STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003004467 AHCA No.: 2003003704 Vv. Return Receipt Requested: 7002 2410 0001 4236 8659 DOS OF NORTH SHORE, LTD, d/b/a 7002 2410 0001 4236 8666 MIAMI SHORES NURSING AND 7002 2410 0001 4236 8673 REHABILITATION CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA” or the “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against DOS of North Shore, Ltd., d/b/a Miami Shores Nursing and Rehabilitation Center (hereinafter “Miami Shores Nursing and Rehabilitation Center” or the “facility”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statute (2002) (hereinafter “Fla. Stat.”), and alleges: NATURE OF THE ACTIONS L. This is an action to impose and maintain the Agency’s administrative fine of $5,000.00 pursuant to Sections 400.102, 400.23(8), Fla. Stat., for the protection of the public health, safety and welfare. 2. This is an action to impose and maintain the Agency’s assignment of a Conditional Licensure status to Miami Shores Nursing and Rehabilitation Center, pursuant to Section 400.23(7) (b), Fla. Stat. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat. and Chapter 28-106, Florida Administrative Code (hereinafter “F.A.C.”). 4. Venue lies in Miami-Dade County, pursuant to Section 400.121(1)(e), Fla. Stat. and Rule 28-106.207, F.A.C. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Fla. Stat. and Chapter 590-4, F.A.C. 6. Miami Shores Nursing and Rehabilitation Center is a 99-bed skilled nursing facility located at 9380 N.W. 7° Avenue, Miami, Florida 33150. Miami Shores Nursing and Rehabilitation Center is licensed as a skilled nursing facility; license number SNF1372096; certificate number 10332, effective 05/01/2003 through 02/14/2004. Miami Shores Nursing and Rehabilitation Center was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. 7. Because Miami Shores Nursing and Rehabilitation Center participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule 59A-4.1288, F.A.C. COUNT _I MIAMI SHORES NURSING AND REHABILITATION CENTER FAILED TO IMPLEMENT WRITTEN POLICIES AND PROCEDURES THAT PROHIBIT MISTREATMENT, NEGLECT AND MENTAL ABUSE OF ALL RESIDENTS. Title 42, Section 483.13(c) (1), (2)and(3), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code. (STAFF TREATMENT OF RESIDENTS) CLASS II DEFICIENCY 8. BHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. During the survey conducted by the Agency on 4/29/03 through 5/01/03 and based on interview anc record review, the Agency found that the facility failed to implement written policies and procedures that prohibit mistreatment, neglect and mental abuse of all residents, specifically for 3 residents (residents #R19, #R20 and #R21, as identified by AHCA in the survey) of 5 grievances reviewed by the Agency. 10. Review of the facility's grievance log for the month of October 2002 indicated that there were 3 resident we grievances regarding "conflict with CNA" (certified nursing assistant) as the nature of the concern. The actual "Resident Concern, Complaint; Grievance/Resolution Record" form reviewed disclosed that the facility failed to implement its policy on reported allegations of mistreatment, neglect, and abuse, by not investigating/reporting the allegations made by these 3 residents (residents #19, 20 and 21), regarding the staff's behaviors toward them. The following is a description of the documentation written by the facility on the grievance form: (a) Resident #21 complained that on 10/11/02, "CNA wakes him/her at 5:00 am, talking loud. She is rough when providing care and told the resident that she doesn't want to be assigned to the resident". The resident reported that he/she does not want the CNA to be assigned to him/her any longer. The resolution was that the CNA was counseled. Review of the counseling form provided disclosed that the CNA received a verbal counseling for defective work. (i) There was no indication that the facility investigated the alleged rough behavior of the CNA toward the resident. During an interview with the Social Service Director on 4/30/03 in the afternoon, he disclosed that an “investigation of abuse and neglect was not conducted". The Director of Nursing (DON) stated at the same time that, "we treated it as a grievance". She further added that the facility did not report the allegation of abuse to the Florida Abuse Hotline at any time. (ii) Review of the facility's "Abuse Prevention Policy", section VII, "Reporting/Response", A.1. revealed that it states, "The Abuse Prevention Coordinator or designee as assigned by the Administrator will begin his/her investigation immediately upon notification and report to: Adult Protective Service (1-800-96-ABUSE) within 5 days providing the following information: (a description of the resident and other pertinent data)". The definition of abuse in the facility's policy includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical well-being. The facility's definition of mental abuse includes humiliation or deprivation. (b) Resident #20 filed a grievance stating that on the night of 9/29/02 he/she was watching telev.sion in the East dining room. The CNA came to the east dining room and began working on some papers. She then changed the channel on the television from the program that the resident was watching. When the resident asked her to return the station to what he/she was watching, the CNA ta told him/her, "no", that if he/she wanted to watch TV, he/she should go into his/her own room. When the resident continued to discuss the matter, the CNA turned the television off, unplugged it and wrapped the cord, placing it out of the resident's reach. The resident stated that the incident was witnessed by security and a nurse. The CNA agreed that she did unplug the TV and asked the resident to go watch TV in his/her room because he/she was being loud and disturbing the other residents who were sleeping. The CNA received a verbal counseling. (i) There was no indication that the facility investigated the alleged behavior of the CNA toward the resident. During an interview with the Social Service Director on 4/30/03 in the afternoon he d:.sclosed that an "investigation of abuse and neglect was not conducted". The DON stated at the same time that "we treated it as a grievance" and further reported that the facility did not report the allegation of abuse to the Florida Abuse Hotline at any time. (ii) Review of the facility's "Abuse ?revention Policy”, section VII. "Reporting/Response", A.1l. revealed that it states, "The Abuse Prevention Coordinator or designee as assigned by the Administrator will begin his/her investigation immediately upon notification and report to: Adult Protective Service (1-800-96-ABUSE) within 5 days providing the following information: (a description of the resident and other pertinent data)”. The facility's definition of mental abuse includes humiliation or deprivation. (c) Resident #19 complained that at 9:30 pm on 11/28/02, he/she asked the CNA for assistance with bathing. The CNA left the room stating that she would return. About 1 hour and 1/2 later at 11:00 pm, the resident went outside his/her room and observed that the CNA was clocking out. The resident proceeded to speak to the CNA at tne time clock and asked why she had not come back. The CNA told the resident she would assist him/her the following night. The resolution was that the CNA was counseled verbally for defective work. Review of the initial minimum data set dated 8/13/02 disclosed that the resident requires one- person extensive assistance in bathing. (i) There was no indication that the facility investigated the alleged behavior of the CNA toward the resident. During an interview with the Social Service Director on 4/30/03 in the afternoon disclosed that an "investigation of abuse and neglect was not conducted". The DON stated at the same time that "we treated it as a grievance" and further reported that the facility did not report the allegation of abuse to the Florida Abuse Hotline at any time. (ii) Review of the facility's "Abuse Prevention Policy", section VII. "Reporting/Response", A.l. reveal that it states, "The Abuse Prevention Coordinator or designee as assigned by the Administrator will begin his/her investigation immediately upon notification and report to: Adult Protective Service (1-800-96-ABUSE) within 5 days providing the following information: (a description of the resident and other pertinent data)". 11. The definition of abuse in the facility's policy includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical well-being. The facility's definition of mental abuse -ncludes humiliation or deprivation. 12. Based on the foregoing, Miami Shores Nursing and Rehabilitation Center violated Title 42, Section 483.13(c) (1), (2)and(3), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II deficiency pursuant to Section 400.23(8)(b), Fla. Stat., which carries an assessed fine of $2,500.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b), Fla. Stat. COUNT II MIAMI SHORES NURSING AND REHABILITATION CENTER FAILED TO PROVIDE ADEQUATE AND APPROPRIATE HEALTH CARE FOR A RESIDENT; THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO ATTIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL, AND PSYCHOSOCIAL WELL-BEING, IN ACCORDANCE WITH THE COMPREHENSIVE ASSESSMENT AND PLAN OF CARE . SECTION 400.022(1) (L) and(3), FLA. STAT., AND/OR TITLE 42, SECTION 483.13(c) (1), (2) and(3), CODE OF FEDERAL REGULATIONS, AS INCORPORATED by RULE 59A-4.1288, F.A.C., and 59A-4.106(4) (aa), F.A.C. (QUALITY OF CARE) CLASS II DEFICIENCY 13. BHCA re-alleges and incorporates paragraphs (1) through (7) as is fully set forth herein. 14. During the survey conducted by the Agency from 4/29/03 through 5/01/03 and based on review of the clinical record for resident #2, the Agency found that Miami. Shores Nursing And Rehabilitation Center failed to provide adequate and appropriate health care for a resident; the facility failed to 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. The Agency found that the facility failed to manage a cancer resident’s constipation on around the clock morphine, which increased the risk of fecal impactions and eventually ied to the development of fecal impaction without an interdisciplinary team assessing, developing and implementing a care plan for constipation/fecal impaction for the resident. Review of the clinical record for resident #2 revealed that the resident was initially admitted on 3/29/99, with diagnoses of cerebral degeneration, depression, chronic obstructive pulmonary disease, atypical psychosis, congestive heart failure, hypertension, anxiety, and arteriosclerotic heart disease. During an interview with the Director of Nursing (DON) on 5/1/03 at 3:45pm, the DON stated that the resident also had a diagnosis of prostate cancer. 15. Review of the Minimum Data Set (MDS) dated 10/21/02 and 4/7/03 revealed that the resident was assessed as needing extensive assistance with ADLs. In addition, the resident was assessed on 4/7/03 as being totally incontinent with bowel and bladder functions. 16. Observation on 4/30/03 at 2:30pm revealed resident #2 crying out in pain and moaning. The licensed practical nurse (LPN) that responded stated the resident received his break through pain medication at 1:00 om - she gave it to him prior to disimpacting him. She stated the feces were "very high up and it was painful". 17. Review of the "Nurse's Notes" dated 4/27/03, at 10:30am, revealed the, "Res. crying aloud" and, "Res. 10 impacted. Several balls of B.M. removed. Resident administered MOM (Milk of Magnesia) 30cc via peg given" and, "Perineum care provided after impaction removed. When asked was he feeling better, res. replied, "Yes". Will monitor for B.M". on 4/30/03 at 10 am, the resident is described in the nursing note as groaning. When the nurse questioned the resident if his/her stomach was furting, he/she replied "yes". The nurse reported that the resident did not have any bowel movement in days with 30 cc of MOM given via PEG tube. At 11:00 am, the resident is described in the nursing notes as continuing to groan. At 1:00 pm the resident is still described as being restless. At 2:45 pm the resident continues to groan. Finally, at 3:00 pm, the nurse observed one large, hard bowel movement, with a request for a stronger pain medication for pain. At 3:30 pm, the resident was described as resting quietly. 18. A review of the "VITAS initial plan of care/orders" revealed the resident was admitted to hospice care on 10/12/02. Review of a "medication administration record" dated 10/1/02 through 10/31/02 revealed the resident was started on Roxanol 20:1, 1 cubic centimeter (cc) every four hours around the clock and Roxanol 20:1, lcc every hour as needed for respirations greater than 22 per minute of pain. 19. Review of the Nursing 2003 Drug Handbook reveals that Roxanol is morphine sulfate usually administered for severe pain, best given around the clock for severe chronic pain and that it can cause constipation, which is "usually severe with maintenance dose”. 20. Review of resident #2's care plan, last reviewed on 4/28/03, fails to address the risk of constipation secondary to long term around the clock morphine administration. Review of the "nutritional progress notes" dated 11/20/02 through 4/17/03 fail to address the risk of constipation secondary to long term around the clock morphine administration. 21. Review of the physician's order sheet revealed the resident was placed on stool softeners, such as Dulcusate 15 cc (milliliters) at bedtime from 9/27/02 and Dulcolax 10 mg (milligrams) suppository every three days from 1/22/03. The resident was also placed on iron supplementation of iron sulfate 325 mg daily from 10/31/02. 22. Review of the 2000 Nursing Diagnosis Journal (volume 11) revealed that some of the causes of fecal impaction as reported in literature include immobility, narcotic pain medication and iron supplementation. 23. During an interview with the charge rurse at 12:10 pm on 5/1/03, she was asked what is being done about 12 the resident's constipation and recurrent fecal impactions. She stated the resident is on the same medications for some time. When asked if a care plan had addressed the problem sane said, "no" and that, "they don't do the care planning. The Minimum Data Set (MDS) coordinator does that." 24. During an interview with the MDS coordinator at 12:42 on 5/1/03, she stated she was unaware of any problem (regarding the resident). When asked if the nurses had communicated the fact that the resident had to be disimpacted twice recently, she said “no.” During an interview with the MDS coordinator at 1:50pm, she provided a page from a VITAS care plan that has nothing checked off on it. She stated she had found the page in a plastic sleeve on the chart. Review of the form reveals it is a generic form but no conditions or interventicns are checked. 25. On 5/01/03 at 2:13 pm, during an interview with the LPN who took care of resident #2 on the day shift on 4/30/03, she confirmed the fact that the resident was impacted with feces and required manual disimpaction for the second time in the last week. She also offered the observation that the resident was much calmer today. 26. On 5/01/03 at 3:45 pm, during an interv.ew with the Director of Nursing, she acknowledged that a care plan 3 for the constipation for the resident was not developed, increasing the inherent risk for its development with regular morphine administration. 27. On 5/01/03 at 3:55 pm, during an interview with the Assistant Director of Nursing (ADON), she stated that she saw the "hard formed stool" after the disimpaction but did not see the actual disimpaction. She further stated that the nurse intervened appropriately yesterday. She stated she was unaware of last week's disimpaction. 28. Unmanaged constipation can result in fecal impaction, which can result in physical pain and, in extreme circumstances, a painful death. 29. Based on the foregoing, Miami Shores Nursing and Rehabilitation Center violated Section 400.022(1)(L) and (3), Fla. Stat., and/or Title 42, Section 483.13(c) (1), (2)and(3), Code Of Federal Regulations, as incorporated by Rule 59A-4.1288, F.A.C., and 59A- 4.106(4) (aa), F.A.C., herein classified a Class II deficiency pursuant to Section 400.23(8) (b), Fla. Stat., which carries, in this case, an assessed fine of $2,500.00 This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Miami Shores nursing and Rehabilitation 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. The Conditional License is attached hereto as Exhibit Na” CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I and II. B. Assess and maintain the Agency’s administrative fine totaling $5,000.00 against Miami Shores Nursing and Rehabilitation Center on Counts I and II. Cc. Assess and maintain the Agency’s assignment of a conditional license status to Miami Shores Nursing and Rehabilitation Center, in accordance with Section 400.23(7) (b), Florida Statutes. D. Grant such other relief as this Court deems ig just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida 32308, attention Lealand McCharen, Agency Clerk. Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar No. 0142832 8355 N. W. 53 Street Miami, Florida 33166 (305) 499-2165 Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration 8355 N.W. 53° Street Miami, Florida 33166 (Interoffice mail) ) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) FLORIDA AGENCY FOR HEALTH ‘CARE ADMINSSTRATION i JEB BUSH, GOVERNOR RHONDA M. MEDOWS, July 17, 2003 MIAMI SHORES NURSING AND REHABILITATION CENTER 9380 N.W. 7TH AVENUE | [ MIAMI, FL 33150 1_Le Dear Administrator: The attached license is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Status Change Agencyfor att Care Administration DivisiOn of Health Quality Assurance Enclosure ce: AHCA Area Office 11 Long Term Care Section file Medicaid Contract Management Certificate of Need —_———$—$$—$— Visit AHCA Online at ——$<$—$——— 2727 Mahan Drive # Mail Stop #33 www fdhe.state.flus Tallahassee, FL. 32308

Docket for Case No: 03-003314