on that date, the notes record that the resident was observed to have been walking down the hallway exhibiting an unsteady gait. There is no documentation that either the attending physician or the resident's family was notified. 11.12. On December 17, 2002 two nurse’s note entries record the resident as having had an unsteady gait. 11.13. On December 18, 2002 at 1:00 a.m. a nurse’s note indicated that the resident [#12] exnibited an unsteady gait and observed that the resident's left eye and left forehead were bruised as a result of his/her last fall. 11.14. On January 7, 2003 a nurse's note at 7:15 a.m. reveals that resident #12 was observed ambulating in the halls with a laceration to his left eyebrow and that there was a large amount of dry blood on the floor and at the site of the laceration. The note further reflects that the laceration site on the resident’s left eyebrow was cleansed with normal saline solution and that a dry pressure dressing was applied to the site following steri strip. The attending physician was notified and the resident #12 was sent to the emergency room for evaluation and stitches. A telephone message was left for the resident's wife. 11.15. On January 9, 2003 resident #12 was noted to have unsteady gait and a decreased equilibrium. 11.16. On January 14, 2003 a nurse's note at 10:00 a.m. indicates that a small abrasion was found on the left side of the resident’ s [#12] forehead. The note indicates that the resident's spouse was present at the time. 11.17. On January 26, 2003 at 6:30 a.m. a nurse’s note indicates that a certified nursing assistant [CNA] caught resident #12 before he/she fell to the floor, having suffered an apparent seizure with a duration of less than 15 seconds. The note indicates that the resident was returned to his/her bed. There was no documentation in the clinical record to indicate that either the attending physician or the resident's family was notified of this event. At 12:00 p.m. [noon] a nurse’s note indicates that resident #12, while seated at the dining room table awaiting lunch, suffered a seizure and fell from his chair to the floor. The note further indicates that the resident sustained a laceration to his/her right forehead and that the affected area was cleansed followed by the application of steri strips, a pressure dressing and the application of ice. The note further reveals that a physician who was on call for the attending physician was contacted and advised that resident #12 had sustained seizures at 6:30 a.m. and 12:00 noon and of the resulting laceration to his/her right forehead. The physician ordered Dilantin 100 mg. to be administered three times a day. The note further indicates that the resident's spouse was informed of the events. The note concludes with the observation that the resident ‘s pupils were equal and reactive to light and that the resident was unable to grip or open his/her eyes when addressed verbally. 11.18. On February 8, 2003 at 6:50 a.m. a nurse’s note indicates that resident #12 tripped and fell onto his/her face while ambulating. As a result of the fall the resident sustained redness of nose with a smail open area as weil as a hematoma to the left eyebrow and bruising of the left eye area. The note indicates that ice was applied to the left eye and eyebrow area and that a band-aid was applied to the resident’s nose and that a note was faxed to the physician. At 9:00 a.m. the note indicates that the bruising was observed to have intensified around the left eye and that the swelling in the affected area had increased, not having been cooperative with the ice pack. At 11:00 a.m. the notes reflect that the resident's right eye was reactive to light, but that it was difficult to assess and that the swelling around the left eye was worsening. The note also reflects that multiple unsuccessful attempts had been made to reach the resident’s spouse, but the telephone line had been busy on each attempt. At 1:00 p.m. the nursing note indicates that the resident's right pupil was reactive, the left eye was swollen and unresponsive to the ice and that the resident was rubbing his eye. The note further reveals that the bruising had intensified to a deep purple coloration and that the resident’s son had visited during lunch. At 10:00 p.m. a nurse’s note indicates that resident #12 was ambulating independently in the hallway, that his/her left eye was swollen shut and that his/her right eye was reactive. 11.19. On February 9, 2003 a nurse’s note at 6:15 a.m. states that the nurse was called to the hallway, where resident #12 was lying face down on the floor next to his wheelchair. The note reflects a slightly greater swelling in the resident's left eye as weil as a small skin tear on the resident’s left arm. The note states that the resident was assisted back to his/her wheelchair and that no other apparent injuries were noted. The note informs that the application of a cool compress to the resident's left eye was attempted but that the resident became agitated and uncooperative. A nurse’s note at 8:45 a.m. indicates that the resident’s spouse was notified of both the incident and the resident's status. A note indicates that at 9:00 a.m. the attending physician was notified by fax. At 2:15 p.m. a nurse's note states that the resident's left eye was swollen shut and had a deep purple coloration. The note also indicated that the resident had a minor abrasion with hematoma to the upper portion of the left head and that the resident's eyebrow was open to air. The note further reveals that the resident had a minor abrasion to the bridge of his/her nose with mild swelling. Also indicated was a minor tear to the resident's left elbow. The note reflects that a wheelchair with a quick-release belt was used for mobility and reflects that the resident be screened for physical therapy and/or occupational therapy to check. A nursing note at 11:00 p.m. indicates that resident #12's left eye was swollen and dark purple in coloration and that his/her spouse had come in to assist with his/her supper. 11.20. On February 10, 2003 a late entry is noted for 10:30 a.m., which reveals that resident #12 was observed lying on the floor on his/her right side and that a skin tear to his/her left hand was observed. The note reflects that the physician was notified and that several unsuccessful attempts had been made to contact the resident’s spouse. At 1:00 p.m. a late entry note indicates that resident #12 was in his wheelchair with a tabs monitor and that an attempt had been made to contact the resident’s spouse. A nurse’s note timed at 11:00 p.m. indicates that the staff had been reminded that the resident requires frequent supervision and safety precautions to prevent falis. A late entry note made on February 11, 2003 for February 10, 2003 at 10:00 a.m. indicates that resident #12 was alert and oriented to self only and that the resident was confused. The note observed that the resident had gross facial bruising and swelling and that his/her left eye was swollen shut. The note further observes that the resident had been sitting in his wheelchair at the nurse’s station and that he/she was constantly getting up and ambulating “ad lib”. The observation was made that the resident’s gait was becoming increasingly unsteady and that the staff enforced redirection and safety measures. 11.21. On February 11, 2003 at 7:00 a.m. resident #12 was noted to have been in the hallway in his/her wheelchair and that he/she stood up without assistance resulting Bl in the sounding of his/her pressure alarm. The resident had to be redirected by two staff members to his/her wheelchair. The note further indicates that at 7:55 a.m. the pressure alarm was sounding in the resident's room and that the resident was found on the floor sitting on his/her buttocks next to the bed. The note reflects that both the attending physician and the resident’s spouse were notified. 11.22. When resident #12 was readmitted to the facility on November 26, 2002 a new Minimum Data Set [MDS] and care plan were developed for the resident. The assessment referenced date for the MDS was December 1, 2002. The resident was assessed in Section B, “Cognitive Patterns”, as having both long and short-term memory loss, only able to recall staff names/faces, and being moderately impaired in decision making. The resident's cognitive status was noted to have changed in that it declined since the last MDS assessment. The resident was assessed in Section |, “Disease Diagnoses’, as having Alzheimer’s disease, dementia other than Alzheimer’s, seizure disorder and anxiety disorder. in Section J, “Health Conditions’, the resident was assessed as having fallen within the last 30 days. 11.23, The facility completed a fall risk assessment form for resident #12, which indicated the resident has a seizure disorder and unsteady gait, impaired vision due to wearing glasses and psychiatric/cognitive issues due to Alzheimer’s and dementia. Interventions suggested on the fall risk assessment to be care planned for residents with these risks included but were not limited to restorative ambulation, chair/bed alarm, regular monitor and monitoring during shift change. 11.24. Intervention care planned on December 10, 2002 as relates to activities of daily living reveals under “Problems and Strengths” that the resident ambulates independently but is dependent on staff for his/ner wheelchair and that his/her gait is unsteady at times. It reflects that resident #12 had sustained a recent fal! [November 28, 2002) without injury. The enunciated goal was that the resident would sustain no fall- related injuries through the next review date. The approaches identified included that the resident be transported off his/her unit in a wheelchair and that the resident be monitored for change in his/her gait and balance and that the monitoring be documented. 11.25. The facility failed to take into consideration previous falls, seizures and injuries, which resident #12 had sustained from the September 2002 admission. 11.26. On December 18, 2002, the resident’s care plan was updated. The problem identified was that resident #12 occasionally declined to sleep in his/her bed but would instead sleep on the couch in the day room, with the result that the resident would often fall off the couch. The only intervention identified was to attempt to redirect the resident back to his/her bed. 11.27. The care plan for psychotropic drugs dated December 10, 2002 included the information that resident #12 was on antipsychotic [risperdal], antidepressant [remeron] and anxiolytic [ativan] medication. Commonly known side effects of these medications include but are not limited to falls and orthostatic hypotension [low blood pressure which can cause fainting/dizziness when rising too quickly from a sitting or prone position]. The enunciated goal was for the resident to have no complications from the use of psychotropic medications as evidenced by no side effects noted on the lowest therapeutic dose through the next review date. The approaches identified were: (a) to monitor resident #12 for side effects from anti-anxiety and to document any side effects observed [i.e., agitation, insomnia, unsteady, disoriented, depression, hypotension, unusual disturbances and high range liver function results] and report them to the attending physician and (b) to monitor resident #12 for side effects of anti-depressants [i.e., dizziness, tremors, edema, nausea...] and to document any side effects observed and report them to the attending physician. 11.28. There were no new interventions to prevent injuries due to falls or injuries resulting from seizures from December 10, 2002 until after surveyor entry into the facility on February 9, 2003 and surveyor review of resident #12’s records on February 10, 2003 for obvious injuries which resulted in the resident having sustained two [2] black eyes, a bruised forehead and a left eye that was swollen shut on the survey team’s initial tour of the facility at 5:00 p.m. on February 9, 2003. 11.29. After the survey team selected resident #12 for record review, the facility updated the resident's care plan. New problems identified in the updated care plan were fails relating to unsteady gait and the enunciated goal was to prevent the resident from falling through nursing interventions. The approaches identified included (a) monitor the progress of strengths and weaknesses; (b) keep the resident near staff for observation; (c) use a pressure monitor in the resident’s wheelchair and bed; (d) check safety equipment to ensure proper functioning; (e) monitor resident's medications as relates to the potential for falls and (f) keep resident occupied in activities and redirect. 11.30. After resident #12 fell again on February 10, 2003, the following additional problem was identified: fall relating to resident continuing to stand with unsteady gait. The enunciated goal was for the resident to have no further falls with injury for the next 30 days and the new approaches identified included (a) therapy to screen as urdered by both physical therapy and occupational therapy and (b) utilization of a soft clip belt/soft waist restraint as ordered. 11.31. On February 9, 2003 a surveyor observed resident #12 with two black eyes. At 5:08 p.m. the surveyor, after knocking and being invited into the room by the resident's spouse, observed that the resident presented with two grossly blackened eyes. The left eye was noted to be swollen shut. The surveyor inquired of the resident's spouse as to what had occurred and the spouse informed the surveyor that the resident had fallen twice in the past two days — once on February 8, 2003 and once again on February 9, 2003. The surveyor asked the spouse if the resident had fallen previously and the spouse indicated that the resident had fallen several times since being admitted to the facility. The surveyor inquired of the spouse as to whether the resident had ever sustained injuries as a result of the falls and the spouse told the surveyor that the resident had required stitches on several occasions. The surveyor noted that the resident’s spouse appeared nervous and the spouse advised the surveyor that she did not want to be seen talking to the surveyor because he/she knew that they take it out on the residents. The spouse then began to cry and indicated to the surveyor that he/she wished that the facility would have done something to treat the resident's injuries, even if only to have applied ice bags. At 5:30 p.m. the spouse was observed by the surveyor in the dining room holding a washcloth to the resident's left eye. 11.32. On February 11, 2003 at approximately 12:30 p.m. the director of nurses entered the conference room where the survey team was working and informed them that resident #12 had fallen again that day and the previous day, making him “4 for 4”. 11.33. On February 12, 2003 at approximately 9:15 a.m. a surveyor interviewed the Alzheimer’s 7-3 charge nurse, who was asked about resident #12 and his/her falls. The charge nurse stated that the resident has a long history of falls. When asked about the unit’s process for notifying the physician about an injury, the charge nurse indicated that the physician would be called and then a report would be faxed to his/her office. The charge nurse was informed that based upon record review it appeared that the attending physician was not notified by telephone of the injuries sustained by resident #12 on February 8 or February 9 and that the facility had only faxed injury reports to the physician's office. The charge nurse informed the surveyor that he/she was aware that the physician was called on February 8 and February 9 and stated that she was not aware that the phone calls had not been documented in the clinical record. 11.34. Ina later interview on February 12, 2003 at approximately 10:35 a.m. the charge nurse stated that she knew that the nurse on February 8, 2003 had called the physician and she thought that the nurse on February 9, 2003 had called the physician. 11.35. A telephone interview was conducted on February 12, 2003 at 1:30 p.m. with the nurse who was on duty when resident #12 fell on February 8, 2003. When asked to whom she had reported the fail, the nurse indicated that she had reported the fall to the 7-3 nurse. When asked whether she had reported the fall to a supervisor, she indicated that she had not and was not required to so report, because there is no 11-7 supervisor. The nurse stated that she called the physician’s answering service and was instructed by the service to fax the report to the physician. 11.36. On February 12, 2003 at approximately 2:05 p.m. a telephone interview was conducted with the nurse who worked on February 9, 2003 when the resident fell. The nurse stated that the resident had been found on the floor and indicated that the resident has a slight increase in edema. The nurse indicated that this information was faxed to the physician and that she put the information on the 24-hour nurse's report for the 7-3 shift. When asked, as an agency nurse, if she was aware of the facility policy and procedure for reporting falls, she indicated that she never received the policy and procedure on falls. The nurse indicaied that the 3-11 nurse had informed her that in the Alzheimer’s unit, they just fax fall reports to the physician and that if you call the answering service, they simply instruct you to fax the report to the physician's office. 11.37. A telephone interview with the physician’s answering service on February 12, 2003 at approximately 6:15 p.m. revealed that there were no telephone calls from the facility reporting resident #12’s injury to the attending physician on either February 8, 2003 or February 9, 2003 between the hours of 6:30 a.m. to 7:30 a.m. A further phone call on February 14, 2003, for clarification, revealed that there were no phone calls received from the facility reporting resident #12’s injury to the attending physician on either date. 11.38. A telephone call to the attending physician on February 13, 2003 at approximately 10:00 a.m. revealed that he knew about resident #12’s fall on February 8, 2003 from a facsimile. The physician, however, indicated that he did not believe that he received a facsimile relating to the fall on February 9, 2003. The physician stated that he did not know about the falls that occurred on February 8 and 9, 2003 until February 10, 2003 since he was not on call over the weekend. 11.39. Facility nursing staff failed to notify the attending physician that resident #12 had fallen on two separate occasions. A computerized tomography scan of the resident's face performed on February 11, 2003 initially diagnosed the resident with an acute fracture of the anterior wall of the left maxillary antrum. A subsequent entry in the resident’s clinical record by a consulting maxillary facial surgeon on February 11, 2003 indicated there was no fracture of the maxillary antrum. In a telephone interview with the surgeon on February 13, 2003 at approximately 10:10 a.m. it was revealed that the CT scan had been reviewed with 2 radiologists and that it was determined that there had not been a fracture of the maxillary antrum. The surgeon noted that there was a very small, non-dispiaced, nasal fracture. The surgeon indicated that no treatment was indicated. 11.40. On February 12, 2003 at approximately 9:30 a.m. the charge nurse was asked for the identity of the nurse in charge of the facility over the weekend. The charge nurse indicated that the staff development nurse was in charge of nursing services over the weekend. 11.41. In an interview on February 12, 2003 at approximately 10:10 a.m. the staff development nurse was asked if she had been notified by the staff in the Alzheimer's Unit about the resident’s [#12] falls on February 8 and February 9, 2003. The staff development nurse indicated that staff on the unit had not notified her. The 17 staff development nurse indicated that she had made rounds in the unit on Monday morning and then saw resident #12 for the first time since the falls. The staff development nurse said that she asked another person assigned to the unit what had happened to the resident, and indicated to the surveyor that she should have been contacted by personnel on duty in the Alzheimer’s unit about the injuries sustained by the resident as a result of the falls. 11.42. A review of the facility’s Accidents and Incidents Policy and Procedure provides in item (1)(d) that “The nurse supervisor/charge nurse must be immediately informed of accidents or incidents so that medical attention can be provided”. Item (3) of the same policy, designated as “Medical Attention” states: “The nurse supervisor and/or charge nurse shall (a) Examine all accident/incident victims; (b) Notify the medical director or the victim’s personal or attending physician, and inform the physician of the accident or incident; (c) If necessary, transfer the injured person to the emergency room, medical treatment center, hospital; and (d) If necessary or appropriate, designate an employee to accompany the victim to the emergency room, medical treatment center or hospital’. In the same policy, in section (4), designated “Investigative Actions” it reads in part (a): “The nurse supervisor/charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident”. ’ 11.43. The staff development nurse, as charge nurse of the facility over the weekend, was not informed of the condition of resident #12 by the unit manager of the Alzheimer's Unit. Facility staff put the resident in jeopardy of not receiving care and treatment by not following established procedures to protect residents. 11.44. On February 12, 2003 at approximately 9:45 a.m. the restorative nurse was asked why the restorative program for resident #12 was stopped on January 26, 2003. She stated that the resident was Baker-Acted that day. She went through the chart and found that he had not been Baker-Acted that day and then stated that she had no idea why the program had been discontinued. 11.45. On February 13, 2003 at approximately 3:45 p.m. the wound care nurse and 7-3 charge nurse stated that the unit is too noisy with alarms going off at all the doors and that they spend too much of their time running down the halls to use the key to shut off the alarms. They further stated that there is nothing for the residents to do except pace the halls. The wound care nurse was reviewing the fall records at this time and told the surveyor that the unit needs one on one care due to the number of falls. 11.46. On February 14, 2003 at approximately 10:15 a.m. the wound care nurse told the survey team that more help is needed in the Alzheimer’s unit because there are too many falls. The wound care nurse added that a process needs to be implemented and said that the improvement must come from the top. 11.47. The resident's [#12] spouse was approached by the survey team on February 12, 2003 at approximately 1:00 p.m. to schedule an interview. The resident's spouse was reluctant to speak with the survey team because she expressed the concern that her spouse would be retaliated against by the facility. During this conversation the resident’s spouse was asked whether he/she had ever discussed with the facility what they could do to prevent falls. The resident's spouse informed the survey team that it doesn’t heip to talk to the facility. 11.48. The survey team interviewed the spouse of resident #12 on February 12, 2003 at approximately 3:30 p.m. relating to the care the resident was receiving at the facility. During the interview the resident’s spouse expressed concern that she had not been contacted by the facility on February 8, 2003 regarding the resident's fall. The resident's spouse indicated that his/her son had called him/her at approximately 1:30 p.m. and informed him/her of his/her spouse's injury. The resident's spouse indicated that he/she had not been contacted by the facility on February 10, 2003 regarding the 19 resident's fall on that date either. The spouse further indicated that the restorative nurse had called her on February 10 but did not mention that the resident would be undergoing a CT scan of the head that day. The resident’s spouse then expressed concern because he/she had not been informed of the first seizure when it occurred on January 26, 2003. The survey team asked the resident’s spouse if he/she had limited any approaches that the facility might attempt to implement to decrease the resident's falls. The spouse indicated that he/she had not limited the facility in its approaches to decreasing the risk of the resident's fails. 11.49. A review by the survey team of the incident reports for resident #12 revealed the following: a. 12/14/02 — “feil on floor’. The section designated as “steps to prevent recurrence” is blank. No fall investigation form was located. b. 12/16/02 — “fell on face, forehead bruised”. The section designated as “steps to prevent recurrence” is blank. No fall investigation form was located. c. 1/7/03 — “Ambulating in hall with left eyebrow laceration with large amount bleeaing on floor and at laceration site’. The section designated as “steps to prevent recurrence” contained the notation “monitor whereabouts”. A form entitled “Potential Adverse Incident Investigation” dated 1/8/03 contained the notation “Found ambulating in hallway of dementia unit with laceration over left eyebrow. Sent to ER for sutures.” There is no documentation of any investigation and no Fall Investigation Form was located. 20 d. 1/14/03 — “Abrasion on left side of forehead”. Sections for investigation and steps to prevent recurrence are blank. The incident report is not signed by the director of nurses to indicate that the incident report was reviewed. 2/8/03 — “Walking in front of nurse’s station, fell and landed on face”. The incident report is not signed by the director of nursing to indicate the report was received. The section for steps to prevent recurrence is blank. A fall investigation form has been completed with information from the incident report but there is no documentation of an investigation or conclusion. 2/9/03 — “Found on floor, increased swelling of left eye and skin tear on left arm.” The incident report is not signed by the director of nursing to indicate the incident was reviewed and steps to prevent recurrence is blank. 2/10/03 — “On floor.” The section designated as “steps to prevent recurrence” contains the notation “Resident is monitored more frequently”. No fall investigation form was located. 2/11/03 — “On floor, pressure TABS sounding.” The incident report is not signed by the director of nursing to indicate the report was reviewed and the section designated “steps to prevent recurrence” is blank. A fall investigation form is dated and signed by a licensed practical nurse but ail _ sections of the form are blank and there is no indication that an investigation was completed. 21 i. The fall investigation worksheet forms that were completed contained data from the incident reports but no documentation that this information was used to investigate the falls or to determine any interventions to prevent or reduce further falls. 12. Resident #18 was admitted to the facility on January 24, 2003 with diagnoses including short bowel syndrome and an abdominal wound. Review of the physician’s history and physical dated December 23, 2003 from the transferring hospital revealed that the resident had a past history of multiple surgeries and resections of his/her colon and has approximately 3 feet of small bowel and one foot of large intestine. Review of the infectious disease progress note dated January 10, 2003 indicated that the resident had elevated liver function studies while hospitalized, possibly associated with his/her total parenteral nutrition. Review of the laboratory data sent from the hospital revealed that the hospital was monitoring the resident's labs daily. The last hospital labs, dated January 23, 2003 were within normal limits except for a low albumin level that was indicative of moderately depleted protein stores and a low hemoglobin and hematocrit indicative of anemia. 12.1 Review of admitting physician’s orders dated January 24, 2003 revealed that ihe resident was admitted with total parenteral nutrition to meet her total nutritional needs. Review of the total parenteral nutrition orders sent with the resident from the hospital dated January 24, 2003 revealed that the resident was to receive a total parenteral nutrition solution that contained 6.7% amino acids, 15.9% dextrose at 75 mi/hour with 250 ml/day of a 20% tipid [fat] emulsion. 12.2 Review of resident #18’s clinical record revealed a laboratory report dated January 29, 2003 that contained a CBC with differential. There was no comprehensive metabolic profile from January 27, 2003 in the resident’s record to monitor the resident's intravenous nutrition. 22 12.3 Review of the nurse’s notes dated February 3, 2003 at 2:00 p.m. noted, “Reviewed labs. Requested to MD [medical doctor] CMP, BMP [basic metabolic profile], Mg+ [magnesium] and a hemoglobin and hematocrit for monitoring needs. Faxed and called request”. 12.4 Review of the nurse/physician communication form dated February 3, 2003 at 2:00 p.m. in the physician’s telephone orders revealed the request for a “routine” CBC, BMP and magnesium and a hemoglobin and hematocrit. The physician approved the request on February 3, 2003. 12.5 Further review of the laboratory data section of the clinical record for resident #18 revealed that it contained no laboratory data since the CBC obtained on January 29, 2003. 12.6 Review of the January 2003 medication administration record [MAR] revealed that the nursing staff was monitoring the resident’s blood sugar levels twice a day in January 2003 with normal results. Review of the February 2003 MAR revealed that the resident had an AM blood sugar of 55 on February 3, 2003 and 53 on February 7, 2003. No AM blood sugar levels were documented on February 8, 2003, February 11, 2003 and February 12, 2003. 12.7 Review of the nurse’s notes dated February 3, 2003 at’ 7:00 a.m. revealed that the nurse noted the 6:30 a.m. blood sugar of 55 for resident #18 and documented “without s/s [signs/symptoms] of glycemia [low blood sugar] noted”. There was no indication that the physician was notified of the resident's iow blood sugar level. Review of the nurse’s note dated February 7, 2003, “7-3” revealed that it contained no assessment of the resident’s low blood sugar level or notification of the physician. Review of the nurse’s notes for February 8; February 11; and February 12, 2003 revealed no documentation that the resident's a.m. blood sugar levels were obtained at 6:30 a.m. on those dates. 23 12.8 An interview with the assistant director of nursing on February 12, 2003 at 11:30 a.m. revealed that he was not aware that !ab work to monitor resident #18’s total parenteral nutrition was never obtained. Review of the lab work documentation book with the assistant director of nursing indicated that a CBC was the only lab work requested. Further review of the book revealed the CMP from January 27, 2003 and the CBC, BMP, magnesium and hemoglobin and hematocrit from February 3, 2003 were never obtained. The assistant director of nursing also stated that the request for lab work sent to the physician on February 3 2003 should have been clarified by the nursing staff as to how frequently the physician wanted the lab data checked. The assistant director of nursing also confirmed that there were no policies and procedures for monitoring total parenteral nutrition in the facility. He stated, “We just follow physician’s orders”. He also confirmed that there was no specific time frame or guidelines that the nurses could follow for ordering lab work for residents receiving total parenteral nutrition. The assistant director of nursing stated that he would fax a request to the physician to clarify the labs he wanted to monitor and the frequency of the monitoring. 12.9 Review of the physician’s response to the fax sent by the assistant director of nursing on February 12, 2003 at noon revealed that the physician had wanted resident #18’s lab data to be monitored weekly. 12.10 Subsequent to surveyor intervention, the facility obtained a BMP, CBC and magnesium level on February 13, 2003. Review of the lab work provided by the facility on February 13, 2003 at 10:00 a.m. revealed that resident #18 had an elevated chloride level and his/her blood urea nitrogen [BUN] had increased since the last laboratory tests conducted at the hospital. The resident's BUN to creatinine ration remained elevated. An elevated BUN and BUN/creatinine ratio could be indicative that the resident was not receiving adequate fluids. 24 12.11 Review of the nurse/physician communication form sent to the physician on February 13, 2003 at 9:30 a.m. reveaied that the facility requested that the physician review the abnormal lab values and total parenteral nutrition ingredients and advise on further lab data and/or adjustment to the total parenteral nutrition for resident #18. The physician responded with an order to continue with weekly labs and current total parenteral nutrition until the resident saw the surgeon for follow-up. A total parenteral nutrition form was attached that stated the resident should continue to receive the total parenteral nutrition solution of 6.7% amino acids, 15.9% dextrose at 75 ml/hour and 250. mi of 20% lipids to be included in the total parenteral nutrition. 12.12 Review of the initial nutrition assessment completed for resident #18 on January 29, 2003 revealed that the resident needed 1952 calories with 93 to 124 grams of protein secondary to his/her low albumin and abdominal wound. The consultant registered dietitian noted that the resident was receiving the total parenteral nutrition as prescribed and calculated her assessment on this formula. She estimated that the total parenteral nutrition would provide 1905 calories with 120.6 grams of protein. She documented the resident's weight as 138 pounds on January 28, 2003. The consultant registered dietician noted the low albumin and hemoglobin and hematocrit. Her plan was to monitor weights and labs. There were no recommendations by the dietician regarding which labs were appropriate to monitor for a resident on total parenteral nutrition, nor did she recommend how often labs should be monitored and how frequently weights should be checked. 12.13 The next note by the consulting registered dietician on resident #18's chart was documented on February 5, 2003. She indicated that the resident had lost weight and now weighed 133.2 pounds. She noted that lab work was ordered on February 3, 2003. There were no documented recommendations regarding adjustment to the resident’s total parenteral nutrition with the weight loss. 25 12.14 On February 6, 2003 the consultant registered dietician noted that resident #18 was discussed at the standards of care meeting. The dietician documented that there was a possibility that the resident's oral intake could be increased and recommended resource fruit beverage three times a day, if approved by the physician. There was no documentation that the team discussed the resident’s weight loss, adequacy of the current total parenteral nutrition formulation or lack of lab results. 12.15 Further review of the clinical record for resident #18 revealed that there was no order or fax request in the record for the resource fruit beverage. There was no further documentation by the registered dietician, certified dietary manager or nursing staff in the clinical record after February 6, 2003 regarding the dietician’s recommendation. 12.16 An interview with the registered dietician on February 12, 2003 at 11:30 a.m. revealed that resident #18’s weight had decreased further on February 11, 2003 to 131.6 pounds. The dietician stated that she had recommended at the standards of care meeting that they provide the resident with resource fruit beverage to increase her oral intake and stop the weight loss. The dietician confirmed that she was not aware that the assistant director of nursing had not followed through on her recommendation. The registered dietician confirmed that she had not spoken to the resident yet regarding the resource fruit beverage and was not sure if the resident could tolerate it. The dietician Stated that she was waiting for approval from the physician prior to approaching the resident. She confirmed that she had not considered making a recommendation regarding increasing the resident's total parenteral nutrition, secondary to the weight loss, since the resident was stable on the current formula at the hospital. 12.17 Further interview with the assistant director of nursing on February 12, 2003 at 11:30 a.m. revealed that he would fax the registered dietician’s request for the 26 resource fruit beverage for resident #18 with request for clarification of the lab monitoring. 12.18 Review of the nurse/physician communication form dated February 12, 2003 at noon revealed that the physician had agreed to let resident #18 try the resource fruit beverage three times a day. 12.19 An interview on February 12, 2003 at 12:15 p.m. with resident #18, who was very alert and oriented, revealed that he/she was extremely nauseous and was vomiting mucous and bile. He/she also stated that he/she was having diarrhea. He/she stated that he/she could not take anything orally except for some chocolate ice cream occasionally. He/she stated that there had been some problem with the facility getting the proper tubing for her lipids when they were in a separate bottle. He/she further stated that up until today he/she had not been getting ail of her lipids as prescribed. He/she stated that today was the first day that the lipids were mixed in with the amino acids and dextrose into one bag. Observation of the resident's total parenteral nutrition revealed that the label stated that the resident was receiving a solution that contained 5% amino acids and 15% dextrose with 250 mi of 20% lipids. The pump was running at 75 cc per hour. 12.20 Review of the February 2003 medication administration record revealed that the total parenteral nutrition solution was documented as 5% amino acids and 15% dextrose and not as the physician had ordered. The nursing staff were signing off that they had provided this incorrect formulation since February 1, 2003. Review of the January 2003 medication administration record revealed that the total parenteral nutrition was listed as “TPN at 75 cc per hour’ with no indication of the composition of the formula provided. 12.21 On February 12, 2003 at 3:41 p.m. the interim director of nursing provided the survey team with the pharmacy policy on total parenteral nutrition. Review of the 27 policy revealed that it contained information on how to administer the total parenteral nutrition but it did not contain information on monitoring labs for tolerance and adverse reactions. The policy referred to “the protocols”. The acting director of nursing confirmed that the protocols were not in the building. 12.22 An interview with the unit nurse assigned to resident #18 on February 13, 2003 at 1:12 p.m. confirmed that she was not aware that the total parenteral nutrition she was providing to the resident did not match the physician’s order. She stated that the label on the bag rhatched the medication administration record. She also confirmed that the nursing staff was not keeping intake and output [I & O] records on resident #18 for the month of February 2003. Review of the January 2003 intake and output records revealed that the nursing staff had documented the resident's intake on a sporadic basis from January 25, 2003 through January 30, 2003. Twenty-four [24] totals were not completed for any day in this time period. Output was monitored for only the 11 p.m. to 7 a.m. shift on January 26, 2003, with the remaining days left blank. 12.23 An interview with the consultant registered pharmacist on February 13, 2003 at 3:20 p.m. revealed that she was not aware of the total parenteral nutrition that resident #18 was receiving. The pharmacist stated that the intravenous [IV] pharmacist from her company was in communication with the physician regarding the total parenteral nutrition composition and rate. She stated that the resident was “probably” receiving the same total parenteral nutrition he/she was on in the hospital. The pharmacist stated that there was no IV policy book in the facility up until the date of the interview. She stated that the IV book contained a total parenteral nutrition protocol for the nursing staff to follow to monitor total parenteral nutrition. Review of the total parenteral nutrition policy with the consultant pharmacist revealed that the policy stated, “A copy of current CBC, chemistry panel, electrolytes and blood glucose is to be provided to the IV pharmacist on admission and weekly thereafter’. The policy also 28 stated that on admission to the facility, the facility was to obtain a CBC with differential, a comprehensive chemistry panel, serum transferrin, serum pre-albumin, prothrombin time and magnesium. Ongoing monitoring included lab work for monitoring 2 times a week for 2 weeks and if stable, decrease to a variety of lab work every 2 weeks. The consultant pharmacist confirmed that she was not aware that lab data was not being obtained on an ongoing basis and that she was not aware that the resident was not receiving the prescribed total parenteral nutrition formulation. She stated that she would clarify with the IV pharmacist regarding the total parenteral nutrition formulation. 12.24 Further interview on February 14, 2003 at 11:10 a.m. with the consultant pharmacist and the nurse who admitted resident #18 revealed that the nurse stated that she had received a call from the pharmacy on January 24, 2003 regarding the total parenteral nutrition orders. The nurse stated that the pharmacy had sent her a list of standard total parenteral nutrition solutions and told her that the physician had to choose one of them. The nurse stated that she faxed the form to the physician's office and that the physician had selected a formula. She said that she then sent the orders to the pharmacy via a telephone order. The nurse further stated that she put the original fax in the chart but could not find it now. The nurse stated that the physician had approved the 5% amino acid and 15% dextrose standard solution. The nurse confirmed that the order for this was not in the medical record. The pharmacist confirmed that the pharmacy progress notes documented a telephone call from the nurse confirming the physician’s approval of the standard high protein central formula that contained 5% amino acids and 15% dextrose. The pharmacist could not provide a written copy of the physician's order for this formula. The pharmacist also confirmed that she was not aware of the standards of practice regarding lab monitoring of total parenteral nutrition solutions. She stated that she was unaware that her company’s total parenteral nutrition protocol did not 29 reflect the current A.S.P.E.N. [American Society of Parenteral and Enteral Nutrition] guidelines regarding total parenteral nutrition monitoring. 12.25 Further interview with the registered dietician on February 14, 2003 at 11:45 p.m. revealed that since the resident was on total parenteral nutrition at home prior to admission and was on lipids in the hospital, she was not concerned that the facility was not monitoring the resident's lipid and/or triglyceride levels. The dietician confirmed that the American Dietetic Association Manual! of Clinical Dietetics was the current diet manual in the facility. She stated that they followed the total parenteral nutrition guidelines in this manual when the previous corporation owned the facility but now they had changed to the current policy from the pharmacy. She stated that she had provided the facility yesterday with a revised policy with updated lab monitoring and did not know why the facility administration had not shared this with the survey team. The dietician confirmed that she was not aware that the new pharmacy protocol for total parenteral nutrition monitoring did not agree with A.S.P.E.N. guidelines. She stated that she had not made recommendations regarding appropriate labs to monitor on her February 6, 2003 visit because she was waiting for the labs that she thought were ordered on February 3, 2003. The dietician further stated that she would have “picked up or ins” when she came in to consult this week. She also confirmed that she thought that resident #18 was on the 6.7% amino acid and 15.9% dextrose solution because she remembers that they discussed this in the standards of care meeting and the pharmacy had indicated that they would make this formulation. 12.26 Review of the registered dietician progress note dated February 13, 2003 indicated that resident #18 weighed 131.6 pounds on February 11, 2003. She documented that the resident stated that the volume of resource fruit beverage was too great and that the resident requested 1 tablespoon of yogurt daily. The note indicated that the resident stated that a good weight for him/her was 135 to 140 pounds. The registered dietician’s plan was to continue to monitor weekly weights and weekly labs. 12.27 Review of the registered dietician’s recommendations, dated February 13, 2003 and faxed to the physician, revealed that she had recommended a BMP every other week and a CMP on alternate weeks. She also recommended that the physician order a CBC with differential, prothrombin time, serum transferrin, magnesium, triglycerides, cholesterol and liver enzymes every 2 weeks. The physician approved this request on February 14, 2003. 12.28 Review of the ADA diet manual, 6" edition, 2000, currently in use at the facility as the nutrition standards of practice, revealed that in stable residents calcium, magnesium, phosphorus, liver function tests, prothrombin time and CBC with differential should be monitored weekly. Electrolytes, BUN and creatinine should be monitored 1-2 times per week. Triglycerides should be monitored weekly or as needed. Glucose should be monitored 3 times per day until consistently less than 200 mg/di and then 2 times per week. Intake and output should be monitored daily with weights 2 to 3 times per week. 12.29 Further interview with the registered dietician and assistant director of nursing on February 14, 2003 at 2:30 p.m. confirmed that they both remembered the discussion at the standards of care meeting that the amino acids would remain at 6.7%. The assistant director of nursing confirmed that he did not know that the total parenteral nutrition solution had been changed to 5% amino acids. The registered dietician further stated that the staff nurse had taken it upon herself to obtain an order from the physician on February 14, 2003 to change the amino acid concentration to 5% without consulting with the dietician first. The registered dietician stated that the amino acids needed to remain at 6.7% to provide resident #18 with adequate protein and the dextrose at 15.9% to provide adequate calories. The registered dietician further stated that she would have 31 to change her recommendation made to the physician regarding lab monitoring on February 13, 2003 to agree with A.S.P.E.N. guidelines. 12.30 An interview with the consultant registered pharmacist on February 14, 2003 at 2:45 p.m. confirmed that the pharmacy would make a tailored total parenteral nutrition formulation for resident #18. She stated that her company’s policy had been updated to include appropriate labs to monitor for total parenteral nutrition. 12.31 Subsequent to surveyor intervention, on February 14, 2003 at 2:52 p.m., the registered dietician provided the survey team with a revised total parenteral nutrition policy and protocol for the facility that included current A.S.P.E.N. guidelines on lab monitoring. 12.32 Observation of resident #18’s total parenteral nutrition on February 14, 2003 at 5:00 p.m., prior to the survey team exiting the facility, revealed that the resident continued to receive the incorrect total parenteral nutrition formulation. Neither had the resident's triglyceride, phosphorus levels and prothrombin time been obtained to monitor the resident's current nutritional status. 13. Review of the clinical record for resident #19 revealed that the resident had been admitted to the facility from the hospital on January 24, 2003 with diagnoses including necrotizing fasciitis, coronary artery disease, hypertension and airial fibrillation. Review of the physician's orders for resident #19 revealed the resident has been receiving coumadin [anticoagulant/biood thinner] 2 mg. every day and oxandrin 10 mg. BID [two times a day] since admission three weeks ago. Further review of the resident’s medical record revealed that there were no laboratory tests to monitor the resident’s blood values and no documentation that the facility was monitoring for potential serious drug-to-drug interactions and side effects. 13.1 During an interview conducted on February 12, 2003 at approximately 1:00 p.m. with the assistant director of nursing, the assistant director of nursing stated that he did not know what oxandrin was being used for on resident #19 nor did he know what the action of the drug is when used with coumadin. 13.2 On February 13, 2003 at approximately 3:45 p.m., when asked why there were no laboratory tests to monitor resident #19's blood clotting when the resident is receiving coumadin, the assistant director of nursing stated informed the surveyor that the physician usually picks up on that when he comes in and further informed the surveyor that the physician had come in on January 29, 2003. The assistant director of nursing then told the surveyor that the facility would have picked up on it eventually because they always do labs for coumadin. When the surveyor asked when they would have picked up on it, the assistant director of nursing was unable to respond. The assistant director of nursing also stated that he had just received some information about oxandrin from the pharmacy and would look at it as soon as he could. 13.3 During an interview on February 14, 2003 at approximately 8:50 a.m., the assistant director of nursing stated that he had reviewed the information about oxandrin and informed the surveyor that he “had a fax out to the doctor’ and that he was going to call and get a prothrombin time/international normalization ratio. Review of information received by the facinty from their pharmacy revealed that oxandrin, when given with anticoagulants, may increase the anticoagulant effect and this combination should be avoided if possible. Included under the precautions section is edema, indicating that edema, with or without congestive heart failure, may occur. 13.4 Review of nurse’s notes dated February 11, 2003 revealed that resident #19 has 4+ edema in bilateral hands and forearms and has some shortness of breath and difficulty breathing. 13.5 On February 14, 2003 at approximately 12:00 p.m. the assistant director of nursing informed the survey team that he had just received the order for prothrombin iva) ta At time/international normalization ratio and was getting it done right then. approximately 2:00 p.m. the assistant director of nursing stated that the test results were high and that the doctor had ordered the facility to hold the coumadin for a couple of days. Review of the prothrombin/international normalization ration for resident #19 revealed the prothrombin time is 54.9 [normal therapeutic range per the facility's laboratory is 10.1-13.3 and the resident’s international normalization ratio is 4.5 [normal therapeutic range is 2.0-3.0]. Review of the physician’s order dated February 14, 2003 revealed the following orders: (1) Hold coumadin today and Saturday. (2) On Sunday begin coumadin at 1 mg. less than current dose [2 mg.]. (3) Repeat Protime on 2/20/03. 13.6 During an interview on February 10, 2003 at approximately 10:10 a.m., during the medication pass observation outside resident #19’s room, the nurse stated that she only had 2 pills of oxandrin, when the resident was supposed to get 4. The nurse then entered the resident's room and asked if he/she was having any pain. The resident replied that he/she was not having pain. The nurse then turned to the surveyor and stated that it was OK then, since the resident was not experiencing pain and further informed the surveyor that she would call the pharmacy and get the rest of the resident’s oxandrin and administer it to the resident upon its arrival from the pharmacy. When the surveyor asked the nurse what oxandrin was, the nurse replied that it was for pain but was unable to describe any side effects or drug-to-drug interactions for which the resident should be monitored, 13.7 Review of the initial care plan for resident #19 dated January 24, 2003 revealed that the facility did not identify the resident to be at risk for any side effects due to the administration of coumadin and/or oxandrin and there are no approaches to monitor for those side effects and/or drug-to-drug interactions. Review of the medical record on February 14, 2003 revealed that the initial care plan is the only care plan that has been developed for resident #19 who was admitted on January 24, 2003. 14. Based on all of the foregoing, VENICE REHAB AND HEALTH CENTER violated: (a) 42 CFR 483.25 via Rule 59A-4.1288, Florida Administrative Code, and 42 CFR 483.13(c)(1){i) by failing to develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents, as evidenced by the facility's having neglected and jeopardized resident #12 by its failure to implement uniform policies and procedures within the facility for staff to follow regarding resident falls and the reporting of such falls to the attending physician and supervisory personnel, by its failure to update the resident’s care plan with progressive intervention for a resident with a long history of falls and who was known to have seizure activity and its failure to adequately review and investigate falls and implement safety procedures to alleviate falls; the facility's failure to provide the total parenteral nutrition formulation prescribed by the physician with regard to resident #18 for a 3 week period, resulting in the resident receiving less than estimated calorie and protein needs and experiencing weight loss, the facility's failure to obtain laboratory data to monitor the total parenteral nutrition as prescribed by the physician, and after a 3 week period the metabolic profile obtained by the facility indicated some abnormal! laboratory results for resident #18 as well as the facility’s failure to document notification to resident #18’s physician of the resident having experienced episodes orf hypoglycemia on two occasions and the facility's failure at the time of the exit of the survey team to provide total parenteral nutrition to resident #18 in accordance with the physician’s orders; and, finally, the failure of the facility to adequately monitor laboratory blood values for resident #19, who was on coumadin therapy, resulting in a highly elevated, 54.9 prothrombin time and 4.5 international normalization ration, leaving the resident exposed to life-threatening harm in a sample of 21 active sampled residents from a total sample of 24 residents and an extended sample of 5 residents with 3 additional closed records reviewed in conjunction with a complaint investigation for a total sample of 32 charts reviewed. 35 15. Pursuant to Section 400.23(8)(a), Florida Statutes, the foregoing is a class | deficiency because it is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. 15.1. AHCA gave VENICE REHAB AND HEALTH CENTER a written mandated correction date of February 15, 2003, in accordance with Section 400.23(8)(a), Florida Statutes. SECOND CLASS | DEFICIENCY 16. In the course of the off-hours annual health licensure and recertification survey conducted by AHCA on or about February 9-14, 2003, at VENICE REHAB AND HEALTH CENTER, AHCA cited VENICE REHAB AND HEALTH CENTER for a second class | deficiency on the basis that the facility failed to ensure that the services provided or arranged by the facility meet professional standards of quality. Based on observations, review of clinical records and facility policies, protocols and procedures, as well as interviews with facility staff, it was determined that the facility jeopardized the health, life and safety of 7 residents [residents #2, #9, #12, #14, #15, #16 and #19] of 21 active sampled residents, 1 resident [resident #28) of 5 extended sample and 2 random sample residents (residents #43 and #44] by failing to ensure that nursing staff maintained professional standards of quality as evidenced by: (1) The facility jeopardized resident #19 by failing to ensure that nursing staff were knowledgeable of the drug- to-drug interactions of oxandrin when given concurrently with coumadin, by failing to contact the resident's physician to determine parameters for pain medication [percocet], by failing to follow procedures for documentation of administration of medications and by not following physician’s orders to administer lasix, which exposed the resident to potential life-threatening harm; (2) The facility jeopardized resident #14 by failing to monitor and document the condition of the resident’s left heel, which was observed to be dark red and soft/boggy and the right heel, which 36 was observed to be dark red and by failing to notify the resident’s physician when the resident refused treatment, which exposed the resident to potential life-threatening harm; (3) The facility jeopardized resident #28 by failing to notify the resident's physician when nurses held the resident's seroquel because the resident was drowsy and lethargic, by continuing to administer vasotec for 4 days after the physician had discontinued the medication, by failing to follow proper procedure for documentation of medication administration and by failing to document the amount of tube feedings and flushes, which exposed the resident to potential life-threatening harm; (4) The facility jeopardized residents #43 and #44 by failing to check placement of their gastrostomy tubes before administering medications and flushes and by failing to follow physician’s orders to check the blood pressure of resident #43 before administering vasotec, which exposed the residents to potential life-threatening harm; (5) The facility jeopardized resident #15 by failing to contact the resident's physician to determine parameters for pain medication [percocet], which exposed the resident to potential life-threatening harm; (6) The facility jeopardized resident #2 by failing to follow physician’s orders for tube feeding flushes, by failing to follow proper procedures for entering late entries and by failing to follow infection contro! procedures for changing open tube feeding bags daily, which exposed the resident to potential life-threatening harm; (7) Professional staff failed to inform the attending physician of a resident's fall/injury [resident #12] in a timeiy fashion by calling the physician or the physician's answering service, failed to assess and care plan the resident for preventive measures to decrease falls for a resident with a known long history of falls, injuries and seizure disorder, which exposed the resident to potential life-threatening harm; (8) Professional staff failed to assure that a resident on restorative ambulation [resident #12] was ambulated and that a resident on a fluid restriction [resident #16] received only the amount of fluid ordered by the attending physician, which exposed the residents to potential life-threatening harm; and (9) The facility jeopardized resident #9 by failing to follow physician's orders for tube feeding flushes, which exposed the resident to life-threatening harm. The findings of the AHCA survey team included: 17. During an interview on February 10, 2003 at approximately 10:10 a.m. during the medication pass observation outside resident #19’s room, the nurse informed the survey team that she only had 2 pills of oxandrin and stated that resident #19 is supposed to get 4 pills. The nurse then entered the resident’s room and inquired of the resident whether he/she was experiencing any pain. The resident stated that he/she was not experiencing pain and the nurse then turned to the surveyor and informed the surveyor that since the resident wasn't experiencing pain it was OK. The nurse then stated that she would call the pharmacy and get the rest of the resident’s oxandrin dose and administer it to the resident when it was delivered to the facility by the pharmacy. When the surveyor inquired of the nurse what the oxandrin was being used for, the nurse stated that it is for pain and was unable to describe to the surveyor any side effects or drug-to-drug interactions for which the resident should be monitored. 17.1 Review of the clinical record for resident #19 revealed that the resident was admitted to the facility from the hospital on January 24, 2003 with diagnoses including necrotizing fasciitis, coronary artery disease, hypertension and atrial fibrillation. Review of the physician’s orders for resident #19 revealed the resident has been receiving coumadin [anticoagulant/bioug thinner] 2 mg. every day and oxandrin [anabolic steroid] 10 mg. two times a day since admission. Further review of the resident's medical record revealed there were no laboratory tests to monitor the resident’s blood values and no documentation that the facility was monitoring for potential serious drug-to-drug interactions and side effects. 17.2 During an interview on February 12, 2003 at approximately 1:00 p.m. the assistant director of nursing, when asked by the surveyor why the oxandrin was being administered to resident ‘#19 and what the action of the drug is when used with coumadin, indicated that he did not know. On February 13, 2003 at approximately 3:45 38 p.m., when asked by the surveyor why there were no laboratory tests to monitor blood clotting for resident #19, who was receiving coumadin, the assistant director of nursing told the surveyor that the physician usually picks up on that when he comes in and further told the surveyor that the physician had been in on January 29, 2003. The assistant director of nursing added that the facility would have picked up on it eventually because they always do labs for coumadin. When the surveyor asked him when the facility would have picked up on it, the assistant director of nursing was unable to answer. The assistant director of nursing also stated that he had just received some information about oxandrin from the pharmacy and would look at it as soon as he could. 17.3 During an interview on February 14, 2003 at approximately 8:50 a.m., the assistant director of nursing stated that he had reviewed the information about oxandrin and that he had a fax out to the doctor, indicating also that he planned to call and get a prothrombin time/international normalization ratio. A review of the information that the facility received from their pharmacy revealed that oxandrin, when given with anticoagulants, may increase the anticoagulant effect and this combination should be avoided if possible. Included under the section entitled “precautions” is “Edema’: indicating that edema, with or without congestive heart failure, may occur. 17.4 On February 14, 2003 at approximately 12:00 p.m. the assistant director of nursing informed the surveyor that he had just received the order for the prothrombin time/international normalization ratio for resident #19 and that he was getting the test performed right away. At approximately 2:00 p.m. the assistant director of nursing stated that the test results were high and that the doctor had ordered the facility to hold the coumadin for a couple of days. Review of the prothrombin time/international normalization ratio for resident #19 revealed that the prothrombin time is 54.9 [normal therapeutic range per the facility’s laboratory is 10.1-13.3] and the resident's international normalization ratio is 4.5 [normal therapeutic range is 2.0-3.0]. Review of the physician’s order dated February 14, 2003 revealed the following orders: (1) Hold coumadin today and Saturday; (2) On Sunday begin coumadin at 1 mg. less than current dose [2 mg.]; and (3) Repeat Protime on 2/20/03. 17.5 Review of the initial care plan for resident #19 dated January 24, 2003 revealed that the facility did not identify the resident to be at risk for any side effects due to the administration of coumadin and/or oxandrin and there are no approaches to monitor for those side effects and/or drug-to-drug interactions. Review of the medical record on February 14, 2003 revealed that the initial care plan is the only care plan that has been developed for resident #19, who was admitted on January 24, 2003. 17.6 Further review of the medical record for resident #19 revealed a physician’s order dated January 24, 2003 for percocet, 1 or 2 tablets every 6 hours as needed. Review of the medication administration record for February 2003 revealed that resident #19 is to receive 1 percocet for moderate pain and 2 percocet for severe pain every 6 hours as needed. Review of the resident’s clinical record revealed the only order for percocet was dated January 24, 2003 and did not include any parameters for severity of pain. 17.7 During interview on February 12, 2003 the assistant director of nursing confirmed that the only order for percocet for resident #19 was the one dated January 24, 2003. He stated that the nurses decided how much medication should be given (1 for moderate, 2 for severe] and wrote those directions on the medication administration record. When reminded by the surveyor that nurses cannot prescribe or determine dispensation of medication, the assistant director of nursing acknowledged that he knew that. 17.8 Review of the medication administration records for resident #19 revealed that there are no nurse's initials to document that the resident received any percocet in February, but review of the controlled drug record revealed that the resident received 2 40 percocet 3 times on February 1, 2003 [at 8 a.m., 2 p.m. and 6 p.m.] and one time on February 6, 2003 at 2 p.m. There is documentation on the back of the medication administration record for February 2003 that 2 percocet were administered on February 1, 2003 at 6 p.m., but there is no documentation for the other doses on February 1, 2003 or on February 6, 2003. Further review of the controlled drug record revealed that on February 1, 2003 the resident received 2 percocet at 2 p.m. and again, only 4 hours later at 6 p.m. 17.9 During an interview on February 12, 2003, the assistant director of nursing stated that the standard of practice for nurses is that they initial the medication administration record each time a medication is given and that a medication error form will need to be filled out because the medication was given in 4 hours instead of 6 hours as ordered. 17.10Review of the nurse’s notes revealed that only 1 note is written for February 1, 2003 at 1:00 p.m., which documents that resident #19 complained of discomfort and was given percocet as needed with good effectiveness. The note indicated that the resident had to be encouraged to take the percocet but later stated that it had helped a lot. There are no other nurse’s notes written on February 1, 2003. Nurse’s notes dated February 6, 2003 at 2:00 a.m. siate “resident is resting comfortably in bed, continue with antibiotic therapy. No signs of adverse reaction. Left PICC line a little difficult to flush at first; resident voiced no complaints of pain/discomfort’. The other nurse’s note dated February 6, 2003 documents, “Resident resting. Continue on antibiotic therapy vanco [vancomycin] via PICC line in left upper arm. Site without redness or swelling, flushes well. No adverse reaction to antibiotic therapy; wound vac therapy for coccyx wound. No complaints of pain voiced”. __ 17.11 After reviewing the medical record for resident #19 the assistant director of nursing was unable to locate any other documentation for the percocet given at 8 a.m., 2 41 p.m. and 6 p.m. on February 1, 2003 and stated that he guessed the 8 a.m. dose is the dose referred to in the nurse’s notes written at 1 p.m. He was unable to locate any documentation for the percocet given on February 6, 2003 and was unable to explain why the resident would be given pain medication when the nurse’s notes for that date document that the resident had no pain. The assistant director of nursing confirmed that a nurse doesn’t give pain medication when a resident doesn’t have any pain. 17.12Review of nurse’s notes dated February 11, 2003 revealed that resident #19 has 4+ edema in bilateral hands and forearms and has some shortness of breath and difficulty breathing. A chest x-ray done on February 11, 2003 documents that the resident has a pieural effusion. Review of the physician’s orders for resident #19 revealed an order dated February 11, 2003 for lasix (diuretic used to reduce edema] 40 mg by mouth today [2/11/03] and another order dated February 12, 2003 to continue lasix 20 mg. by mouth every day. Review of the medication administration record for resident #19 revealed that he/she received lasix 40 mg. on February 11, 2003. A line is drawn from February 1, 2003 through February 12, 2003 indicating that lasix 20 mg. is to be started on February 13, 2003 instead of February 12, 2003 as ordered. Review of the medication administration record on February 14, 2003 revealed that the lasix was not initialed as given on February 12, 2003. 18. Review of the medical record for resident #14 revealed the resident is receiving zinc oxide to excoriated buttocks and skin preparation to heels every shift. There is also an order for the resident to wear heel booties in bed when needed. 18.1 Observation on February 11, 2003 at approximately 9:15 a.m. revealed resident #14’s coccyx area is reddened and has 2 small open areas. The resident’s heels are both red but the left heel is a dark red color and soft. The resident stated, “Oh, my, yes, they are very sore”. 18.2 During an interview on February 11, 2003 at approximately 10:15 a.m., the facility's wound care nurse stated, “I've got this neat new thing to use for his/her heels. It will float his/her heets off the bed. He/she refused the heel booties”. When the surveyor asked the wound care nurse why there was no documentation in the medical record to describe the condition of the resident’s heels and the resident's refusal to wear the heel booties, the nurse said that she did not know. 18.3 At approximately 2:00 p.m. on February 11, 2003 the director of nurses confirmed that she was unable to locate any documentation on the condition of resident #14’s heels and stated that she didn’t know why staff did not contact the physician to obtain alternate orders when the resident refused to wear the heel booties. 19. Review of the medical record for resident #28 revealed he/she was readmitted to the facility on October 25, 2002 after having a subdural hemorrhage. Other diagnoses included hypertension, dementia and psychosis. Review of the physician orders revealed an order dated November 8, 2002 for seroquel 25 mg. three times a day; hold if drowsy. Review of the facility's nursing 2000 drug handbook revealed that seroquel is used for management of psychotic disorders and side effects include somnolence [sleepiness]. 19.1. Review of the resident’s medication administration records revealed that seroquel was held 18 times in November 2002, 17 times in December 2002 and 8 times in January 2003. 19.2. A pharmacy consultant report dated December 2002 asks the physician to please note seroquel has been held due to the resident being sleepy and requests that the physician evaluate the current dose [25 mg. three times a day] to determine if to “reduce seroquel to 25 mg. twice a day and to notify the physician if the resident becomes more agitated. 19.3. Review of the medical record revealed that there is no documentation that facility staff informed the physician that the seroquel was held on numerous occasions for 3 months due to resident #28 being sleepy. 19.4. Review of the nurse’s notes revealed numerous entries indicating that the seroquel was held because resident #28 was sleepy/lethargic and one nurse’s note dated December 30, 2002 documents that a 12:00 a.m. bolus was administered due to the resident having slept through dinner. 19.5. A physician’s order dated December 18, 2002 specifies that resident #28 is to receive a bolus tube feeding of Novasource if he/she eats less than 50% of his/her meal. 19.6. The assistant director of nursing was unable to explain why the nurses had not notified the physician of the need to hold the seroquel so many times and confirmed that they should have notified the physician. 19.7. Review of the physician’s orders for resident #28 revealed that vasotec 10 mg. every 12 hours was discontinued on October 31, 2002. Review of the medication administration record for November 2002 revealed that the resident received the medication twice a day on November 1, 2002 through November 3, 2002 and one time on November 4, 2002. Further review of the November medication administration record revealed that catapres TTS 3 is circled as not given on November 11, 2002. The nurse documented on the back of the medication administration record that a catapres patch was ordered. There is no documentation that resident #28 received the catapres until November 19, 2002. -19.8... Review. of..a_physician’s. telephone orders._for resident #28 dated _ November 8, 2002 revealed the following orders: (1) seroquel 25 mg. three times a day; 44 hold if drowsy; (2) ambien 5mg. every night; (3) Please get Dr.___— OK for above orders. A nurse has written on the side of this order, “OK’d by Dr. ____”, but there is no documentation that the facility called Dr. ___. +=The assistant director of nursing confirmed that this was not the appropriate method of documentation. After reviewing the resident’s clinical record, the assistant director of nursing confirmed that he could find no documentation that Dr.___—shad been called to OK the orders. 19.9. Review of the intake and output sheets for resident #28, who was receiving tube feedings of 1 % cans of fibersource HN five times a day with a 75 cc. Flush of water before and after each tube feeding, revealed that from admission on October 24, 2002 through October 31, 2002, 16 of 21 shifts were blank and 39 of 90 shifts in November were blank with no documentation of the amount of tube feeding intake. The column for documenting the amount of flushes also had blanks and staff did not document the amount of fluid that the resident received. In addition, the resident received a flush of 50 cc. water before and after medications and this flush is not consistently documented. 20. Observation of the medication pass on February 10, 2003 at approximately 9:00 a.m. revealed that the nurse entered resident #43’s room to administer medications. The nurse was observed to insert a 60 cc. catheter tip syringe into the resident’s gastrostomy tube and pour in 60 cc. of water. She then poured 20 cc. of water mixed with the resident's medication and added 60 cc. of water after the medication mixture. The nurse did not check placement of the gastrostomy tube by inserting air while listening to the resident’s abdomen and did not aspirate to check for residual. The nurse did not check the resident's blood pressure before administering vasotec 2.5 mg. 20.1 Review of the physician’s orders for resident #43 revealed an order to hold -_ vasotec for systolic blood pressure below 100. Review of the resident's February 2003, medication administration record revealed the resident’s blood pressure is not 45 documented. After speaking with the surveyor the nurse added “BP’ to the space under the vasotec and drew a line to indicate that the resident's blood pressure is to be checked at 6 p.m. on February 10, 2003. 20.2 The nurse told the surveyor that she didn’t check resident #43’s blood pressure, explaining that she hadn’t seen the physician’s orders. She checked the resident’s blood pressure when the resident returned from therapy and it was 95/69. The nurse commented that the reading was “a little low’. 21, At approximately 9:15 a.m. the nurse entered resident #44’s room to administer medications. ‘The nurse disconnected the resident's tube feeding and inserted a 60 cc. catheter tip syringe into the tube. The nurse poured 50 cc. of water into the gastrostomy tube, then poured in the crushed medications mixed in 15 cc. of water. She put in an additional 10 cc. of water and poured the liquid medication in. The nurse then put in 250 cc. of water and informed the surveyor that the resident gets a 250 cc. flush. The nurse did not check the placement of the gastrostomy tube. 21.1 Review of the facility's 2001 Heaton policy and procedure for “medication administration via feeding tubes” revealed the nurse is to “verify tube placement by forcefully injecting air into tube while listening to the abdomen with stethoscope for a bubbling sound”. 22. Observation of resident #15 on February 12, 2003 at approximately 8:30 a.m. revealed that he/she was in pain. The resident stated that he/she had an ulcer before and thinks it is coming back. A review of the resident's clinical record revealed that on December 22, 2002 the physician ordered 1-2 percocet tablets every 3 hours as needed for pain. This was ordered with no parameters from the physician. 22.1 On the February 2003 medication administration record, the nurse set parameters to administer 1 or 2 percocet-5/325 mg. for pain. The facility staff did not contact the resident’s physician to determine parameters for use. 46 23. Review of resident #2's February 2003 medication administration record on February 10, 2003 revealed that the nursing staff was providing water flushes of 175 cc. every 4 hours via the gastrostomy tube. 23.1 Review of the physician’s orders for resident #2 revealed that the resident was currently prescribed on December 11, 2002 to receive a flush of 125 cc. every 4 hours. No order was found in the resident's clinical record to increase the flushes to 175 cc. every 4 hours. 23.2 Review of the registered dietician’s progress notes dated February 7, 2003 indicated that resident #2 had an elevated blood urea nitrogen to creatinine ratio, which could be indicative of not receiving adequate fluids. The registered dietician recommended increasing the water flushes with the tube feeding to 175 cc. every 4 hours. Her note documented the need to discuss with the resident's physician before requesting the change. 23.3 An interview with the medication nurse on February 11, 2003 at 12:56 p.m. revealed that she had increased the fluid flushes to 175 cc. every 4 hours after the registered dietician recommended the change. The nurse stated that she had changed the medication administration record to reflect the change and had gotten a telephone oraer from the resident’s physician to increase the flushes. She stated that she remembered faxing the lab results to the physician. Review of the physician telephone orders with the nurse revealed that she had not documented the order in the medical record and had just changed the medication administration record. The nurse acknowledged to the surveyor that she had forgotten to write down the order and that it was her error. The nurse then, in the presence of the surveyor, proceeded to change the medication administration record to reflect 125 cc. every 4 hours without following proper procedures for making a late entry and correction. Next, the nurse wrote a__ 47 telephone order that she dated February 6, 2003 to increase the water flush to 175 cc. every 4 hours. The nurse did not date the order as a late entry. 23.4 Review of the record on February 11, 2003 at 2:15 p.m. with the assistant director of nursing revealed that someone had taken the carbon copy of the order that the nurse wrote earlier regarding the flush and wrote “2/11/03” in pen below the 2/6/03 date on the telephone order. The assistant director of nursing stated that he would investigate who had done this. He stated that the nurse had documented the telephone order incorrectly and that she should have done a correction order, not an entry with the date that she thought she got the order from the physician. He further stated that the process is to have the registered dietician get the order for her recommendation from the physician and the nurse then implements the order. He stated that he would follow up with the nurse who had not followed proper documentation procedures. 23.5 Further review of the clinical record the next day revealed that the above order had been removed from the medical record and a new telephone order was entered into the record that was dated 2/6/03. The “6” was written over with an “4 1”. It was noted “error for 2/6”. A new telephone order was written below that was dated “2/11/03”, “Flush peg tube with 175 cc. every 4 hours with water’. 23.6 Review of the medication administration record revealed the order was documented on 2/11/03 and started on 2/12/03 to provide the 175 cc. flush every four hours. 24. Observation of resident #2’s tube feeding bag on February 10, 2003 at 10:20 a.m. revealed that it was on open system and the bag was dated 2/9/03 at 5:30 a.m. Further observation of the resident's tube feeding bag on February 11, 2003 at 12:11 p.m. revealed the same bag dated 2/9/03. 48 24.1 An interview with the registered dietician on February 11, 2003 at 12:32 p.m, revealed that the tube-feeding bag with an open system should be changed every day to prevent infection and contamination of the tube-feeding formula. 24.2 An interview with the resident #2’s nurse on February 11, 2003 at 12:56 p.m. revealed that the 11 p.m. to 7 a.m. shift is supposed to change the tube-feeding bag. The nurse further stated that if she sees formula in it in the morning, she doesn't check it to see if it has been changed. She stated that she would change it today after it was brought to her attention. 25. During tour on February 9, 2003 at approximately 5:00 p.m. a surveyor observed resident #12 with two black eyes. 25.1. At 5:08 p.m. the surveyor, after knocking and being invited into the room by resident #12’s spouse, observed the resident had two grossly blackened eyes. The left eye was noted to be swollen shut. The surveyor asked the spouse what had happened. The spouse stated that the resident had fallen twice in the past two days, once on February 8, 2003 and again on February 9, 2003. The surveyor inquired of the spouse whether the resident had fallen previously and the spouse indicated that the resident had fallen several times since being admitted to the facility. The surveyor asked the spouse whether the resident had ever sustained injuries from the falls and the spouse indicated that the resident had stitches on several occasions. The spouse appeared nervous to the surveyor and told the surveyor that he/she did not want to be seen talking to the surveyor because he/she knows that they take it out on the residents. The spouse then began to cry and said that he/she wished that the facility had done something to treat the resident's injuries, if only to apply ice bags. 25.2. On February 12, 2003 at approximately 9:15 a.m. a surveyor interviewed __.the Alzheimer's 7-3 charge nurse and inquired about the residents and their falis. The charge nurse indicated that resident #12 had a long history of falls. The charge nurse 49 was asked about the unit’s process for notifying the physician about an injury. The charge nurse indicated that you call the physician and then fax a report to the physician’s office. 25.3. The charge nurse was informed by the surveyor that based upon record review it appeared that the attending physician was not notified of the injuries sustained by resident #12 on February 8 and 9, 2003 and that the facility had only faxed injury reports to the physician’s office. The charge nurse indicated that she was aware that the physician had been called on February 8 and 9, 2003 and stated that she was not aware that the phone calls had not been documented in the clinical record. 25.4. Ina later interview on February 12, 2003 at approximately 10:35 a.m., the charge nurse stated that she knew that the nurse on February 8, 2003 had called the physician and that she thought that the nurse on February 9, 2003 had called the physician. 25.5. A telephone interview was conducted on February 12, 2003 at 1:30 p.m. with the nurse who worked when resident #12 fell on February 8, 2003. When asked to whom she had reported the fall, the nurse indicated that she had reported the fall to the 7-3 shift nurse. When asked if she had reported the fall to the supervisor, she indicated that she had not because it wasn't necessary since there was no 11-7 shift supervisor. The nurse told the surveyor that she had called the physician’s answering service and was told to fax the report to the physician’s office. 25.6. On February 12, 2003 at approximately 2:05 p.m. a telephone interview was conducted with the nurse who had worked on February 9, 2003 when resident #12 fell. The nurse stated that the resident was found on the floor. She indicated that the resident has a slight increase in edema and further indicated that this information was faxed to the physician. Additionally it was put on the 24 hour nurse's report for the 7-3 | shift. When asked, as an agency nurse, if she was aware of the facility's policy and 50 procedure for reporting falls, she told the surveyor that she had never received the policy and procedure on fails. The nurse indicated that the 3-11 nurse had informed her that “back here we just fax fall reports to the physician. If you call the answering service, they will just tell you to fax the report to the office”. 25.7. A telephone interview with the answering service was conducted on February 12, 2003 at approximately 6:15 p.m. and revealed that there were no telephone calls from the facility reporting resident #12’s injury to the attending physician on either February 8, 2003 or on February 9, 2003 between the hours of 6:30 a.m. to . 7:30 a.m. A further clarifying telephone call made to the answering service on February 14, 2003 revealed that there were no telephone calls received from the facility reporting resident #12’s injury to the physician on either date. 25.8. A telephone call to the attending physician on February 13, 2003 at approximately 10:00 a.m. revealed that he knew about the fall from a facsimile dated February 8, 2003. The physician indicated that he did not believe he received a facsimile on February 9, 2003. The physician stated that he did not know about the falls on February 8 and 9, 2003 until February 10, 2003. He indicated that he was not on call during the weekend. 25.9. The facility nursing staff failed to notify the physician that a resident had fallen twice. 25.10. A computerized tomography scan of resident #12’s face on February 11, 2003 initially diagnosed the resident with an “acute fracture of the anterior wall of the left maxillary antrum”. A subsequent entry in the resident’s clinical record by a consulting maxillary facial surgeon on February 11, 2003 indicated there was no fracture of the maxillary antrum. A telephone interview with the surgeon on February 13, 2003 at radiologists and it was determined that the maxillary antrum was not fractured. The 31 Surgeon noted that there was a very small, non-displaced fracture of the nose and informed the surveyor that no treatment was indicated. 25.11. On February 12, 2003 the charge nurse, at approximately 9:30 a.m. was asked who was the nurse in charge of the facility over the weekend. The charge nurse indicated that the staff development nurse was in charge of nursing services over the weekend. 25.12. In an interview with the staff development nurse on February 12, 2003 at approximately 10:10 a.m., the nurse was asked if she had been notified about the resident's falls on February 8 and 9, 2003 by staff on the Alzheimer’s unit. The staff development nurse indicated that staff on the unit had not notified her. The staff development nurse indicated that she had made rounds in the unit on Monday morning and saw the resident for the first time since the falls. The nurse said that she asked another person on the unit what had happened to resident #12. The staff development nurse stated that personnel on the Alzheimer’s unit about the falls should have contacted her. 25.13. The staff development nurse, as charge nurse of the facility over the weekend was not informed of the resident’s condition by staff of the Alzheimer’s unit as required. 25.14. Resident #12 was on restorative nursing to (1) maintain and improve ambulation ability and endurance and (2) to maintain and improve lower extremities strength. The plan was for the resident to be able to ambulate 100 feet with no assistive device with supervision. The resident during January 2003 was ambulated through January 26, 2003 when the resident had two seizures. After this date there is no documentation that the resident received restorative ambulation. 25.15. In an interview on February 12, 2003 at approximately 9:45 a.m., the _ restorative nurse was asked by the surveyor why the restorative program for resident 52 #12 was discontinued on January 26, 2003. The nurse told the surveyor that the resident was Baker-Acted on that date. The nurse then went through the resident’s chart and discovered that resident #12 had not been Baker-Acted on that date. The nurse then told the surveyor that she had no idea why the restorative program had been discontinued for resident #12. 25.16. There were no orders in resident #12’s record to discontinue restorative ambulation for the resident. 25.17. During record review and interview it was determined that resident #12 had a history of falls and other incidents. 25.18. On November 23, 2002 resident #12 was transferred out of the facility under a Baker Act transfer. The resident was readmitted to the facility on November 26, 2002. A new minimum data sheet and care plan were developed for the resident following readmission to the facility. The assessment reference date for the minimum data sheet was December 1, 2002. The resident was assessed under the heading “Section B” “Cognitive Patterns” as having both long and short term memory loss, only recalling staff names/faces and being moderately impaired in decision-making. The resident's cognitive status was noted to have deteriorated since the last minimum data sheet assessment. Resident #12 was assessed under the heading “Section |” Disease Diagnoses” as having Alzheimer's disease, dementia other than Alzheimer's, seizure disorder and anxiety disorder. Under the heading “Section J’’Health Conditions’ the resident was assessed as having fallen within the last 30 days. 25.19. The facility completed a fall risk assessment form on November 26, 2002 for resident #12, which indicated that the resident has a seizure disorder and unsteady gait, has impaired vision due to wearing eyeglasses and has psychiatric/cognitive issues due to Alzheimer’s and dementia. Interventions suggested on the fall risk assessment to __ be care-planned for residents with these risks included but were not limited to: 53 restorative ambulation, chair/bed alarm, regular monitor and monitoring during shift change. 25.20. Intervention care-planned on December 10, 2002 under the heading “Activities of Daily Living” “Problems and Strengths’ reflects that resident #12 ambulates independently but is dependent on staff for wheelchair, that the resident’s gait is unsteady at times and that the resident sustained a recent fall [11/28/02] without injury. The enunciated Goal was that the resident have no fall-related injuries through the next 30 days. The enunciated Approaches included transporting the resident off the unit in his/her wheelchair and monitoring the resident for any change in his/her gait and/or balance and documenting the same. 25.21. The facility failed to take into consideration previous falls, seizures and injuries that resident #12 had sustained from the September 2002 admission. The facility did not use any chair/bed alarms for the resident. 25.22. On December 18, 2002 the care plan for resident #12 was updated. The problem identified was that the resident occasionally declined to sleep in bed and instead sleeps on the couch in the day room, often falling off the sofa. The only intervention identified was to attempt to redirect the resident back to bed. 25.23. The care plan dated December 10, 2002 for resident #12 indicated under the heading “Psychotropic Drug” that resident #12 was taking an antipsychotic [risperdal], an antidepressant [remeron] and an anxiolytic [ativan]. Commonly known side effects of these medications include but are not limited to falls and orthostatic hypotension [low blood pressure that can cause fainting/dizziness when rising too quickly from a sitting or prone position]. The enunciated goal was for the resident to have no complications from the use of psychotropic medications as evidenced by no side effects noted on lowest therapeutic dose through the next 30 days. The enunciated _ approach was to monitor the resident for side effects from anti-anxiety and to document 34 and notify the physician [i.e., agitation, insomnia, unsteady gait, disorientation, depression, hypotension, unusual disturbances and elevated liver function results] and to monitor the resident for side effects of anti-depressants and to document and notify the physician [i.e., dizziness, tremors, edema, nausea]. 25.24. There were no interventions to prevent injuries due to falls or injuries resulting from seizures from December 10, 2002 until after the entry of the survey team into the facility on February 9, 2003 and surveyor review of the resident’s record on February 10, 2003 for obvious injuries that resulted in resident #12 having sustained two grossly blackened eyes, a bruised forehead and a left eye that was swollen shut on the survey team’s initial tour of the facility at 5:00 p.m. on February 9, 2003. 25.25, After surveyors selected resident #12 for record review on February 9, 2003 the facility updated the resident's care plan on February 10, 2003. New problems identified were the resident’s fall related to his/her unsteady gait. The enunciated goal was to prevent the resident from falling with nursing interventions. The enunciated approaches included monitoring the progress of the resident's strengths and weaknesses; keeping the resident near staff for purposes of observation; using a pressure monitor in resident's wheelchair and in bed: checking safety equipment to ensure proper functioning; monitoring the resident’s medications relating to his/her fall potential; and keeping the resident occupied in activities and redirecting the resident. 25.26. After resident #12 fell again on February 10, 2003 the resident's care plan was updated to include another problem, identified as the resident having fallen related to the resident continuing to stand with an unsteady gait. The enunciated goal was for the resident to avoid any fall with injuries for the next 30 days and the new approaches included therapy to screen as ordered [occupational therapy and physical therapy] and a soft clip belt/soft waist restraint as ordered. ee ee 5s 25.27. The professional staff failed to aggressively intervene with measures to assure that resident #12 attained or maintained his/her highest practicable level to prevent or decrease the number of times the resident fell from the time of readmission on November 26, 2002 until the survey team selected the resident for review on February 9, 2003. After the survey team selected the resident for review on February 9, 2003 the resident fell again on February 10, 2003 and on February 11, 2003. 26. Resident #16 was admitted to the facility on September 12, 2002. Pertinent diagnoses include but are not limited to congestive heart failure, coronary artery disease, peripheral vascular disease and renal insufficiency. 26.1. Record review on February 12, 2003 revealed that resident #16 had a physician’s order to restrict fluids to 2 quarts/24 hours [64 oz. Times 30 cc’s/oz equais 1920 cc’s per 24 hours]. 26.2. A dietary note in resident #16’s record divided the fluid as follows: Dietary to supply 360 cc’s at breakfast on food tray, 600 cc’s at lunch on food tray, and 600 cc’s at dinner on food tray for a total of 1560 cc’s per day. Nursing was allocated 360 ccs of fluid for medication pass per day. 26,3. Resident #16 had recent laboratory test results that indicated that the blood urea nitrogen [BUN] was elevated at 65 mg/dl. The reference range was 9 — 20 mg/di. The resident’s creatinine was elevated at 1.8 mg/di. The reference range was 0.8 — 1.5 mg/dl. The laboratory results are indicative of dehydration. 26.4. A request was made to resident #16’s physician on January 24, 2003 to liberalize the fluid restriction. The physician indicated that the fluid restrictions were to remain at 1920 ccs per day. Staff was instructed to assure/encourage the resident to drink all the fluids supplied with meals. 26.5. During record review on February 12, 2003 it was verified by the consulting dietician that the resident was on a fluid restriction of 1920 ccs per day. 36 26.6. On February 14, 2003 at approximately 11:35 a.m. a surveyor went to visit resident #16 in his/her room. The resident was not present. The surveyor, with the assistance of a staff nurse, verified the location of the resident’s bed. Beside the bed was an over the bed table with a pitcher of water and two four-ounce plastic glasses. The water pitcher was estimated to contain nearly a quart [32 ounces times 30 cc's equals 960 cc’s] or 960 ccs of water. One of the 4 ounce cups contained about 2 ounces of water. The nurse verified that the water pitcher was almost full. 26.7. The surveyor asked the staff nurse whether she was aware that resident #16 was on any fluid restriction. The nurse told the Surveyor that she was not sure and stated that usually there is a sign posted when a resident is on fluid restriction. There was no sign posted in the room indicating that resident #16 was on fluid restriction. 26.8. At approximately 11:38 a.m. a surveyor spoke with the assistant director of nursing/unit manager about resident #16. The clinical record for the resident was pulled and it was verified that the resident was on a fluid restriction of 1920 cc’s/24 hours. 26.9. The assistant director of nursing told the surveyor that he was not aware that resident #16 had water in his/her room and stated that he would have it removed. The surveyor informed the assistant director of nursing that the resident was to receive only 360 ccs of fluids from nursing for medication passes. The assistant director of nursing told the surveyor that he was aware that the system was broken and stated that he is trying to fix it. 26.10. Professional staff failed to ensure that physician’s orders for fluid restrictions were honored as to resident #16. 27. Review of the physician’s telephone orders for resident #9, dated January 27, 2003, [container] every 4 hours with a flush of 150 cc of water before and after feedings. 57 27.1. Further review of the physician’s telephone orders for resident #9 revealed that on January 29, 2003 the registered dietician had requested a decrease of the fluid flushes to 125 cc before and after each feeding because the resident’s current fluid intake exceeded the resident's estimated needs of 35cc/kg. The physician declined the recommendations and wrote to continue the flush at 150 cc before and after meals. 27.2. Review of the February 2003 medication administration record revealed that the nurses had rewritten the orders on February 3, 2003 at 8:00 a.m. to provide the Novasource 2.0 every 4 hours and flush with 125 cc of water before and after each bolus feeding. 27.3. During an interview with the nurse caring for resident #9 on February 11, 2003 at 1:30 p.m. she confirmed that she was providing 125 cc. of flush before and after each bolus feeding. She stated that she was unaware that this did not agree with the physician’s orders. The order was reviewed with the nurse, who admitted that the Surveyor was correct and that the 125 cc flush was wrong. The nurse told the surveyor that she would check with the assistant director of nursing/unit manager to get the order corrected and changed on the medication administration record. 27.4. After surveyor intervention on February 11, 2003 the medication administration record for resident #9 was changed to read “Flush G-Tube with 150 cc water before and after each bolus”. 28. Based on all of the foregoing, VENICE REHAB AND HEALTH CENTER violated: (a) 42 CFR 483.25 via Rule 59A-4.1288, Florida Administrative Code, 42 CFR 483.20(k)(3)(i) and 400.022(1}(6), Florida Statutes (2002) by jeopardizing the health, life and Safety of 7 residents [residents #2, #9, #12, #14, #15, #16 and #19] of 21 active sampled residents, 1 resident [resident #28] of 5 extended sample and 2 random samples [residents #43 and #44] by failing to facility having jeopardized resident #19 by failing to ensure that nursing staff were 58 knowledgeable of the drug-to-drug interactions of oxandrin when given concurrently with coumadin, by failing to contact the resident's physician to determine parameters for pain medication, by failing to follow procedures for documentation of administration of medications and by failing to follow physician’s orders to administer lasix, all of which exposed the resident to potential life-threatening harm; (2) the facility having jeopardized resident #14 by failing to monitor and document the condition of the resident's left heel, which was observed to be dark red and soft/boggy and the right hee! which was observed to be dark red and by failing to notify the resident's physician when the resident refused treatment, all of which exposed the resident to potential life-threatening harm; (3) the facility having jeopardized resident #28 by failing to notify the resident's physician when nurses held the resident’s seroquel because the resident was drowsy and lethargic, by continuing to administer vasotec for 4 days after the physician had discontinued the medication, by failing to follow proper procedure for documentation of medication administration and by failing to document the amount of tube feedings and flushes, all of which exposed the resident to potential life-threatening harm; (4) the facility having jeopardized residents #43 and #44 by failing to check placement of their gastronomy tubes before administering medications and flushes and by failing to follow physician's orders to check the blood pressure of resident #43 before administering vasotec, all of which exposed the residents to potential life-threatening harm; (5) the facility having jeopardized resident #15 by failing to contact the resident's physician to determine parameters for pain medication [percocet], which exposed the resident to potential life-threatening harm; (6) the facility having jeopardized resident #2 by failing to follow physician orders for tube feeding flushes, by failing to follow proper procedures for entering late entries and by failing to follow infection control procedures for changing open tube feeding bags daily, all of which exposed the resident to potential life-threatening harm; (7) the facility having jeopardized resident #12 by the failure of the professional staff to inform the attending physician of a resident's fall/injury ina timely _ fashion by calling the physician or the physician’s answering service, by the failure of 59 professional staff to assess and care pian resident #12 for preventive measures to decrease falls for a resident with a known long history of falls, injuries and seizure disorder; and by failing to ensure that resident #12, who was on restorative ambulation was ambulated, all of which exposed the resident to potential life-threatening harm; and (8) the facility having jeopardized resident #16, who was on a fluid restriction, by failing to ensure that the resident received only the amount of fluid ordered by the attending physician, which exposed the resident to potential life-threatening harm and (9) the facility having jeopardized resident #9 by failing to follow physician’s orders for tube feeding flushes, which exposed the resident to potential life- threatening harm. 29. Pursuant to Section 400.23(8)(a), Florida Statutes, the foregoing is a class | deficiency because it is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. 29.1. AHCA gave VENICE REHAB AND HEALTH CENTER a written mandated correction date of February 15, 2003, in accordance with Section 400.23(8)(a), Florida Statutes. THIRD CLASS Il DEFICIENCY 30. In the course of the off-hours annual health licensure and recertification survey conducted by AHCA on or about February 9-14, 2003, at VENICE REHAB AND HEALTH CENTER, AHCA cited VENICE REHAB AND HEALTH CENTER for a third class | deficiency on the basis that based on observation, review of clinical records, facility policies, protocols and procedures and interview with corporate, administrative, nursing, dietary and pharmacy staff, practicable status for 10 (residents #1, #4, #8, #11, #12, #14, #16, #18, #19, #21 and #29] 60 active sampled residents and 1 [resident #30] extended sampled resident from an initial sample of 24 with 8 extended residents for a total of 32 residents, as well as 11 random sampled residents [residents #33, #34, #35, #36, #37, #38, #39, #40, #41, #42 and #47}. Asystem failure was demonstrated by a lack of coordination of services between departments and the absence of policies and procedures in the facility that the staff could utilize to provide the highest quality of care. This resulted in the facility jeopardizing the health and safety of residents as evidenced by: 1) The facility jeopardized Resident's #12 ability to reach his highest practicable functioning level by failing to revise the resident's care plan to include aggressive measures to prevent or decrease the number of times the resident fell. 2) The facility failed to complete a comprehensive assessment and plan of care to provide the highest practicable physical well-being and failed to coordinated approach between the Hospice staff, nursing and dietary for Resident #11 as evidenced by the resident's significant weight loss, and areas of skin breakdown, without new approaches or interventions to the care plan which was initiated by dietary on 6/5/02. 3) The facility did not have a policy and protocol for the nursing and nutrition staff to follow to ensure that resident's on TPN received the appropriate intravenous solution in accordance with physician orders and did not have a standardized panel of labs and a protocol to monitor resident tolerance to TPN. There was no coordinated system between the priarmacy, the physician's office, the Consultant Dietitian and the nursing staff to ensure that the correct TPN solution was provided and monitored as ordered. This affected Resident #18 who received the incorrect TPN solution for 3 weeks after admission and had no ongoing lab data to monitor her tolerance to TPN resulting in weight loss and abnormal laboratory data which affected her highest practicable physical status. 4) The facility did not have a coordinated system in place to ensure that fluid restrictions were provided as ordered, documented accurately and monitored by the administrative nursing and nutrition staff. This affected Residents #14, #16, #21 and #30 who received excessive fluids that did notcomplywith physician orders. 5) The facility did not have a system in place to ensure that Minimum Data 61 Sets (MDS) were completed with Resident Assessment Protocols (RAPS) before completing the final care planning process. Lack of completion of the MDS's resulted in the care plans being incomplete or not reflecting the current status of the residents. The MDS Coordinator did not have the resources to complete the MDS's and was not attending care planning meetings and providing input on current resident data to meet the residents highest practicable needs. This affected Residents #4, #8, #14, #16, #29 and #33 through #42. 6) The facility did not have a coordinated system with the pharmacy to ensure that medications were ordered and delivered in a timely manner so that medications were available when the residents needed them. The facility failed to provide staff with pharmacy policies and procedures to ensure that staff provided quality of care to the residents. The staff was not aware of the pharmacy policies and procedure for ordering medications or how to handle IV tubing. This affected Residents #18, #19 and #47 who did not receive medications in a timely manner and Resident #29, who had a compromised immune system, was placed at risk for infection due to the staff's lack of knowledge of IV policies. 7) The corporation did not ensure that a cohesive set of policies and procedures were in place in the facility that was tailored to meet the specific needs of the facility. Two sets of policy and procedure manuals were in Place at the same time and staff was unsure of which policy and procedure was in effect at the time of the survey. The findings include: 31. Resident #12 was originally admitted in September 2002. On 9/12/02 at approximately 7:00 A.M., the resident "fell to floor with (with symbol) jerky movement & all body movement with seizure like activities lasts 15 seconds pt (patient) hit head sustained abrasion back, arm, and head." The resident was transferred to a local hospital and admitted. The resident was readmitted to the facility on 9/16/02. 31.1. From the time of readmission on 9/1 6/02 until 2/11/03 the resident had seizure, falls or both on at least nine (9) occasions. The resident was transported to a local hospital on 9/27/02 for sutures as a result of a seizure. The residentwas a i transported to a local hospital on 1/7/03 for stitches after a fall. On 1/26/03 the resident 62 had 2 seizures. The second seizure resulted in a laceration to the forehead, which was closed with a steri-strip. On 2/8/03 and 2/9/03, the resident fell sustaining blackened eyes. The resuits from a Facial Computerized Tomography (CT) scan initially reported a fractured Maxillary Antrum. Later reading of the CT scan revealed that the Maxillary Antrum was not fractured. However, telephone interview with the Maxillary Facial Surgeon revealed the resident has a non-displaced nose fracture, which requires no additional treatment. 31.2. On 11/23/02, the resident was transferred out of the facility under a Baker Act transfer. The resident was readmitted to the facility on 11/26/02. A new MDS (Minimum Data Set) and care plan were developed for the resident. The assessment reference date for the MDS was 12/1/02. The resident was assessed in Section B. Cognitive Patterns as having both long and short-term memory loss, only recalling staff names/faces, and being moderately impaired in decision making. The resident cognitive status was noted to have declined since the last MDS assessment. The resident is assessed in Section |. Disease Diagnoses as having Alzheimer's disease, Dementia other than Alzheimer's, Seizure Disorder, and Anxiety Disorder. In Section J. Health Conditions the resident was assessed as having fallen within the last 30 days. 31.3. The facility completed a Fall Risk Assessment Form for the resident, which indicated the resident has a seizure disorder and unsteady gate, has impaired vision due to wearing glasses, and has Psychiatric/Cognitive issues due to Alzheimer's and Dementia. Interventions suggested on the Fall Risk Assessment to be Care Planned for residents with these risks included but are not limited to: Restorative Ambulation, Chair/bed alarm, regular monitor, and monitoring during shift change. 31.4. Interventions care planned on 12/10/02 included but were not limited to in but is dep (dependent) on staff for w/c (wheelchair). ... gait is unsteady at times. He has 63 had a recent fall (11/28/02) w/o (without) injury." The Goal was the resident "will have no fall related injuries through NRD (next review date)." The Approaches included, "22. Transport off unit in w/c (wheelchair). 23. Monitor for change (Delta symbol) in gait/balance and document.” 31.5. The facility failed to take into consideration previous falls, seizures, and injuries, which the resident had sustained from the September 2002 admission. 31.6. On 12/18/02, the resident's Care Plan was updated. The Problem identified was "Resident occ (occasionally) declines to sleep in bed and will sleep on the couch in the day room. Hx(history) of falls off sofa. The only intervention was to “attempt to redirect back to bed.” 31.7. The 12/10/02, Care Plan for Psychotropic Drug included /noted the resident was on an antipsychotic (Risperdal), Antidepressant (Remeron), and an Anxiolytic (Ativan). Commonly known side effects of these medications include but are not limited to Falls and Orthostatic Hypotension (low blood pressure which can cause fainting/dizziness when rising too quickly from a sitting or prone position). The Goal was for the resident to have "no complications from the use of psychotropic meds(medications) as evidenced by no side effects noted on lowest therapeutic dose through NRD(next review date). The Approach was "2. monitor for side effects from anti-anxiety-document & notify MD (i.e. agitation, insomnia, unsteady, disoriented, depression, hypotension, unusual disturbances, and liver function results). 3. Monitor for side effects of anti-depressants - document and notify MD (i.e. dizziness, tremors, edema, nausea...).” 31.8. There were no new interventions to prevent injuries due to falls or injuries resulting from seizures from 12/10/02 until after the survey team’s entry into the facility 64 which resulted in the resident having two (2) black eyes, a bruised forehead, and a left eye which was swollen shut on initial tour of the facility at 5:00 P.M. 31.9. After surveyors selected the resident for record review on 2/9/03 the facility updated the resident's care plan on 2/10/03. New Problems identified were "Fall R/T (related to) unsteady gait." The goal was the "resident will not fall with nursing interventions." The Approaches included, 1. Monitor progress of strengths and weaknesses. 2. Keep resident near staff to observe. 3. Use pressure monitor in wheel chair and bed. 4. Ck (check) safety equipment for good functions. 5. Monitor medications relating to fall potential. 6. Keep resident in activities and redirect. 31.10. After the resident fell again on 2/10/03, the following additional problem was identified and the care plan was updated to include, "Fall R/T (related to) resident continues to stand with (with symbol) unsteady gait." The Goal was "Resident to have no further fall with injury through next 30 days." The new Approaches included "7. Therapy to screen as ordered (OT/PT Therapy). 8. Soft Clip belt/soft waist restraint as ordered.” 31.11. The facility failed to aggressively intervene with measures to assure the resident attained or maintained his/her highest practicable level to prevent or decrease the number of times the resident fell from the time of readmission until surveyors Selected the resident for review on 2/9/03. After the surveyors selected the resident for review on 2/9/03 the resident fell again on 2/10/03 and 2/11/03. 32. During an observation on 2/10/03 at 9:50 A.M., Resident #11 was observed mouth breathing, with dry oral mucosa, lying flat on his/her back in bed. At his/her bedside was tepid water in the pitcher, and the cup upside down on his/her over bed table. The resident has an emaciated appearance and all extremities are severely contracted. The resident did not respond to the surveyor’ attempts at verbal communication. There was dried, dark brown. drainage noted on his/her top sheet. 65 32.1. A review of the resident's clinical record revealed a weight loss of 14.38% between September 2002, and February 2003. The resident has been a Hospice patient since 1/13/03. He/She was originally admitted to the facility 12/00, and readmitted 4/01 with diagnoses of: Paralysis agitans (Parkinson's), malaise, fatigue, failure to thrive, hypertension, hypothyroidism, and dementia among others. Her current skin assessment revealed bilateral bunions red and irritated, buttocks and coccyx with nonblanchable red areas, mid-back with 2-centimeter pressure area open and with a scant amount of serous drainage, covered with a Duoderm dressing, and bilateral lower arms with skin tears covered with clear occlusive dressings. 32.2. Dietary progress notes dated 6/5/02 state, "Weight down from 107.6 pounds to 92.4 pounds. Anticipate decline. Nourishment, House Supplement 2.0, 4 ounces qid (4 times a day)." He/She is fed in his/her room by staff. On 1/7/02 his/her labs were within normal limits. In August 2002, it was noted in the Dietary Progress note that the resident was on Hospice Service. The dietary note from 9/4/02 stated there had been no nutritional changes. The resident's weight had dropped from 98 pounds in 6/02 to 84.8 pounds in 9/02. 32.3. The care pian for this resident stated, "Encourage food and fluid intake," but the CNA flow sheets from October 2002 through February 2003 revealed this approach was followed inconsistently. The documentation revealed there were many shifts days with nothing extra offered to eat or drink. 32.4. The care plan said to document the percentage of regular meals and snacks consumed by the resident. The percentages were not documented 17% of the time. 32.5. The care plan stated, "House Supplement as Ordered.” The House Supplement 2.0 was ordered 4 times a day, and on the Medication Administration Record (MAR) it directs staff to document the percentage of the house supplement 66 consumed by the resident. The amount consumed by the resident was less than 20% daily from June 2002 until February 2003. 32.6. Review of the Hospice Care Plan, dated 1/14/03, revealed that it contained no integrated approaches that were coordinated with the facility and did not address dietary interventions. 32.7. During an interview conducted 2/12/03 with the Registered Dietician and Certified Dietary Manager regarding this resident, the surveyor asked them to explain why this resident's weight loss was unavoidable. The Registered Dietician and Certified Dietary Manager stated the resident was terminal and was expected to lose weight. They had care planned him/her to have the supplement. The RD stated, "The resident wasn't taking his/her medications or supplement. | did not see any reason to try another supplement." The surveyor asked the Certified Dietary Manager if she observed the resident eat and the Certified Dietary Manager stated, "He/She is bedfast so | don't observe him/her eating." Neither the Certified Dietary Manager nor the Registered Dietician could expiain their notes that the resident was on Hospice effective 8/26/02. Hospice did not assume care for the resident unti! 1/13/03. Therefore, there was no coordination of this resident's care or a comprehensive assessment to review the approaches in the care plan, change the supplement, try tortified foods, or attempt any other intervention to help the resident maintain his/her highest practical well-being. 33. Resident #18 was admitted to the facility on 1/24/03 with diagnoses that included Short Bowel Syndrome and an abdominal abscess. The resident was prescribed Total Parenteral Nutrition (TPN) on admission to meet his/her nutritional needs. 33.1. Review of the clinical record revealed that the facility had not obtained laboratory data ordered by the physician on 1/27/03 and 2/3/03, 33.2. Interview with the Assistant Director of Nursing (ADON) on 2/1 2/03 at 11:30 A.M., revealed that he was not aware that lab work to monitor the resident's TPN 67 (total parenteral nutrition) was never obtained. He confirmed that there were no policies and procedures for monitoring TPN (total parenteral nutrition) in the facility. He stated, "We just follow physician orders." He also confirmed that there was no specific time frame or guidelines that the nurses could follow for ordering lab work for resident's receiving TPN (total parenteral nutrition). The Assistant Director of Nursing further stated that they had been using the policies of the former corporation that owned them, but now the current corporation had provided the Heaton manuals, which were generic. He stated that his nursing staff was currently following both sets of policies at this point, since the Heaton policies had not been tailored to the facility. 33.3. Observation of the resident's TPN (total parenteral nutrition) solution on 2/12/03 at 12:15 P.M. revealed that the Lipids were mixed in with the Amino Acids and Dextrose into one bag. Review of the label indicated that the resident was receiving a solution that contained 5% Amino Acids and 15% Dextrose with 250 mi of 20% Lipids. The pump was running at 75 cc per hour. 33.4. Review of the February 2003 Medication Administration Record (MAR) revealed that the TPN (total parenteral nutrition) solution was documented as 5% Amino Acids and 15% Dextrose and not the 6.7% Amino Acids with 15.9% Dextrose that the physician had ordered on 1/24/03. The nursing staff were signing off that they had been giving the resident the incorrect formulation since 2/1/03. Review of the January 2003 MAR (medication administration record) revealed that the TPN (total parenteral nutrition) was listed as "TPN at 75 cc per hour” with no indication of the composition of the formula provided. 33.5. On 2/12/03 at 3:15 P.M., the Corporate Nurse, who was now the interim Director of Nursing (DON), revealed that she had just started with the company on Monday, 2/10/03, She stated that she didn't know the corporate policies and would have _ 68 to check with the Corporate Clinical Director regarding whether there were policies and procedures for monitoring TPN (total parenteral nutrition). 33.6. On 2/12/03 at 3:41 P.M., the interim Director of Nursing provided the survey team with the pharmacy policy on TPN. Review of the policy with the interim Director of Nursing revealed that it contained information on how to administer the TPN (total parenterai nutrition) but it did not contain information on monitoring labs for tolerance and adverse reactions. The policy referred to the "protocols." The interim Director of Nursing confirmed that the protocols, which were in the IV policy book, were not in the building. 33.7. Further interview with the interim Director of Nursing on 2/13/03 at 8:20 A.M., confirmed that no policies for nursing and infection control have been in place in the building until last night. She stated that she put the policies on the units herself. She stated that there has been a lack of direction of nursing staff by the former Director of Nursing. She confirmed that currently an IV manual that directed the nurses on administering IV's including TPN (total parenteral nutrition) was not in the facility. She stated that the Pharmacist would deliver the manual today, which supplements the first book that the pharmacy provided that addresses oral medications. The interim Director of Nursing was intormed by the survey team that the resident was receiving a TPN (total parenteral nutrition) formula that was not consistent with the physician's orders. 33.8. Interview with the Consultant Registered Pharmacist on 2/13/03 at 3:20 P.M., revealed that she was not aware of the TPN (total parenteral nutrition) that the resident was receiving. She stated that the IV (intravenous) Pharmacist from her company was in communication with the physician regarding the TPN (total parenteral nutrition) composition and rate. She stated that the resident was "probably" receiving the same TPN (total parenteral nutrition) he/she was on in the hospital. She confirmed ___ that there was no IV policy book in the facility up until today. She stated that the IV book 69 contained a TPN (total parenteral nutrition) protocol for the nursing staff to follow to monitor TPN (total parenteral nutrition). Review of the TPN (total parenteral nutrition) policy with the Consultant Pharmacist revealed that the policy stated, "A copy of current CBC, Chemistry Panel, Electrolytes and blood glucose is to be provided to the IV Pharmacist on admission and weekly thereafter." The Consultant Pharmacist stated that she would contact the IV Pharmacist to clarify the TPN (total parenteral nutrition) orders and check if the pharmacist had received lab data. 33.9. On 2/14/03 at 11:10 A.M., an interview was conducted with the Consultant Pharmacist and the nurse who had admitted the resident regarding Resident #18's TPN (total parenteral nutrition) orders. The Consultant Pharmacist stated that she had brought the notes from her company that the IV Pharmacist had completed regarding Resident #18. The LPN stated that she had received a call from the pharmacy on 1/24/03 regarding Resident #18's TPN (total parenteral nutrition) orders. She stated that the pharmacy had sent her a list of standard TPN (total parenteral nutrition) solutions and told her that the physician had to choose one of them. She stated that she faxed the form to the physician's office and he had selected a formula. She said that she then sent the orders to the pharmacy via a telephone order. She further stated that she put the original fax in the chart but could not find it now. She stated that the physician had approved the 5% Amino Acid and 15% Dextrose standard solution. The nurse confirmed that the order for this was not in the medical record. The pharmacist could not provide a written copy of the physician's order for this formula. The pharmacist also confirmed that she was not aware of the standards of practice regarding lab monitoring of TPN (total parenteral nutrition) solutions. She stated that she was unaware that her (American Society of Parenteral and Enteral Nutrition) guidelines regarding TPN (total. a parenteral nutrition) monitoring. 70 33.10. Review of the notes from the IV Pharmacist revealed that there was no documentation of labs being provided to the pharmacy by the facility. The notes included documentation dated 1/24/03 that indicated that the IV Pharmacist had spoken to a Licensed Practical Nurse (LPN) at the facility regarding switching the resident to a premixed TPN solution of 5% Amino Acids and 15% Dextrose. The note stated that the pharmacist had faxed a standard TPN sheet to the LPN and had suggested a High Protein Central Formula, closest to the physician's order. The pharmacist further documented that he/she had received a call from the LPN at the facility indicating that the physician had "ok'd change to standard formula of AA 5% Dextrose 15%." The New & Refill Prescription Orders form dated 1/24/03 included documentation that the IV pharmacist had written an order for "Clinimix 5/15 premix TPN. Dr. (doctor) Ok'd switching resident to premix TPN (total parenteral nutrition). Will fax change in order after received from MD office.” There was no signed physician order in the notes. 33.11. Review of the Initial Nutrition Assessment dated 1/29/03 revealed that the Registered Dietitian (RD) had based her assessment of the resident's nutritional intake on the 6.7% and 15% Dextrose TPN solution with the 250 ml. of 20% lipids. 33.12. Interview with the Consultant RD on 2/14/03 at 11:45 A.M., revealed that she was not aware that the resident was receiving the premixed TPN solution that contained 5% Amino Acid and 15% Dextrose. She stated that it was discussed at the Standard of Care meeting that the pharmacy would provide the 6.7% Amino Acid and 15.9% Dextrose solution. Review of the pharmacy protocol! with the RD revealed that it did not meet the current standards of practice established by the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding Monitoring of laboratory parameters for residents on TPN (total Parenteral nutrition). She concurred that the facility ADA Diet Manual. 71 33.13. Observation of the (total parenteral nutrition) and the Registered Dietician on 2/14/03 at approximately noon revealed that they were at the second floor nurses’ station reviewing the resident's paperwork. The Assistant Director of Nursing was overheard stating, "This is wrong we have to do something about it”, referring to the TPN (total parenteral nutrition). 33.14. Further interview with the Registered Dietician and Assistant Director of Nursing on 2/14/03 at 2:30 P.M., confirmed that they both remembered the discussion at the Standards of Care meeting that the Amino Acids would remain at 6.7%. The Assistant Director of Nursing confirmed that he did not know that the TPN (total parenteral nutrition) solution had been changed to 5% Amino Acids. The Registered Dietician further stated that the staff nurse had taken it upon herself to obtain an order from the physician on 2/14/03 to change the Amino Acid concentration to 5% without consulting with her first. The Registered Dietician stated that the Amino Acids needed to remain at 6.7% to provide the resident with adequate protein and the Dextrose at 15.9% to provide adequate calories. The Registered Dietician further stated that she would have to change her recommendation she made to the physician regarding lab monitoring on 2/13/03 to agree with A.S.P.E.N. guidelines. 33.15. The facility failed to obtain laboratory testing to monitor the resident's total parenteral nutrition as ordered by the physician and the facility failed to coordinate between and among the various disciplines to determine the appropriate laboratory testing to monitor for this resident. 34. Review of the medical record for Resident #14 revealed the resident was admitted to the facility on 10/24/02 with diagnoses, which include Renal Failure and Congestive Heart Failure (CHF). The resident started Hemodialysis treatments 3 times a week in November | Failure. Review of 2/03 physician orders reveals the residentis ona fluid... 2002, due to the Rena restriction of 1000cc /24 hours. Review of a care plan dated 10/25/02 revealed that a problem 72 “Alteration in nutrition R/T (related to) renal failure without dialysis" was revised on 12/12/02. The words "without dialysis" were highlighted to indicate this was no longer appropriate and the words “and fluid restrictions of 1000 cc QD (per day) to receive 120 cc with each meal. Receives dialysis 3 X (times) week" were added. 34.1. Observation of the resident's tray in the kitchen on 2/9/03 at approximately 5:30 P.M., revealed that the meal ticket stated that the resident was to receive 4-ounces of milk with his/her meal. The dietary aide put an 8-ounce carton of milk on his/her tray. The aide was questioned regarding if she knew how to determine from the meal ticket whether the resident was ona fluid restriction. The aide stated that she did not. Observation of the cart revealed that a 4-ounce portion of milk had not been prepared for this resident. The aide proceeded to get an 8-ounce glass and pour the milk into the glass without measuring it. She served this unmeasured portion of milk to the resident. 34.2. Observation on 2/9/03 during the initial tour at approximately 6:10 P.M., revealed an empty 16-ounce (480 Cc) water bottle on the resident's over bed table. Staff informed this surveyor that the resident was receiving dialysis and was on a fluid restriction. 34.3. Observation on 2/10/03 at approximately 8:20 A.M., revealed the resident had just finished breakfast, which included 8 ounces (240 cc) of milk and 4 ounces (120 Cc) of juice. A full 16-ounce (480 cc) bottle of water is observed on the over bed table. 34.4. Observation at approximately 11:20 A.M. on 2/10/03 revealed the bottle of water is half empty and the resident confirmed that he/she drank half (8 ounces or 240 Cc). The resident stated, "My boys buy it forme." At approximately 12:15 P.M., the resident received lunch, which included 4 ounces (120 cc) of apple juice. S49. Review of the 1&0 (Intake and Output) sheet on 2/12/03 for 2/10/03 revealed the 7-3 column is blank and has no documentation of how much fluid the resident drank on that shift. Further review of the 1&0 (Intake and Output) sheets for the months of 12/02, 1/03 and 2/03 for Resident #14 revealed there are blanks for 52 shifts in 12/02; 31 shifts in 1/03 and 1 shift through 2/11/03. Total fluid intake for all days with blanks is not completed and 4 of the 9 days that were totaled for 12/02, 1/03 and 2/03, are added incorrectly. The 1&O forms have a column for the amount of water the resident consumes with medications but this column is blank for 143 shifts during 12/02, 1/03 and 2/03. 34.6. Resident #14 receives medications 4 times a day and his/her nurse confirmed that he/she usually gets about 120 cc each time. 34.7. Review of the CNA (Certified Nurses Aide) Monthly Hydration/Nutrition Offering Form for the months of 12/02, 1/03 and 2/03 revealed the amount of fluids documented as consumed by Resident #14 does not match the amount documented on the 1&0 (Intake and Output) sheets. 34.8, There is no documentation of any communication between the Dietary and Nursing Departments to determine the amount of fluids that will be provided by each department. The care plan does state that dietary will provide 120 cc on each tray. There is no evidence that the facility attempted to control the amount of fluids the resideni received and no evidence that supervisory staff were monitoring the fluid restriction. No one had determined how much fluid the nurses could provide with medications and how much the Certified Nursing Aides could provide on each shift. During interview on 2/11/03 at approximately 10:00 A.M., the Assistant Director of Nursing stated, "Nothing matches. We need to fix this." 35. On 2/10/03, Resident #21 was admitted with a diagnosis of renal failure and was put on a renal diet with 1000 cc per day fluid restriction. Review of Resident #21's clinical record revealed that he/she had received 1250 cc of fluid on 2/12/03. ae ee 74 35.1. During interview on 2/12/03 at 11.55 A.M., with the Registered Dietitian (RD), she was asked how the fluids are regulated. The Registered Dietician Stated, "I don't know how they decide the amount of fluids.” At 12:00 noon, the Certified Dietary Manager (CDM) stated during interview that she had allotted 360 cc for dietary. 35.2. The care plan and the February 2003 Medication Administration Record (MAR) stated 4 oz. fluid on meal trays (360 cc daily). 35.3. At 12:10 P.M. on 2/12/03, the medication nurse stated," | didn't know the liquids in meds are counted in the total fluids." 35.4. Review of the February 2003 MAR revealed that Resident #21 gets intravenous antibiotics (100 cc) four times a day to equal 400 ccs plus his/her pills that he/she takes with water (60 cc) four times a day to equal 240 ccs and 2 containers of Novasource Renal a day (237 cc per box) for a total of 1114 cc per day not including the 360 cc provided with the meal trays. 35.5. At 1.30 P.M., after discussing fluid restriction with the Registered Dietician and the Assistant Director of Nursing, it was decided to fax the doctor to clarify whether he wanted fluid restriction of 1000 cc by mouth (PO) intake not including intravenous fluid and triple lumen flushes. At 2.10 P.M., the Assistant Director of Nursing received a fax back from the doctor stating fluid restriction is PO only. After receiving the fax the Assistant Director of Nursing made an intake Guide giving dietary 360 cc a day and nursing 240 cc for the supplements and 60 cc for meds on the 7-3 shift and the 3-11 shift and giving 40 cc for the 11-7 shift, and that all shifts should document intakes. 35.6. At 12.20 P.M., when the Assistant Director of Nursing (ADON) was asked how he caiculates fluids for fluid restriction diets he Stated, "I took the dietary allotment (360 cc) and subtracted from 1000 cc, then divided by 3 for each nursing shift." 75 35.7. Review of the Monthly Hydration and Nutrition Offering Form and the Medication Administration Record revealed on 2/1 3/03, after development of the Intake Guide, that the nursing staff provided 480 cc for oral intake without including the supplements and meds, which when added together came to 1114 cc. 35.8. In an interview with the Assistant Director of Nursing on 2/14/03 at 11.30 A.M. he was asked, "How are you going to monitor the intake and output?” The Assistant Director of Nursing stated, "I have to change the system. All staff needs to be re-in serviced so that the nurses and the Certified Nurses Aides are all on the same track." 36. Resident #16 was admitted on 9/12/02. Pertinent diagnoses include but are not limited to Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), Peripheral Vascular Disease (PVD), and Renal Insufficiency. 36.1. Record review on 2/12/03, revealed the resident had a physician's order to restrict fluids to 2 quarts/24 hours (64 oz times 30 ccs/oz equals 1920 ccs per 24 hours). 36.2. A dietary note in the resident's record divided the fluid as follows: Dietary to supply 360 ccs at breakfast on food tray, 600 ccs at lunch on food tray, and 600 ccs at dinner on food tray for a total of 1560 ccs per day. Nursing was allocated 360 ccs of fluid for medication pass per day. 36.3. A request was made to the physician on 1/24/03 to liberalize the fluid restriction. The physician indicated the fluid restriction was to remain at 1920 ccs per day. Staff was instructed to assure/encourage the resident to drink all the fluids supplied with meals. 36.4. During record review on 2/12/03, it was verified by the Consulting 76 36.5. On 2/14/03 at approximately 11:35 A.M., a surveyor went to visit the resident in their room. The resident was not present. The surveyor, with the assistance of a staff nurse, verified the location of the resident's bed. 36.6. Next to the bed was an over the bed table with a pitcher of water and two (2) four ounce plastic glasses. The water pitcher was estimated to contain nearly a quart (32 ounces times 30 ccs equal 960 ccs) or 960 ccs of water. One of the 4 ounce cups contained about 2 ounces of water. The nurse verified that the water pitcher was almost full. 36.7. The surveyor asked the nurse if she was aware the resident was on any fluid restriction? The nurse replied, "| am not sure. Usually there is a sign posted when There was not a sign posted in the room indicating the resident is on fluid restriction.” the resident was on fluid restriction. 36.8. At approximately 11:38 A.M. a surveyor spoke with the Assistant Director of Nurses (ADONY/Unit Manager about the resident. The clinical record for the resident was pulled and it was verified the resident was ona fluid restriction of 1920 ccs/24 hours. 36.9 The Assistant Director of Nursing indicated he was not aware the resident had water in the room and stated he would have it removed. The surveyor informed the Assistant Director of Nursing that the resident was to only receive 360 ccs from nursing for medication pass. The Assistant Director of Nursing stated, “| know the system is broken. | am trying to fix it’. 37. Review of Resident #30’s closed record revealed that the care plan completed on 12/9/02 indicated, “at nutritional risk r/t {related to] therapeutic diet and fluid restriction of 800 cc/24 hr.” 37.1. Review of the December 2002 CNA Monthly Hydration/Nutrition Offering. form revealed that the resident received greater than his/her 120 cc allotted fluids per 77 meal at 39 of his/her meals in December. The Intake and Output Record was incomplete for every day between 12/4/02 and 12/30/02 with no documentation of the resident’s total fluid intake on these days. Calculation of comparison of the CNA Hydration/Nutrition forms and the 12/02 medication administration record revealed that the resident received from 330 cc to 2400 cc of fluid a day. 37.2. Interview with Consultant Registered Dietician [RD] on 2/12/03 at approximately 11:00 a.m. revealed that the certified dietary manager [CDM] did not immediately address the amount of fluid that dietary would be sending to resident #30 because when a fluid restriction is very low it is assumed that nursing will use ail of the allowed fluids. She did not know why the resident’s fluid restriction was not noted for the first time until 12/9/02. When questioned why she did not address the fact that she had calculated the resident's fluid needs to be 500-700 cc higher than the ordered 800 cc fluid restriction, the Registered Dietician Stated, “If! didn’t say anything then | agreed with the doctor.” 37.3. Further interview with the Registered Dietician on 2/14/03 at 11:30 a.m. revealed that the Certified Dietary Manager talks to nursing and decides how fluid will be divided between dietary and nursing. The Registered Dietician stated that she doesn't know if the Certitied Dietary Manager changed from no fluid on the tray to 4 ounces with meals secondary to a resident preference. She further stated that the nurse’s aides meal sheet shows what the aide gave for fluids at the meal, not what dietary sent on the trays. From review of the notes the Registered Dietician stated that she could not tell what happened with the resident's fluids. She did not know if the Certified Dietary Manager altered nursing that she changed from sending no fluids on the trays to 4 ounces with meals. The policy is when a fluid restriction is less than 800 cc, then no fluids are sent with the trays. The Registered Dietician confirmed that she shad not documented regarding the resident's Strict fluid restriction but felt the 800 cc of fluid was 78 ok since the resident had a low sodium level. The Registered Dietician confirmed that she had not documented this assessment. 38. Review of resident #8’s clinical record revealed that his/her last quarterly assessment was completed on 11/4/02. His/her next quarterly Minimum Data Set was due on 2/4/03. This Minimum Data Set was not found in the resident’s medical record. 38.1. Interview with the Director of Nursing on 2/11/03 at 11:00 a.m. revealed that there had not been a Minimum Data Set Coordinator in the building for a while. During that time the staff did their specific parts of the Minimum Data Set and brought it to the care-planning meeting so that the care plan could be written or updated. She did not state how the staff was completing the Resident Assessment Protocols [RAPs]. She further stated that the staff was at least trying to keep up with the care plans and do what they could even though there were not Minimum Data Sets and Resident Assessment Protocols completed. She stated that the new Minimum Data Set coordinator would complete the quarterly Minimum Data Set today. 38.2. On 2/12/03, the Minimum Data Set coordinator provided the surveyor with a hand written quarterly Minimum Data Set for the resident dated 2/11/03. She confirmed that it was not completed until today. 38.3. Review of the Care Pian Conference and Review of the Care Plan form revealed that the care plan had been completed on 2/5/03 and was Signed off by the Assistant Director of Nursing as being reviewed. Review of the care plan revealed that it contained approaches that were not currently in use with the resident. 39. Resident #29 was admitted to the facility on 1/10/03. The care plan was reviewed on 1/30/03. There was no Minimum Data Set completed since the resident was admitted. During an interview with the Director of Nursing on 2/10/03, she stated that they decided to do the care plans and catch up on the Minimum Data Set later. OC a 79 40. Review of the clinical record for resident #14 revealed the Admission MDS [Minimum Data Set] was signed as complete on 11/5/02 but the quarterly assessment which was due to be completed on 2/5/03 is not in the resident’s record. 40.1. The MDS/Care Pian Coordinator stated she was trying to “catch up” as the facility had not had a Minimum Data Set Person until she was requested by the facility to take the position on 2/7/03. She provided a partially completed Minimum Data Set dated 1/30/03 at the top for resident #14. Review of the Care Plan Conference and Review Sheet revealed it was signed on 2/6/03 that a care plan conference had been held on that date. This was before the Minimum Data Set had been completed, 41. During record review the surveyor noted the resident's initial Minimum Data Set [MDS] for resident #16 was completed on 9/19/02. The quarterly MDS due 12/19/02 was not in the record. The surveyor requested the unit secretary on 2/12/03 at approximately 2:30 p.m. to try to locate the missing Minimum Data Set. At approximately 3:06 p.m. the MDS Coordinator informed the surveyor that the Minimum Data Set could not be located. 42. During record review for resident #1 on 2/10/03 the surveyor observed that the resident's quarterly Minimum Data Set due on 1/27/03 was not in the resident's clinical record. The surveyor requested the Unit Secretary to locate the missing quarterly Minimum Data Set. On 2/10/03 the MDS Coordinator provided the surveyor with a copy of a partially completed hand written Minimum Data Set for resident #1 with a date of 1/30/03. The MDS Coordinator acknowledged the quarterly Minimum Data Set had not been completed. 43. Review of resident #4's clinical record revealed that there was no quarterly MDS [Minimum Data Set] in the resident's record. Interview with the MDS Coordinator on 2/12/03 revealed that she was in the process of completing it. The Minimum Data Set was provided to the surveyors on 2/12/03. Review of the quarterly Minimum Data Set dated 2/11/03 revealed that it was not correctly coded for falls and pressure sores. No Resident 80 Assessment Protocols ___ being completed first. The MDS Coordinator further stated, “It will be fixed by next week”. 44. Further review of the remainder of the care plans in the Director of Nursing’s inbox on 2/12/03 at 3:05 p.m. revealed that the care planning process had been completed for random sampled residents #33 through #42 on 2/12/03. The MDS Coordinator confirmed that she had not completed all of the Minimum Data Sets and Resident Assessment Protocols on these residents and had not attended their care plan meetings. 44.1. During an interview with the MDS Coordinator on 2/14/03 at 12:30 p.m., she indicated that she had inherited this position and was “left with a mess”. The Minimum Data Sets were backed up waiting to be completed. She stated that there was no tickler system for monitoring when Minimum Data Sets needed to be completed. She also stated that she had no current Minimum Data Set books or a functioning computer system to print out the current section from the federal website. She further stated that the staff person given to help her with input of the Minimum Data Set data was not trained to do the job, since she was a supply clerk. She stated that she had spoken to the Administrator and Interim Director of Nursing this morning and requested another nurse to help her with the assessments. She stated that her request was declined. The nurse further stated, “I was hired to be the Unit Manager on the second floor. | did that for one day before | was told | would be the MDS Coordinator’. 45. During observation of the medication pass on 2/10/03 at approximately 10:10 a.m., the nurse stated that resident #19 was supposed to get 4 oxandrin tablets but there were only 2 in the drawer. After checking the stock supply of medications, the nurse said that the zinc sulfate 220 mg. which the resident was scheduled to receive was not there either. She stated that she would have to call the pharmacy and have some delivered. Review of the pharmacy 82 were provided with the Minimum Data Set or found in the resident's record. The care plan was also not in the care plan book on the unit, 43.1. During an interview with the MDS Coordinator on 2/13/03 at 2:30 p.m. she stated that she knew there were some mistakes in the assessments. She stated that she had only been employed by the facility for 4 days and was trying to catch up on the assessments that needed to be completed. She stated that she was a Registered Nurse [RN] and did all of the assessments herself, but she had an employee from the central supply department who had been assigned to input the Minimum Data Set data into the computer. The MDS Coordinator stated that the central supply aide was still in the learning process and had made the input errors on resident #4’s Minimum Data Set. The MDS Coordinator stated that she had planned to check all of the assessments for accuracy and make necessary changes to correct as soon as possible. She stated that the Minimum Data Set process was not completed on this resident and she would do a significant correction of the quarterly Minimum Data Set. When asked where resident #4’ s care plan was, she said that she did not know but would try to find it. 43.2. An interview with the MDS Coordinator on 2/13/03 at 3:05 p.m. revealed that she had found resident #4’s care plan in the Director of Nursing’s box for signature. 43.3. Review of the care plan revealed that a care pian conference had been conducted on 2/12/03. The form indicated that the LPN on the unit, the Activities Director, the Certified Dietary Manager and the Social Services Director participated in the meeting. The MDS Coordinator's signature was not on the form. 43.4. Further interview with the MDS Coordinator at this time revealed that she had not been notified regarding the care plan meeting for resident #4 and didn’t even know that the interdisciplinary team had met to discuss the resident's care plan. She confirmed that she had not attended the meeting. The MDS Coordinator was ; questioned regarding how the team could go to care plan without the MDS process 81 sulfate had been ordered. The nurse stated, “The nurses are supposed to order sooner so we won't run out”. 45.1. Observation at approximately 11:00 a.m. revealed the pharmacy delivered some medications but not the oxandrin or zinc. The resident received the oxandrin at approximately 1:30 p.m. There is no documentation that the resident received the zinc sulfate on 2/10/03. 46. During an observation of 2/13/03 at 2:20 p.m., resident #29 was sleeping in bed with an IV of DSW with 20 Megs KCL [potassium choride] infusing at 30 ccs an hour via IV pump. The IV tubing was dated 2/5/03. there was also an empty IV bag of Levaquin 500 mg. with the tubing dated 2/12/03 on the IV pole. 46.1. An interview on 2/13/03 at 2:25 p.m. with the ADON revealed that he was not sure how often the tubing should be changed but he thought it was every 24 hours. The surveyor requested the policy and procedure, however the ADON was unable to provide one. 46.2. A copy of the IV policy and procedure was obtained from the pharmacy consultant on 2/14/03. Review of the policy revealed that the IV tubing should have been changed every 72 hours. Using this policy, resident #29’s tubing should have been changed on 2/8/03. The Levaquin should have been removed from the room, as it was the resident’s last dose. 47. During observation of medication pass on the 200 hal! on Monday, 2/10/03 at 12:43 p.m., resident #47 did not receive his prescribed dose of Risperdal 0.25 mg; it was unavailable. A review of the MAR revealed he did not receive two doses of Risperdal on 2/9/03 or during the observed medication pass. 47.1. An interview with the Unit Manager on 2/11/03 at 9:15 a.m. revealed that the resident missed 5 doses before the medication arrived at the facility. 47.2. During an interview with the Medistat Pharmacy delivery person on 2/11/03 at 9:15 a.m., he stated that they routinely make two trips a day to deliver pharmaceuticals and do stats [emergency medications] as needed. 48. During clinical record review for resident #18 the January 2003 MAR revealed the resident is to receive octreotide 0.05 mg. subcutaneous every 6 hours. It was ordered on 1/25/03 and the resident did not receive 10 of the ordered doses. 49. During an interview with the ADON on 2/12/03 at 11:30 a.m., he revealed that there were two sets of policies in the facility, both the old I.H.S. policies and the Heaton policies. He stated that they had been using the I.H.S. policies since the nurses were familiar with them. He stated that they had been in the process of developing new facility policies from the Heaton policies but they had not been completed yet. He stated that the nurses were confused about which policies to use and were using policies and procedures from both sets in the facility based on what they needed. 49.1. During an interview on 2/13/03 the Corporate Director of Clinical Services stated, “We have been using Heaton policies since 10/02, no I.H.S. [former corporation who owned the facility] policies since 10/02 unless Heaton doesn’t have it. Then it needs to be pulled out and revised. | brought them in and gave them to the DON [Director of Nursing]”. 49.2. The Corporate Director of Clinical Services also stated that he had not been coming to the building to consult because he thought that the DON had been doing a good job. He stated that he had 13 buildings to cover and couldn't be at all of them. He stated that around October 2002 he realized that “something was happening to her’ and she was not completing her job duties. He stated that he provided her with the Heaton policy manuals and that she was supposed to implement them in the facility. He 84 50. Based on all of the foregoing, VENICE REHAB AND HEALTH CENTER violated: (a) 42 CFR 483.25 via Rule 59A-4.1288, Florida Administrative Code, 42 CFR 483.20(k)(3)(i) and 400.022(1)(6), Florida Statutes (2002) through its failure to provide nursing and care services to residents as determined by resident assessments and individual care plans for one resident with pain [resident #2], for one resident with a fall [resident #15] and for one resident with falls and elopement [resident #18] and for residents who required supervision to prevent accidents in a sample of 36 residents. 51. Pursuant to Section 400.23(8)(a), Florida Statutes, the foregoing is a class | deficiency because it is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. 52, AHCA gave VENICE REHAB AND HEALTH CENTER a written mandated correction date of February 15, 2003, in accordance with Section 400.23(8)(a), Florida Statutes. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1)... That the imposition of the moratorium issued by the Agency on Fébruary.18, 2003 under AHCA Case No. 2002047615 be upheld for the time period in question; 2) Make factual and legal findings in favor of AHCA on Count |; 3) Uphold the issuance of the conditional license with an effective date of 02/14/2003, a copy of which is attached hereto as Exhibit “A”; and 4) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002). 85 DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, VENICE REHAB AND HEALTH CENTER shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE VENICE REHAB AND HEALTH CENTER is hereby 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 Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. VENICE REHAB AND HEALTH CENTER IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY AHCA. Respectfully submitted on this / 9 tay of May, 2003. VL Riselli Fla. Bar. No. 325821 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 we ~ (850) 921-9313 (fax) 86 (850) 921-5873 (office) = Exhibit “A” CONDITIONAL LICENSE License # SNF1570096 Certificate #9814 Effective Date: 2/14/03 Expiration Date: 06/27/03 88 CERTIFICATE OF SERVICE | HEREBY CERTIFY that the original Administrative Complaint and Exhibit “A” has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # TiDb- 4545- 1244- 20D -Z op AND HEALTH CENTER, 4002 78" Drive East, Sarasota, FL 34234 and that a true and correct ) to Anthony O. Brunicardi, Administrator, VENICE REHAB copy of the Administrative Complaint and Exhibit “A” has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # “TlOlo -4575- 1204-2050 -@ss) to Eliezer Scheiner, Registered Agent for VENICE REHAB AND HEALTH CENTER, 7491 West Oakland Park Boulevard, Suite 100, Fort Lauderdale, FL 33319. DONNA RISELKI; COPIES TO: Elizabeth Dudek Deputy Secretary Managed Care and Health Quality Assurance Agency for Health Care Administration 2727 Mahan Drive, M.S. #9 Tallahassee, Florida 32308 (via interoffice mail) 87

Docket for Case No: 03-002571