STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2003004503 vs. 2003004738 KISSIMMEE HEALTH CARE ASSOCIATES, INC., d/b/a DONEGAN REHABILITATION AND HEALTH CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against Kissimmee Health Care Associates, Inc., d/b/a Donegan Rehabilitation and Health Center, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of four thousand five hundred dollars ($4,500) pursuant to Sections 400.102(1) (a) and (d), 400.23(8) (b) and (c), Florida Statutes (2002). 2. The Respondent was cited for the deficiencies set forth below as a result of surveys conducted on or about May 22, 2003 and June 25, 2003. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2002). 4. Venue lies in Osceola County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes (2002), and Chapter 28-106.207, Florida Administrative Code (2002). PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes (2002) and Rules 59A-4, Florida Administrative Code (2002). 6. Respondent is a nursing home located at 1120 West Donegan Avenue, Kissimmee, FL 34741. The facility is licensed under Chapter 400, Part II, Florida Statutes (2002) and Chapter 59A-4, Florida Administrative Code (2002), having been issued license number SNF1128096. COUNT I RESPONDENT FAILED TO ENSURE THAT A RESIDENT WHO ENTERS THE FACILITY WITHOUT PRESSURE SORES DOES NOT DEVELOP PRESSURE SORES UNLESS THE INDIVIDUAL’S CLINICAL CONDITION DEMONSTRATES THAT THEY WERE UNAVOIDABLE. R.59A-4.1288, Fla. Admin. Code (2002), INCORPORATING BY REFERENCE 42 CFR § 483.25 (c) CLASS II DEFICIENCY ISOLATED 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about May 22, 2003, a complaint survey was conducted at Respondent’s facility. 9. Based on observation, interview and record review, it was determined that Respondent failed to ensure that one of four sampled residents, who entered the facility without a pressure sore, did not develop a pressure sore (Resident #2). Findings: During initial tour of the facility on May 22, 2003 at approximately 10:40 a.m., resident #2 was observed in the 300 hallway across from his/her room sitting in a Geri- chair with booties on both feet. The resident was not verbally responsive but looked with his/her eyes when addressed. At 11:30 a.m., the resident was in the same area. At approximately 1:30 p.m., the resident was again observed in his/her Geri-chair outside of his/her room. Per record review, resident #2 was admitted to the facility on January 24, 2003 with diagnoses of post cerebral vascular accident, aphasia and hemiplegia. The initial care plan, dated January 24, 2003, documented that the goal was "to minimize the risk of skin impairment" with a goal date of February 24, 2003. Interventions documented for skin care were to "inspect skin daily, keep skin clean & dry, turn Q(every) 2 hours and prn (as needed), apply barrier cream after each episode of incontinence". Review of the admission weekly skin sweep completed January 24, 2003 indicated intact skin. The initial minimum data set assessment, completed January 30, 2003, indicated no skin breakdown. The plan of care documented the following: Problem onset dated 2/11/03: “at risk for alteration in skin integrity r/t (related to) he/she is totally dependent for bed mobility transfers, he/she has an indwelling Foley catheter and he/she is totally incontinent of bowel." Goals and Target included: "he/she will remain free of skin breakdown as evidenced by appearance of pink health tissue free of reddened areas or breaks in skin integrity on a daily ongoing basis thru next review date of 5/11/03. Approaches documented: "record percentage of meals eaten daily. CNA (certified nursing assistant) to observe skin daily with care and report any changes to nurse. Weekly skin assessment by nurse with documentation. Keep linens and pads clean, dry and wrinkle free. Anti-pressure reduction device on bed. Turn and reposition every two hours and prn. Encourage 100% of dietary intake." Review of clinical record on May 22, 2003, at approximately 3:00 p.m., revealed weekly skin sweep, completed on January 24, 2003, with skin intact. The next documented assessment on the weekly skin sweep was February 23, 2003, in which skin was documented as intact. There was no documentation of weekly skin assessments from January 24-February 23, 2003 for a total of 29 days (4 weeks). Review of the nurses' progress notes on May 22, 2003, at approximately 3:00 p.m., revealed no documentation of skin assessments from January 24,2003 through February 26, 2003. Progress notes dated February 26, 2003, revealed "nurse in charge of this resident requested writer to check resident's right heel. 1.3 x 1.2 intact blister noted on later aspect of right heel with redness on the edge, no warmth, (+) pain when touched. M.D. updated by fax; awaiting response." Progress notes dated February 27, 2003 at 8:10 a.m. Fax received from M.D.. " Don't touch blister. Place pillow underneath ankle to keep heel from touching bed; Have wound care evaluate case for recommendations of protective boots". "Staff CNAs informed, will endorse to wound care nurse." Progress notes dated February 28, 2003, at 11:55 a.m., revealed a faxed response from MD received regarding "TX to (R) heel blister. Order for 'skin prep to (r) heel blister BID and cover with dressing'." Treatment sheet, dated February 2003; first date February 2, 2003, revealed no documentation of preventative skin care. An additional treatment sheet, dated February 12, 2003, documented initiation of the February 27, 2003 faxed physician order. Care Plan dated, February 11, 2003, for skin alteration began documenting (r) heel wound: 2/27/03 = 1.3 x 1.2 - stage 2 3/11/03 = 2.3 x 2.8 - stage 2, 3/15/03 = 2.4 x 3.0 - stage 2 3/25/03 = 2.4 x 3.0 - stage 2 Approaches were added February 27, 2003: "skin prep to (r) heel blister BID and cover with dressing, heel protector on at all times." March 13, 2003 "Clean (r) heel with normal saline and apply TAO and dry dressing daily till healed. Avoid pressure to (r) heel." March 25, 2003 "Clean (r) heel ulcer with normal saline then apply accuzyme cover with sterile gauze and Kerlix bandage." Review of notes dated February 19, 2003 revealed: "Family in to visit. Concerned that resident has ‘poor appetite’ and is 'depressed'. Request to start med pass 2.0 (dietary supplement) 60 cc qid faxed to Dr; Currently on Zoloft, requested Dr. to advise." Progress notes, dated February 20, 2003 revealed "Medpass 2.0 60 cc (cubic centimeters) po gid (four times a day), CBC, UA, BMP." Progress notes of February 21, 2003 revealed "resident out of bed in w/c(wheel chair); appetite remains fair to poor, needs lots of encouragement to eat and drink; consuming 100% of med pass 2.0...continue to encourage fluids." Further review of clinical record revealed a plan of care for the feeding tube, placed on March 25, 2003. The resident was dependent on nutrition and hydration. The resident also had abnormal labs and a urinary tract infection. Thirty-five days lapsed before a care plan was completed for this nutritional. Progress notes of February 19, 2003 identified a decline in the resident's nutritional intake. Interview on May 22, 2003 with the resident care coordinator confirmed that the resident was admitted to the facility without skin breakdown and had acquired a stage 2 right heel pressure sore while at the facility. 10. The above actions or inactions are a violation of Section 42 CFR 483.25(c) (2002), which requires the facility to ensure that (1) a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and (2) a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 11. Pursuant to Section 400.23(8) (b), Florida Statutes (2002), the foregoing is a class II deficiency and as such, has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 12. Respondent was provided a mandated correction date of June 13, 2003. 13. A civil penalty is authorized and warranted in the amount of $2,500, as this violation constitutes an “isolated” Class II deficiency. COUNT IT RESPONDENT FAILED TO CONDUCT LEVEL TWO BACKGROUND SCREENINGS FOR STAFF WHO HAVE NOT MAINTAINED CONTINUOUS RESIDENCY WITHIN THE STATE FOR THE FIVE YEARS IMMEDIATELY PRECEDING THE DATE OF REQUEST FOR BACKGROUND SCREENING. Section 400.215(2) (b), Florida Statutes (2002) Section 435.04, Florida Statutes (2002) CLASS III DEFICIENCY ISOLATED 14. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 15. On or about May 22, 2003, a complaint survey was conducted at Respondent’s facility. 16. Based on record review and interview, Respondent failed to conduct Level Two background screenings for one staff member (#1). Findings: Review of personnel file for one registered nurse hired January 8, 2003 revealed there was no documentation of level two background screenings. Record revealed that this nurse recently relocated to Florida in November 2002. Interview with the administrator on May 22, 2003 revealed that there had been a recent change in the human resources staff and she was not aware if the missing information was within the facility's possession. 17. Respondent was provided a mandated correction date of June 13, 2003. 18. On or about June 25, 2003, a complaint survey was conducted at Respondent’s facility. 19. Based on record review and interview, Respondent failed to ensure that Level Two background screening was conducted on four (Staff #4,#5, #7 and #9) of fourteen staff members. Findings: A review of the files of employees hired since May 22, 2003 revealed that four of fourteen staff members did not have evidence of the performance of a Level Two background screen for the State of Florida. 20. The above actions or inactions are a violation of Section 400.215(2) (b), Florida Statutes (2002), which requires the facility to conduct level two background screening for employees who have not maintained continuous residency within the state for the five years immediately preceding the date of request for background screening, as provided in Chapter 435, Florida Statutes. 21. Pursuant to Section 400.23(8)(c), Florida Statutes (2002), the foregoing is a class III deficiency and as such, will result in no more than minimal physical, mental or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 fora widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A citation for a class III deficiency must specify the time within which the deficiency is required to be corrected. If a class III deficiency is corrected within the time specified, no civil penalty shall be imposed. 22. A civil penalty is authorized and warranted in the amount of $1,000, as this violation constitutes an “isolated” Class III deficiency. 23. However, since Respondent was cited on May 22, 2003 for a class II deficiency, the fine amount shall be doubled. Therefore, the Agency is authorized to impose a fine in the amount of $2,000. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: a. Enter actual and legal findings in favor of AHCA; b. Impose a $4,500 civil penalty against RESPONDENT; ec. Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002); and d. Grant any other general and equitable relief as appropriate. NOTICE The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2002). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Mitra. Fi (oA Katrina D. Lacy, tesize AHCA - Senior Attorney Fla. Bar No. 0277400 525 Mirror Lake Drive North St. Petersburg, Florida 33701 (727) 552-1525 office (727) 552-1440 fax 10 CERTIFICATE OF SERVICE aaa VED ERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Return Receipt No. 7003 1010 0003 4303 8029 to CT Corporation System, Registered Agent for Donegan Rehabilitation and Health Center, 1200 South Pine Island Road, Plantation, FL 33324 dated on September lot, 2003. Hehe he atrina D. Lacy, Esquire Copies furnished to: CT Corporation System Registered Agent for Donegan Rehab. & Health Ctr. 1200 South Pine Island Road Plantation, FL 33324 (Certified Mail) Diane Rodriguez, Administrator Donegan Rehab. & Health Center 1120 W. Donegan Avenue Kissimmee, FL 34741 (U.S. Mail) Katrina D. Lacy AHCA ~ Senior Attorney 525 Mirror Lake Drive Suite 330G St. Petersburg, FL 33701 It

Docket for Case No: 03-003868