FILED STATE OF FLORIDA PEC 30 03 AGENCY FOR HEALTH CARE ADMINISTRATION " HCA DEPARTMENT CLERK STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, LDs- Desed v. AHCA NO. 2003001959 / 03: 53339 2003006976 / 03-4011 DESOTO HEALTH AND REHABILITATION, ; L.L.C., d/b/a DESOTO HEALTH AND RENDITION NO.: AHCA-03- ‘1&-S-OLC REHABILITATION Respondent. ee ——SS FINAL ORDER Having reviewed the administrative complaint dated July 17, 2003 and the Notice of Intent to Deny dated September 25, 2003, attached hereto and incorporated herein (Ex. 1 & 1a), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised in the premises, finds and concludes as follows: The attached Stipulation and Settlement Agreement (Ex. 2), is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. ORDERED: 1. The attached Stipulation and Settlement Agreement is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. 2. DeSoto Health & Rehabilitation shall Participate in a six - month survey cycle commencing from March 2003. 3. DeSoto Health & Rehabilitation shall pay the Agency $3,000.00 in survey fees, to be paid at the completion of the next survey occurring after the execution of this settlement agreement. 4, DeSoto Health & Rehabilitation shall withdraw its Petition for Formal Hearing. 5. The Agency shall withdraw its revocation of license and denial of DeSoto Health & Rehabilitation’s licensure renewal. DONE and ORDERED this © day of Lec en beer , 2003, in Tallahassee, Leon County, Florida. VR Pud ely edows, MD, Secretary ] ealth Care Administrat Rhonda M. Agency for A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE Copy OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Jonathan S. Grout, Esquire Goldsmith, Grout & Lewis, P.A. 2180 Park Avenue North, #100 Post Office Box 2011 Winter Park, FL 32790-2011 (U. S. Mail) Eileen O’Hara Garcia Senior Attorney Agency for Health Care Administration 525 Mirror Lake Dr. N. #330D St. Petersburg, FL 33701 (Interoffice Mail) Jean Lombardi Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive MS#14 Tallahassee, FL 32308 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Bldg#1, MS#9 Tallahassee, FL 32308 (Interoffice Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS#3 Tallahassee, FL 32308 (Interoffice Mail) William H. Roberts Informal Hearing Officer Agency for Health Care Administration 2727 Mahan Drive, Bldg #3, MS#3 Tallahassee, FL 32308 (Interoffice Mail) T. Kent Wetherell, II Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Fl 32399-3060 (U.S. Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the &O day of DeLee , 2003. ye ary mcChaken Meeecy Cell Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 921-8177 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 2003001959 DESOTO HEALTH & REHABILITATION, L.L.c., DESOTO HEALTH AND REHABILITATION Respondent. ADMINISTRATIVE COMPLAINT EME EVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against DESOTO HEALTH & REHABILITATION, L.L.C., d/b/a DESOTO HEALTH AND REHABILITATION (hereinafter "Respondent") and alleges: NATURE OF THE ACTION 1. This is an action to revoke the license of the Respondent Pursuant to Section 400.121(1) and (3) (d), Florida Statutes. 2. The Respondent was cited for the deficiencies set forth below as a result of surveys conducted on or about March 4, 2002 and March 6-7, 2003. JURISDICTION 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. EXHIBIT SP RO: { i 4, Venue lies in Desoto County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28- 106.207 Florida Administrative Code. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 1002 North Brevard Avenue, Arcadia, Florida 34266. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT DEMONSTRATED CONFIRMED PAST NON-COMPLIANCE FROM THE DATES OF 2/1/03 THROUGH 2/7/03 VIOLATING Fl. Admin. Code R.59A-4.1288 INCORPORATING BY REFERENCE 42 CFR 483.13 (c) and 483.25 (m) CLASS I DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. A Complaint survey was conducted on or about March 06-07, 2003. 9, On that date, based on staff and resident interviews, clinical records and investigation reports it was determined the facility failed to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness for 1 (Resident #1) of 5 residents. ( { 10. Tag F224 Requirement: S/S J Resident Behavior and Facility Practices. The facility must develop and implement written polices and Procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. ll. This requirement was not met as evidenced by: a. On 3/4/03 at 2:15 P.M., during a phone interview the complainant stated, "Dr. had told her she was to get two injections a day to prevent problems with her legs. I was transferred to DeSoto Health and Rehab after attempts were made with two other facilities that had no beds. I arrived at DeSoto at 8 P.M. on Saturday 2/1/03 and was there Sunday, Monday and Tuesday Morning. All this time I did not get any of my medications. The facility nurse also took my inhalers (which I brought with me) away and did not give them back to me until discharge. I did not see a doctor and I had made arrangements to be transported to (nursing home) in (town) ." b. According to interview with the Licensed Practical Nurse (LPN) conducted on 3/6/03 at 2:50 P.M., the complainant was admitted to DeSoto Health and Rehab on 2/1/03 at 8:00 P.M. This LPN had never done an admission before. This LPN also stated she had called the Registered Nurse Supervisor (RNS) six times to make sure she was doing the admission process correctly. However, the Supervisor states, "I don't recall talking to her (LPN) about an admission." ( c. However, the resident was admitted with a diagnosis of Status/Post Left Knee Replacement, Diabetes, Asthma and Angina. Her orders read: Physical Therapy (P.T.) daily BID (twice a day). Full Code Status. Keep incision clean/dry. Remove black sutures 2/2/03. Follow up with Dr. on 2/10/03 or 2/12/03. 1800 Calorie ADA (Diabetic) Diet. Her Meds: Peri-colace 1 capsule P.O. (by mouth) QD (every day) (stool softener) Cetirizine 10 mg. P.O. Q.D. (for allergies) . Terbutaline 2.5 mg. P.O. TID (three times a day) (anti-fungal agent). Montelukast 10 mg. P.O. Q.H.S. (every hours sleep). Simvastatin 20 mg. P.O. Q.H.S. (lowers Cholesterol). Acetaminophen 650 mg. P.O. Q 4 H PRN (as necessary) pain or temp. >101. NuIron 150 mg. P.O. Q.D. (anemia). Triazolam 0.125 mg. P.O. Q.H.S. (for sleep). Oxycodone 5 mg./APAP 325 mg. Q 4 H PRN 1-2 tabs for moderate pain. Enoxaparin 30 mg. Injection Q 12 H (Clot Prevention) . Begin Ecotrin 1 P.O. when Levonix is D/ced (discontinued) . Advair 100/50 1 inhalation B.I.D. with Combivent (Asthma Med.). ( ( Prevacid 30 mg. P.o. Q.D. (Gastric Secretion Inhibitor) . Prednisone 20 mg. P.o. daily x (times) i week (Respiratory Diseases) . d. On 3/6/03 at 2:50 P.M., in an interview with the LPN who admitted the resident, Stated, "I faxed the med order to Med Choice at about 8:30 P.M. or 9:00 P.M, f knew Eckerd's supplied medications but they were closed. I forgot we were supposed to Call the courier," e. The facility policy with Med Choice Pharmacy reads, "Providing routine and timely pharmacy service seven days per week and emergency pharmacy service 24 hourg a day, seven days a week." f£. On the pharmacy hours and delivery schedule the weekend delivery schedule reads, Saturday - one delivery - leaves pharmacy at 4:00 P.M. (please fax orders by 3 P.M.), After regular business hours, a Pharmacist is always on call. Simply call the pharmacy and speak with the pharmacy emergency service operator. If you have an emergency, the operator will page a Pharmacist to return your call. 12. Clinical record review revealed: a. On 2/2/03 at 1430 in the nurses notes it states, "Resident c/o (chief complaint) pain in legs. Tylenol 2 P.O. given with some effect. She has been asking for her medications { { of breath). Up and 00B (out of bed) in w/e (wheelchair) for short period to make a Phone call. She's alert and oriented. Had black sutures removed today." This note is signed by a RN. b. The 3-11 Summary for 2/2/03 states, "Resident given Neb. Tx. Albuterol. Tylenol 2 at 5:30 P.M. for left knee pain. P.T. taken in room. Resident unhappy about unavailability of meds. Reassured meds will be coming this P.M." These notes were also signed by a different RN. Cc. The nurses notes for 11-7 on 2/3/03 at 0205 A.M. State, "Resident has been awake this shift, upset about medications. Given Tylenol 2 tabs for headache at 0130 A.M. Also requested Neb Tx. for difficulty breathing. Reassured her meds were ordered." d. At 1500 on 2/3/03, the nurses notes read, "Resident is angry for not having her meds in the facility. She made arrangements to be transported to Wauchula nursing home." e. At 1620 on 2/3/03, the facility doctor wrote an admission note stating all her diagnosis and her meds. No mention was made about the resident not receiving her medications. £. At 0130 on 2/4/03, resident was given Percocet for pain to left leg. Her medication had been delivered Monday evening at around 11:00 P.M. { { g. There is conflicting information noted on the MAR (Medication Administration Record), so it is hard to determine if this resident received Percocet on 2/2/03 and 2/4/03. During the phone conversation with the complainant it was learned that the nurses stated they were borrowing meds from another resident for her. h. On 2/7/03, the DON had given an in-service on not accepting admissions without a completed 3008. i. At 0750 on 2/4/03, resident was discharged to Nursing Home. j. It was learned during a conference with Adult Protective Services that Ace Medical was taking the resident to Nursing Home when they received a phone call that a bed was available at Hospital Transitional Care Unit. So they turned around and took the resident there because that is where she originally wanted to go. k. At 0900 A.M. on 2/4/03, she was admitted to Hospital. The nurses notes read, has deep cough, has wheezes, 4+ edema to both legs. She came from DeSoto Memorial (Rehab) and was in need of transfer. 1. According to the admission note (from the doctor) dated 2/4/03, the patient initially went toa nursing home after the initial post-op period and apparently, "she had a poor situation there." She wasn't provided with the adequate treatment that she needed. The patient has left knee pain and she has become short i i of breath associated with bilateral leg swelling and not doing very well. The plan by the physician indicates Hospitalized in the Transitional Care Unit with evaluation by P.T. and 0.7. (Occupational Therapy). The Patient will be on bed rest today after she stabilizes. She will be on intravenous Lasix. Heparin lock will be inserted and we will obtain blood work today including the Troponin-I, BNP, and Chemistry panels. [I will follow the patient. Pertinent orders are written in the chart. She will be on ace inhibitors, nitrates, and calcium channel- blockers for aortic insufficiency. She will also be on Combivent and Advair to take care of the Chronic Obstructive Pulmonary Disease component and continue on Zocor and Singular. Patient appears to be a good candidate for rehab but we will limit the rehab at this point in time until we feel that volume over-load is controlled. m. On 3/6/03, in an interview with the DON (Director of Nursing) she stated, "We (the facility) did not know about this incident until you (the surveyor) walked in today." However, on 2/7/03 the DON had given an in-service on not accepting admissions without a completed 3008 (Transfer Form) . n. Interviews with the four nurses that had cared for this resident indicated all knew the proper steps to take to get medications on a weekend. The LPN stated, "We faxed the med sheet at night and there is no delivery on Sunday so the day shift should have called the pharmacy." An RN stated, "It was my RAS evens ereeenaneeee sntirns f . ; { 1st or 2° night working and I noticed they (meds) weren't in but figured they were ordered and should be here by 11:00 P.M. and the night nurse would give them." 13. On 3/6/03, during this complaint investigation all staff interviewed knew the Proper procedure for ordering medications and 4 new admission charts were reviewed (none were admitted on a weekend) and all their medications were ordered and given as ordered. 14. The DON stated she would have to counsel the involved employees and possible Suspension. Then she would in-service all nurses. 15. Tag F333 Requirement: Medication Errors. The facility must ensure that residents are free of any significant medication errors. 16. Based on clinical record review, staff and resident interviews the facility failed to administer medication for 1 (Resident #1) of 5 residents, which caused the resident discomfort and jeopardized her health and safety. This occurred during a period of eight shifts and involved five different nurses. 17. This is evidenced by: a. On 2/1/03, resident was admitted to DeSoto Health and Rehab with diagnosis of status/post left knee replacement, Chronie Obstructive Pulmonary Disease, Diabetes, Asthma, and History of Angina. eam hae: re cece ; Her Meds: Peri-colace 1 capsule P.O. (by mouth) oD (every day) (stool softener) . Cetirizine 10 mg. P.O. Q.D. (for allergies). Terbutaline 2.5 mg. P.O. TID (three times a day) (anti-fungal agent). Montelukast 10 mg. P.O. Q. H.S. (every hours sleep). Simvastatin 20 mg. P.O. Q.H.S. (lowers Cholesterol). Acetaminophen 650 mg. P.O. Q 4 H PRN (as necessary) pain or temp. >101. NuIron 150 mg. P.O. Q.D. (anemia). Triazolam 0.125 mg. P.O. Q.H.S. (for sleep). Oxycodone 5 mg./APAP 325 mg. Q 4 H PRN 1-2 tabs for moderate pain. Enoxaparin (Levonix) 30 mg. Injection Q 12H (Clot Prevention) . Begin Ecotrin 1 P.O. when Levonix is D/cd (discontinued) . Advair 100/50 1 inhalation B.I.D. with Combivent (Asthma Med.). Prevacid 30 mg. P.O. Q.D. (Gastric Secretion Inhibitor). Prednisone 20 mg. P.O. daily x (times) 1 week (Respiratory Diseases) . b. On 3/6/03 at 2:50 P.M., in an interview with the LPN who admitted the resident, stated, "I faxed the med order to Med Choice at about 8:30 P.M. or 9:00 P.M. I knew Eckerd's supplied medications but they were closed. 1 forgot we were supposed to call the courier." RR enna A TN, ( ( Cc. In an interview with the DON on 3/6/03 at 1:00 P.M., it was discovered that the initials on the MAR with a circle around them means they were not given. d. The MAR showed that Peri-colace 1 capsule, Acetaminophen 650 mg., and Oxycodone 5mg/325 mg. APAP were the only meds given on 2/2/02. e. On 3/4/03, during an interview with the resident it was learned that the nurses had told her they were borrowing meds for her from their EDK (Emergency Drug Kit) and other residents. f. On 2/3/03, the MAR showed that only Acetaminophen 650 mg., Peri-colace 1 capsule, and Montelukast 10 mg. were given. g. On 2/4/03, Peri-colace 1 capsule, Claritin 10 mg., Terbutaline 2.5 mg, Combivent Inhaler 2 puffs, Advair 100/50 1 inhalation, Prednisone 10 mg., and Oxycodone 5 mg/325 mg. APAP and Lovenox 30 mg. SQ injection were the only meds given. h. The MAR clearly shows on 2/2/03, 2/3/03 and 2/4/03 the resident did not receive all her ordered medications. This error was not noticed on eight consecutive shifts by five different nurses caring for this resident. i. According to nurses notes dated 2/2/03 and 2/3/03 the resident did receive Nebulizer treatments of Albuterol for which no written order could be found. j. On 2/4/03, this resident was admitted to Hospital TCU (Transitional Care Unit) with a diagnosis of fluid over-load. On admission the resident's weight 211 lbs, was short 11 of breath, has significant leg swelling associated with some tachycardia and uncontrolled blood pressure. She received intravenous Lasix therapy and on 2/5/03 weighed 206 lbs. k. The deficient practice was corrected on 2/7/03. 18. The above actions or inactions constitute a violation of (1) Chapter 59A-4.1288 Fl. Admin. Code. R. incorporating by reference 42 CFR 483.13(c) which requires the facility to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. (2) Chapter 42 CFR 483.25(m) which requires the facility to ensure that it is free of medication error rates of five percent or greater; and residents are free of any significant medication errors. 19. The above referenced violations constitute the grounds for the one (1) imposed Class I deficiency. COUNT ITI RESPONDENT WAS CITED FOR TWO CLASS I DEFICIENCIES ARISING FROM SEPARATE SURVEYS OR INVESTIGATIONS BETWEEN SEPTEMBER 2000 AND MARCH 2003 (30 MONTH TIME PERIOD) VIOLATING §400.121(3) (ad) Fl. Stat. (2002) CLASS I DEFICIENCY 20. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 21. A Health Licensure and Certification survey was conducted on or about March 04-08, 2002. 22. Tag 325 Requirement: 23. On that date, based on observations, clinical record review, and interview with the facility's consultant RD (Registered 12 ( Dietician), MDS (Minimum Data Set) Coordinator, Director of Nursing (DON) and facility nursing staff, the facility failed to provide adequate nutrition resulting in significant weight loss for 1 of 13 active sampled residents (Resident #27). 24. This is evidenced by: 1. Resident #27, who receives all hydration and nutrition via Gastrostomy Tube, being admitted to the hospital with Sepsis from a UTI (Urinary Tract Infection) and severe dehydration as evidenced by abnormal lab results including elevated WBC (White Blood Count), sodium, BUN (Blood Urea Nitrogen) and Creatinine and an Albumin of 2.4 which is indicative moderate protein depletion. 2. Calculation of the resident's BMI (Body Mass Index) of 18 that is indicative of being severely underweight. Normal is 19 ~ 27. 3. Lack of intervention to correct inadequate amount of calories by Gastrostomy tube being administered until surveyor intervention. 4. Failure of RD evaluating and assessing resident within 72 hours of admission as outlined in the facility's Policy and Procedures. 5. Administering incorrect tube feeding by not following physician orders. 13 25. ( ( 6. Incorrect assessment of RD evidenced by calculating incorrect tube feeding contents and not following physician orders for the correct formila to be given. 7. Evidence of a 6.8-pound weight loss (9.3%) in 16 days. 8. Incomplete documentation on the MAR (Medication Administration Record) of amount of fluids and tube feedings given prior to admission to the hospital and after re- admission to the facility on 2/28/02. 9. Incomplete monitoring for fluid administration for residents on tube feedings per facility protocol. 10. Failure to develop and implement a plan of care for tube-feeding maintenance as indicated by RAP (Resident Assessment Protocol) on 11/22/01. Due to inaccurate amounts of calories given to this resident, lack of planning for this resident's care, pre and post hospital stay, and in light of the fact this resident is dependent on staff for nutrition and hydration, the facility failed to maintain the nutritional parameters necessary to prevent significant weight loss for Resident #27. The findings include: a. Resident #27 was re-admitted to the facility on 2/28/02, following a 9-day hospital stay. The resident has a history of CVA (Cerebral Vascular Accident), Dysphagia with Gastrostomy tube placement for nutrition and hydration, Aphasia Hypertension, and Seizures. The resident also returned with a Stage II pressure 14 sore to the right lateral ankle and a Stage I pressure sore to the coccyx. b. Clinical record review revealed that a late entry was written on 2/19/02 at 3:15 P.M., by facility nursing staff. The entry reads, "...Unresponsive, cold and clammy, temp taken 101.7 ax (Axillary ~ meaning under the arm pit - clinical significance, one must add one degree Fahrenheit to equal an oral temperature) . ARNP (Advanced Registered Nurse Practitioner) in to see resid (Resident) and rec'd order to send to E.R. (Emergency Room) for eval. (Evaluation). ... Approx (Approximate) time of exit of facility with 911 is 1:45 P.M." Emergency room records were requested and received from the facility. Review of the E.R. records reveal that the resident was admitted to the hospital with the diagnosis of Septic Shock, Dehydration, Pneumonia and Urosepsis. c. The resident's History and Physical written by the attending physician on 2/19/02 reads, "The patient is a 74 - year old --- very well known to me, ...total care in the nursing home, was seen by my nurse practitioner this afternoon and found to be febrile with noisy breathing and respiratory distress. 'His/her' urine color had become extremely dark and she transferred "him/her' to the emergency room where 'he/she' was evaluated and found to have evidence of elevated WBC count, infiltrate in the right lower lobe, and severely hypotensive. 'He/she' was fluid resuscitated and diagnosed as septic shock, stabilized in the 15 ( ( Emergency Room and transferred to the floor for continued care." The note continues, "GENERAL: The patient is conscious, barely responsive, barely opening 'his/her' eyes to command, but does not seem to be in acute distress. VITAL SIGNS: 99.5, 64 regular, 24, 102/50 now. Height 5'10, weight 113 lb 4 oz. --- ASSESSMENT: 1. Pneumonia. 2. Urinary Tract Infection with sepsis 3. Cerebrovascular Accident with hemiparesis and contractures on the right." da. The first available laboratory work-up is dated on 2/20/02 and was on the resident's facility clinical record. WBC = 40.7 H - Reference range of normal = 4.8 - 10.8 thou/ulL. BUN = 74 H - Reference range of normal = 8 - 23.0 mg/dL. Creatinine 1.6 H - Reference range of normal = 0.8 - 1.5 mg/dL. Sodium = 168 H - Reference range of normal = 137 - 145 mmoi/1. Potassium = 3.0 L - Reference range of normal = 3.5 - 5.1 mmol/l. Chloride = 128 H - Reference range of normal = 95 - 108 mmo1/1. Total Protein = 5.7 L - Reference Range of normal = 6.3 - 8.2 g/dl. Albumin = 2.4 L - Reference range of normal = 3.2 5.0 g/dl. e. Review of the nurses' notes prior to 2/19/02, does not indicate that the resident had refused any tube feeding or water flushes. The only documented incidences of the resident pulling apart the connection of the Gastrostomy tube from the pump was noted on 1/23/02 and 1/31/02. 16 f. Prior to the resident's admission to the hospital on 2/19/02, the resident was receiving NutriVent 42 ec/hr via pump with 200 cc of flush per shift and 50 cc of water before and after medications. The resident was receiving medications at 6:00 A.M., 2:00 P.M., 9:00 P.M. and 10:00 P.M. This would equal 1000 cc per day of free water plus 787 cc of fluid from the tube feeding and 1,512 K/cal in a 24-hour period. This order was written on 2/5/02. g. The resident's weight on 1/1/02 was 120 pounds. on 2/2/02, the residents weight increased to 122 pounds. h. Review of the History and Physical dictated by the attending physician on 2/19/02, in the hospital has a recorded weight of 113.4. This is a 9.3% weight loss in 17 days. i. Review of the resident's MAR reveals blank spaces of documentation for tube feeding per pump on 2/10/02 and 2/13/02. j- The facility's Policy and Procedure entitled - SPECIAL NEEDS: ENTERAL FEEDINGS - reads, "9. Enteral feeding intake is recorded on the Enteral Feeding guide and incorporated into the clinical record on the shift/24 hour Intake totals of the Intake and Output monitoring sheet in the record." k. The surveyor requested all copies of the Intake and Output monitoring sheets for Resident #27. Even though the resident had been on Gastrostomy tube feedings since 10/4/01, the only records that could be found start on 1/15/02. 17 1. Review of the Intake and Output sheets reveal the documentation to be incomplete. Indeed, since the new order for tube feeding and fluids was ordered on 2/5/02, there are no shifts that are complete in documentation of Intake and Output. In fact, all documentation of Intake and Output cease on 2/10/02. m. Review of the physician's discharge summary from the hospital for Resident #27, dated 2/28/02 reads: "Course and Progress: ...Since patient was getting continuous infusion, and apparently there has not been proper monitoring, I decided to place the patient on bolus feeds with water supplements." n. On 3/5/02 at approximately 8:00 A.M., the surveyor observed the facility staff nurse administer the tube feeding. The nurse aspirated for residual but did not check the Gastrostomy tube for placement. The nurse then administered 30 cc of water; one can of Choice DM and then flushed with 50 cc of water. °. Review of the physician order dated 2/28/02 reads, "Feed 1 can of Choice TF (Tube Feeding) Q 6 (every 6) hours Bolus - 6 oz water flush after Choice TF." (6 oz = 180 cc.) The nurse gave a total of 100 cc less water than ordered at this time. p. Review of the Intake and Output monitoring record since re-admission to the facility on 2/28/02, lacks any documentation from 2/28/02 through 3/3/02. There are Intake and Output 18 ( ( monitoring records for 3/4/02 through 3/6/02, but none are complete. 26. Further review of the label from the tube feeding revealed that Choice DM is a nutritional supplement for oral use for persons with diabetes. This is different from Choice DM Tube Feeding (which the physician ordered) that is nutritionally complete tube feeding formula for persons with diabetes. In addition the surveyor noted that the order for 4 cans of Choice DM (Non-Tube feeding formula) provided only 892.8 calories per day. 27. The nutritional breakdown for Choice DM vs. Choice TF for 4 cans per day are as follows: Choice DM - oral Choice TF 892.8 calorie (4 cans) 1017.6 calories (4 cans) 37.4 grams of protein 43.2 grams of protein 816 mg sodium 816 mg of sodium Four cans formula per day only provided 73% of the Recommend Dietary Intake for vitamins and minerals, and the resident was not on a multivitamin supplement. 28. At 65 inches and 111.8 (weight taken on 2/28/02), the resident's ideal body weight should be 142 pounds with a range of 127 to 156 pounds. At 111.8 pounds the resident is 78% of ideal body weight. 29. The resident's BMI is only 18 which is indicative of being severely underweight. Normal is 19 to 27. 19 f ( 30. Albumin of 2.4 is indicative of moderate protein depletion. 31. The method of calculating protein needs of a resident with pressure sores would be 1.2 to 1.5 grams per kg per day or up to 1.9 grams per kg per day with compromised pulmonary status. 32. Protein needs of Resident #27 are estimated at 61 to 76.2 grams per day with a pressure sore and 61 to 96.5 grams per day if also pulmonary compromised. Four cans of tube feeding administered to Resident #27 would provide only 40 to 60% of protein needs regardless of which formula was used. 33. On 3/6/02, an interview was held with the facility's RD. She stated that she had been ill recently and had not planned on coming in until the survey team requested her presence. The RD does not have a replacement. 34. The RD was shown the note written on Resident #27 on 3/4/02, by the facility Dietary Manager. The note reads, "Resident returned from the hosp. (Hospital) to be bolus feeding, RD notified, no problems with feedings or weight at this time." 35. The RD stated that calculating the nutritional needs was not the Dietary Manager's duty. The RD stated that she spoke with the nurse who admitted the resident to the facility on 2/28/02 and told the nurse that the formula was not suitable for this resident and the resident had been on NutriVent previously because of a history of Chronic Obstructive Pulmonary Disease. However, the RD was not sure whether the amount of calories was brought up as an issue at this time. 20 36. On 3/6/02, the nursing staff notified the physician that the resident was only receiving 892 calories per day. Per the RD the physician did not want to change the tube feeding back to NutriVent but now increased the Choice DM TF to six cans per day. 37. An RD statement added to the note from 3/6/02 stated that the change in tube-feed formula had been made. On 3/7/2 at 9:00 A.M., the survey team discovered the tube feeding was being given was still not correct. The tube feeding used was still the oral supplement and not the formula specifically designed for tube feedings. 38. Review of the latest MDS (Minimum Data Set) dated 11/22/01, was generated for an admission. The RAP (Resident Assessment Protocol Summary) triggers for both Tube Feeding and Dehydration/Fluid Maintenance. The tube-feeding summary reveals that the resident has a Gastrostomy tube and has had problems with aspiration. The dehydration summary reveals that due to decreased independent access to fluids the resident is at risk for electrolyte imbalance and the team will proceed to care plan. The plan of care was unavailable on the chart. The surveyor requested the facility to bring all the old charts from medical records. Extensive search of all records by facility staff and surveyor failed to find any written care plan generated from this MDS. Review of the interdisciplinary care plan conference sheet reflects only the original admission conference from 10/30/01. 21 { Also, no written care plan could be located from the resident's original admission care plan meeting on 10/30/01. 39. A 2-week Interim Nursing care plan for pneumonia is dated 2/28/02. Interim care plans for dehydration reads, flush with water every shift (no amount was indicated), feedings per order, weight, Intake and Output and HOB up. This is not dated. 40. Interview with MDS Coordinator on 3/6/02, revealed that she was sure a care plan had been written on 11/22/01, but she could not explain how the Interdisciplinary work sheet was void of signatures for that meeting. The MDS Coordinator stated the she felt she had written a care plan, but she could not find it. 41. Extended Survey Date: 3/13/02 a. Review of Resident #27 I & O (Intake and Output) record since 3/8/02 indicates that on 3/8/02 the I & O record is incomplete. Neither surveyor nor the charge nurse could locate any documentation of I&0 from 3/9/02 through 3/12/02. b. Resident #27 remains on the 6 cans of Choice DM TF/day. Therefore, the resident's calories are still at 70% of what he/she needs according to calculations of height, weight and metabolic needs to heel pressure sores and promote weight gain. c. The resident's weight on 3/12/02 was 111 pounds. Previous weight on 2/28/02 was 111.8 pounds. d. The RD note dated 3/12/02, reveals a request to the physician that the resident be changed to NutriVent 5 cans per. However, even with this formula change, the resident would only 22 ( ( be at 90% of his/her caloric needs. If the formula were changed to NutriVent, the protein needs of the resident would be met, but as of 3/13/02, the resident is receiving only 82% of his/her protein needs. 42. 43. Tag 327 Requirement: Based on observations, clinical record review and interviews with the resident (agreed to have interview printed), the MDS (Minimum Data Set) Dietician resulting (Resident 44. Coordinator, Director of Nursing (DON) and the Registered (RD), the facility failed to provide adequate hydration in severe dehydration and a 9-day hospital stay for 1 of 13 #27) active sampled residents. This is evidenced by: 1. Resident #27, who receives all hydration and nutrition via Gastrostomy Tube, being admitted to the hospital with Sepsis from a UTI (Urinary Tract Infection) and severe dehydration as evidenced by elevated temperature of 101.7 F and abnormal lab, results including elevated WBC (White Blood Count), sodium, BUN (Blood Urea Nitrogen) and Creatinine. 2. Incomplete documentation on the MAR (Medication Administration Record) of amount of fluids and tube feedings given prior to admission to the hospital and after readmission to the facility on 2/28/02. 23 45. ( ( 3. Incomplete Intake and Output monitoring records for fluid administration for residents on Tube Feedings per facility protocol. 4. Observation of a nurse providing inadequate amounts of water flush ordered by the physician for Resident #27. 5. Failure to develop or implement a care plan for rehydration/fluid maintenance as indicated by RAPs on 11/22/01. 6. After hospitalization for rehydration on 2/28/02, facility staff failed to implement the systems that would identify and prevent further dehydration of Resident #27. The facility did not provide sufficient fluids for Resident #22 resulting in clinical/physical signs of dehydration. The facility failed to provide adequate fluids for 4 of 13 (Residents #11, #21, #22, and #23) active residents sampled and one (RS Resident #37) random sample (RS) by not having water at their bedside within reach, observed on 3/4/02 between 9:15 A.M. and 10:30 A.M., during the initial tour. 46. The findings include: la. Resident #27 was readmitted to the facility on 2/28/02 following a 9-day hospital stay. The resident has a history of CVA (Cerebral Vascular Accident), Dysphagia with Gastrostomy tube placement for nutrition and hydration, Aphasia Hypertension, and Seizures. 24 ( { b. Clinical record review revealed that a late entry was written on 2/19/02 at 3:15 P.M., by facility nursing staff. The entry reads, "...Unresponsive, cold and clammy, temp taken 101.7 ax (Axillary - meaning under the arm pit - clinical significance, one must add one degree Fahrenheit to equal an oral temperature) . - ARNP (Advanced Registered Nurse Practitioner) in to see resid (Resident) and rec'd order to send to E.R. (Emergency Room) for eval (Evaluation). ... Approx (Approximate) time of exit of facility with 911 is 1:45 P.M." c. Emergency room records were requested and received from the facility. Review of the E.R. records reveal that the resident was admitted to the hospital with the diagnosis of Septic Shock, Dehydration, Pneumonia and Urosepsis. d. The resident's History and Physical written by the attending physician on 2/19/02 reads, "The patient is a 74 - year old --- very well known to me, ...total care in the nursing home, was seen by my nurse practitioner this afternoon and found to be febrile with noisy breathing and respiratory distress. 'His/her' urine color had become extremely dark and she transferred ‘him/her' to the emergency room where 'he/she' was evaluated and found to have evidence of elevated WBC count, infiltrate in the right lower lobe, and severely hypotensive. 'He/she' was fluid resuscitated and diagnosed as septic shock, stabilized in the Emergency Room and transferred to the floor for continued care." The note continues, "GENERAL: The patient is conscious, barely 25 ( ( responsive, barely opening 'his/her' eyes to command, but does not seem to be in acute distress. VITAL SIGNS: 99.5, 64 regular, 24, 102/50 now. Height 5'10, weight 1131b 4 oz. ..-ASSESSMENT: 1. Pneumonia. 2. Urinary Tract Infection with sepsis. 3. Cerebrovascular Accident with hemiparesis and contractures on the right." e. The first available laboratory work-up is dated on 2/20/02 and was on the resident's facility clinical record. - WBC = 40.7 H (High) - Reference range = 4.8 - 10.8 thou/uL - BUN 74 H - Reference range = 8 - 23.0 mg/dL - Creatinine 1.6 H - Reference range = 0.8 - 1.5 mg/dL - Sodium = 168 H - Reference range = 137 - 145 mmol/1 ~ Potassium = 3.0 L (Low) - Reference range = 3.5 - 5.1 mmol/1 108 mmol/1 ' - Chloride = 128 H - Reference range = 95 - Total Protein = 5.7 L - Reference Range = 6.3 - 8.2 g/dl - Albumin = 2.4 L - Reference range = 3.2 - 5.0 g/dl f. The preceding labs were drawn at the hospital on 2/19/02. Resident #27's calculated serum osmolality was 375, Sodium was 168, BUN was 74 and BUN/Creatinine ratio was 46. These laboratory results are indicative of severe dehydration. g. Dehydration is indicated when: Serum Osmolality is greater than 295, Sodium is greater than 147, BUN is greater than 10 and the BUN/Creatinine ratio is greater than 25. h. Review of the nurses' notes prior to 2/19/02, does not indicate that the resident had refused any tube feeding or water 26 flushes. The only documented incidences of the resident pulling apart the connection of the Gastrostomy tube from the pump was noted on 1/23/02 and 1/31/02. i. Prior to the resident's admission to the hospital on 2/19/02, the resident was receiving NutriVent 42cc/hr via pump with 200 cc of flush per shift and 50 cc of water before and after medications. The resident was receiving medications at 6:00 A.M., 2:00 P.M., 9:00 P.M. and 10:00 P.M. This would equal 1000 cc per day of free water plus 787 cc of free fluid from the tube feeding in a 24-hour period. This order was written on 2/5/02. j- Review of the resident's February MAR reveals documentation omissions for varying shifts for 200 cc water flushes for eight of nine days (2/11/02, 2/12/02, 2/13/02, 2/15/02, 2/16/02, 2/17/02, 2/18/02 and 2/19/02) before the hospitalization. The water flushes that were to be given before and after medications show omissions on varying shifts on 2/5/02, 2/9/02, 2/11/02, 2/12/02, 2/13/02, 2/15/02, 2/16/02, 2/17/02, 2/18/02 and 2/19/02. k. The facility's Policy and Procedure entitled - SPECIAL NEEDS: ENTERAL FEEDINGS - reads, "9. Enteral feeding intake is recorded on the Enteral Feeding guide and incorporated into the clinical record on the shift/24 hour Intake totals of the Intake and Output monitoring sheet in the record." 27 ( ( 1. The surveyor requested all copies of the Intake and Output monitoring sheets for Resident #27. Even though the resident had been on Gastrostomy tube feedings since 10/4/01, the only records that could be found start on 1/15/02. m. Review of the Intake and Output monitoring sheets reveal the documentation to be incomplete. Indeed, since the new order for tube feeding and fluids was written on 2/5/02, no shifts are complete in documentation of Intake and Output monitoring. In fact, all documentation of Intake and Output monitoring cease on 2/10/02. n. Review of the physician's discharge summary from the hospital for Resident #27, dated 2/28/02, reads: "Course and Progress: ...Since patient was getting continuous infusion, and apparently there has not been proper monitoring, I decided to place the patient on bolus feeds with water supplements." oO. On 3/5/02 at approximately 8:00 A.M., the surveyor observed the facility staff nurse administer the tube feeding. The nurse aspirated for residual but did not check the Gastrostomy tube for placement. The nurse then administered 30 cc of water, one can of Choice DM and then flushed with 50 ce of water. Review of the physician order dated 2/28/02 reads, "Feed 1 can of Choice TF (Tube Feeding) Q 6 (every six) hours Bolus - 60z water flush after choice TF." 6 oz = 180 cc 28 ( ( The nurse gave a total of 100 cc less water than ordered at this time. p. Review of the Intake and Output monitoring record since re-admission to the facility on 2/28/02 lacks any documentation from 2/28/02 through 3/3/02. There are Intake and Output monitoring records for 3/4/02 through 3/6/02, but none are complete. q. Laboratory reports that show improved status after hospitalization dated 3/7/02 are as follows: - BUN = 10 - normal range = 8 - 23.0 mg/dL - Creatinine = 0.6 L - normal range = 0.8 - 1.5 mg/dL - BUN/Creatinine Ratio = 12 - normal range = 12-20 - Sodium = 136 L - normal range = 137-145 - WBC = 13.4 H - normal range = 4.8 - 10.8 thou/uL r. Review of the latest MDS (Minimum Data Set) dated for both Tube Feeding and Dehydration/Fluid Maintenance. s. The tube-feeding summary reveals that the resident has a Gastrostomy tube and has had problems with a aspiration. The dehydration summary reveals due to decreased independent access to fluids the resident is at risk for electrolyte imbalance and the team will proceed to care plan. t. The care plan was unavailable on the chart. The surveyor requested the facility to bring all the old charts from medical records. Extensive search of all records by facility staff and surveyor failed to find any written care plan generated 29 ( from this MDS. Review of the interdisciplinary care plan conference sheet reflects only the original admission conference from 10/30/02. Also, no written care plan could be located from the resident's original admission care plan meeting on 10/30/01. u. Interview with MDS Coordinator on 3/6/02, revealed she was sure a care plan had been written on 11/22/01, but she could not explain how the Interdisciplinary work sheet was void of signatures for that meeting. The MDS Coordinator stated she felt she had written a care plan but she could not find it. Vv. A 2-week Interim Nursing care plan for pneumonia is dated 2/28/02. An interim care plan for dehydration reads: flush with water every shift (no amount was indicated), feedings per order, weight, Intake and Output and HOB (head of bed) up. This is not dated. w. Due to lack of developing and implementing a plan of care, observation of facility nurse giving inadequate fluid, and incomplete and inaccurate documentation fluid intake and output, there is no indication that dehydration will not re-occur for this resident. x. During the Extended Survey on 3/13/02 the Intake and Output monitoring record was reviewed. The record indicates incomplete or no documentation for 3/08/02 through 3/12/02. 2a. Resident #22 was admitted with multiple diagnoses including but not limited to Diabetes Mellitus, Cerebral Vascular Accident, Seizures, Simple Schizophrenia and Depression. 30 ( i b. During initial tour on 3/4/02 at approximately 9:45 P.M., the resident was observed lying flat in bed. The resident's lips were observed to be cracked and dry. The water pitcher was observed to be out of reach from the resident. A call light was observed to be in reach of the resident. The resident stated, "I can't use the call light because I can't use my hands." The resident's care plan revealed, "Special call light- keep so she can press it with her chin." During the initial tour the call light was observed to be approximately 12 inches from her chin. c. The resident's medical record MDS revealed, "2/2 (limitation both sides / full loss) of arms hands legs and feet." The MDS also revealed, "4/2 (Total Dependence / one person assist) for eating." d. The resident's Certified Nurse Aide (CNA) Care Plan on 3/4/02 revealed no documentation of fluids offered from March ist through March 4th. e. The resident was observed in her room on 3/4/02 at approximately 11:35 A.M., being assisted with lunch. Resident's meal tray contained 90 cc of apple juice and 240 cc of low fat milk. The resident requested water and refused the other liquids on her meal tray. The resident was heard requesting crackers for her tomato soup. The CNA assisting the resident stated there were no crackers. The resident stated, "Then I don't want the soup, unless I have crackers." A large container of crackers 31 { were observed in the unit food pantry. Following surveyor intervention, the CNA provided crackers for the resident. During the meal, the resident was observed to drink only water. f. At 1:00 P.M. on 3/4/02, the resident was observed up in a Geriatric Chair with both feet elevated, and the call light was not placed under her chin. The call light was attached to a top sheet covering the resident and was approximately 18 inches from the resident's chin. g. Staff was observed at 1:30 P.M. and again at approximately 2:35 P.M., entering the resident's room no water offered to the resident. At 2:45 P.M., the resident was placed back in bed. No fluids were offered to the resident after placing the resident in bed. h. At 2:55 P.M., the hydration cart was observed outside the resident's room. The dietary aide providing fluids and supplements did not go into the resident's room. She continued down the hallway offering other residents nourishments. The Nourishment List revealed that the resident received nourishment once on the March 1, 2, and 3 but did not receive nourishment on the 4th. The Nourishment Cart is passed twice a day, afternoon and evening. i. During an interview with the resident, on 3/4/02 at approximately 3:00 P.M. stated, "No I was not given any water. The only time I get any water is at meals, when I ask for it. Will you give me some water I'm thirsty." The resident's lips 32 ( ( were observed dry and cracked. The resident drank approximately 270 cc of water. Observation of the resident's call light was not placed under her chin as care planned. 3. On March 5, 2002, the CNA Care Plan was backdated reflecting that the resident had received fluids from the 1st through the 4th during the evening shift. It also revealed that the resident had received fluids on the 5th during the early morning shift. k. On 3/5/02, the resident was observed at 8:15 A.M. in bed. The resident's lips were dry. She stated, "I'm thirsty". At 8:30 A.M., the resident was observed being assisted with breakfast, drinking. The resident's call light was placed approximately 12 inches from her chin (out of reach) . 1. The resident's bedside water pitcher when observed from a 90 cc cup with a straw was half filled with water. The resident's bedside water pitcher when observed from 1:45 P.M. until 4:30 P.M., was one fourth filled and a 90 cc cup was half full. The resident's call light was observed not placed under her chin. m. Observation of the resident from 3/5/02 at 5:00 P.M., found the resident's lips were dry and cracked with dry mucosa of her mouth and red, cracked tongue. Resident stated, "The last time I received water was during lunch and when I received my medications. I only like water with my meals." 33 ( ( n. On 3/6/02 at approximately 9:30 A.M. and again at 11:30 A.M., the resident water pitcher was observed three quarters full and the plastic cup was half full. Resident stated, "No one gave me water, I'm thirsty." The resident's call light was not placed under her chin. °. On 3/6/02 at approximately 4:00 P.M., the resident was observed with cracked dry lips, dry mucosa of the mouth and a dry, cracked, red tongue. The resident requested a drink of water and consumed approximately 240 cc of water. p- A review of the CNA Resident flow sheet for January and February 2002 revealed that the resident was offered fluids, but no refusals were documented. q- The resident's medical record reveals that the resident refuses to have blood drawn, periodically refuses to take her Dilantin, and on occasions refuses to eat (three times in January and February) . r. The resident's Nutritional Risk Assessment on 12/18/01 revealed that the resident is at high risk nutritionally. s. The facilities procedures for hydration risk for provided "sufficient fluid" to meet their identified needs. 2) Residents will be monitored by nursing staff for any clinical signs and symptoms of possible insufficient fluid intake. 3) Alternatives will be offered to encourage residents to take sufficient fluids as needed. 4) If a resident is at risk for dehydration, fluids will be offered at least every 2 hours. 34 ( t. Nursing staff should offer fluids whenever providing care to the resident, no matter how small. u. During an interview with the Dietitian on 3/6/02 at approximately 1:30 P.M., the Dietitian revealed she was unaware the resident was not accepting dietary fluids. The Dietitian recalculated her fluid needs which remained as documented as on 12/18/01. v. An interview with the DON and the Care Plan Coordinator verified they were unaware of the resident's lack of fluid intake, and subsequently, the resident was not identified as high risk for dehydration; therefore, the facility's procedures were not implemented for dehydration 3a. Resident #21 was readmitted to the facility on 1/16/02 with diagnoses including left above knee amputation, Type 2 Diabetes, Cerebrovascular Accident (stroke), Depression and Anemia. b. Review of the Minimum Data Set (MDS) significant change assessment completed on 01/30/02 revealed that the resident had problems with diarrhea and constipation, swallowing problems and had an indwelling catheter. The resident needed limited assistance for eating and had poor vision. The MDS noted that the resident had experienced pneumonia and a Urinary Tract Infection in the last 30 days. The resident also had a fever in the last 7 days. 35 c. Review of the Resident Assessment Protocols (RAPs) revealed that the resident triggered for dehydration secondary to history of Urinary Tract Infections, Pneumonia and recent major surgery. He also has a supra pubic catheter and often suffers from constipation. The RAP concluded that the resident continued to be at risk for electrolyte imbalance and the facility would proceed to care plan. The Nutritional Status RAP indicated that the resident had some swallowing problems, was seen by the speech therapist, and was changed to a Mechanical Soft diet with Nectar Thick Liquids. The RAP concluded that the facility would proceed to care plan to monitor weight status. d. Review of the Physical Assessment completed by the Advanced Registered Nurse Practitioner (ARNP) on 01/29/02 revealed that she had documented that the staff were concerned about the resident having diarrhea for 1 week. She documented "TI was not made aware of diarrhea last wk (week).Water was not readily accessible when I was in room." Physical assessment included: "obvious wt. (weight) loss - noted especially in face." "voice hoarse and scratchy" "mucus membranes somewhat dry." The assessment indicated that the diarrhea may be secondary to antibiotics. The documented plan stated, "Staff reminded to keep water with straw at bedside." The ARNP ordered lab work. e. Review of the lab data dated 01/30/02, indicated normal lab values except for a slightly elevated Blood Urea 36 Nitrogen/Creatinine (BUN /Cr) ratio of 22 (reference range 12- 20). f. Review of the Physician's Telephone Orders dated 01/30/02, revealed a nursing request for sugar-free pudding between meals, three times a day and on 02/09/02, the physician ordered a diet change to nectar thick liquids secondary to swallowing problems at the recommendation of the Speech Therapist. A Modified Barium Swallow was conducted on 02/12/02. g. Review of the resident's Interdisciplinary Care Plan dated 01/25/02, revealed that there was no care plan to address the resident's risk for dehydration. Review of the speech care plan, dated 01/25/02, revealed that the therapist noted that the resident had decreased oral motor strength, range of motion and coordination. The approaches included: consistency modification and compensatory techniques. The care plan did not address the use of thickened liquids and risk for dehydration and aspiration. Review of the nutrition care plan, dated 01/16/02, identified the resident at risk for weight loss. Approaches included "MBS to be done to assess swallowing", "1/25/02 SLP (speech language pathologist) as ordered with D/C (discontinue) 2/22/02", "aspiration precautions", and "2/9/02 Mech (mechanical) soft w/ (with) ground meat and nectar thick liquids NAS (No Added Salt) RCS (Reduced Concentrated Sweets). The care plan did not address the resident's risk for dehydration and approaches to monitor for dehydration. 37 h. Review of the Nutritional Risk Assessment completed on 01/18/02, revealed that the resident's fluid needs were determined to be 2430 cc per day. The Registered Dietitian (RD) assessed the resident to be consuming 26-75% of planned meals and 1500 to 2000 ce of fluid per day. She noted that the resident was at high nutritional risk secondary to multiple drugs, diagnoses, fair appetite, adjust problems following amputation and potential for skin breakdown. She did not address the resident's risk for dehydration with inadequate fluid consumption. i. Review of the Nutritional Progress Notes dated 01/30/02, completed by the Certified Dietary Manger, revealed that the resident had a poor appetite and was depressed. She documented that she would notify the RD. j. The RD documented on 01/30/02, that the resident weighed 168 pounds (a 10 pound weight loss since readmission) . She further documented, "It is my opinion that this is actually the lst wt. (weight) after his amputation + (and) hosp. (hospital) stay." Her plan was to monitor weekly weights and contact the RD with concerns. k. Review of the resident's weekly weights revealed that the resident weighed 178 pounds on admission on 01/16/02, decreased to 172 pounds on 01/23/02 and decreased to 168 pounds on 01/28/02. Weight remained stable at 168 pounds on 02/04/02, gradually increased to 171 pounds on 02/11/02 and 174 pounds on 38 02/18/02. The next recorded weight revealed a decrease to 168 pounds on 02/24/02 and an increased back to 174 pounds on 03/02/02. 1. There was no further documentation by the RD regarding the resident's fluctuating weights, nutrition or hydration status in the clinical record. ™m. Observation of the resident on 03/04/02 at noon, revealed the resident in bed eating lunch with head of bed ata 30-degree angle. The resident was served ground meat and nectar thick liquids, which included 8 ounces of thickened milk, 4 ounces of thickened water, and 4 ounces of thickened juice. The resident was observed coughing on the food. He drank only 8 ounces of thickened milk. Staff were not observed offering assistance with the meal or offering the resident other liquids from his tray prior to removing the tray from the room. n. Observation of the resident on 03/04/02 at 2:40 P.M., revealed the resident in bed in the same position at noon. The resident had no liquids at the bedside. °. Observation of the resident on 03/04/02 at 3:00 P.M., revealed that the resident was offered only sugar-free pudding and no liquids from the hydration cart. p. Observation of the resident on 03/05/02 at 9:05 A.M., revealed that there was a cup of thin water with a straw at the resident's bedside. An empty pill cup was on the bedside table next to the water. 39 \ f q.- Observation of the resident on 03/05/02 at 11:10 A.M., revealed the resident up in his electric wheel chair in the hall outside of his room, which was across from the nurse's station. The resident had a hoarse, dry voice and was complaining of being thirsty. Resident stated that his mouth was dry. He stated, "they tell me to ask for something to drink, but how can I when the don't come in." The resident confirmed he gets pudding between meals, but no liquids. He stated that he had liquids at breakfast and 2 puddings as his morning snack. He confirmed that he had not been offered any other fluids since breakfast. The resident confirmed that he sometimes gets thin water with his pills from the nurses. He further stated that there is water at his bedside, but he can't reach it by himself. He stated, "I'm blind." r. Observation of the resident's room at 11:15 A.M., revealed no water at the bedside. s. At 11:17 A.M., the Surveyor asked an aide who was coming out of the room next door to assist the resident. The resident asked the aide for water and stated to the aide, "J should have gotten some (water) this morning, I haven't yet." t. Interview with the Certified Nursing Assistant (CNA) on 03/05/02 at 11:35 A.M., revealed that the resident had a cooler in his room with thickened water and he gets things from the hydration cart. The CNA stated that the resident was up when she arrived at work at 7 A.M. and had not checked on him. She stated 40 that she had been busy this morning, so she didn't know if he had been offered any fluids. She confirmed that she did not offer him anything to drink. She stated that the aides write the offering of fluids on the ADL (activity of daily living) flow sheets. u. The aide entered the resident's room and showed the surveyor a cooler with cold water that held 2 containers of thickened water. The cooler was across the room on the resident's dresser and not accessible to the resident. The cooler had a screw top lid and could not be opened by the resident. The aide confirmed that the resident was unable to get fluids on his own. When told that the other aides had not offered him fluids that morning, the aide replied, "Well, he gets something from the hydration cart." The aide confirmed that she was unaware that the resident only received pudding at 10 A.M. and that no hydration cart is passed. She was unaware that he receives pudding and no fluids from the hydration cart when the hydration aide passes the cart at 2 P.M. and 8 P.M. Vv. Observation of the resident on 03/05/02 at 11:50 A.M., revealed the resident in his room in his electric wheel chair eating his lunch. The resident confirmed that no one came in and offered him water that morning. The resident stated, "They meant to. This happens every day. I only got 2 puddings this morning." The resident was served 4 ounces of thickened water, 4 ounces of thickened juice and 8 ounces of thickened milk on his lunch tray. 41 The resident stated that he would drink the beverages with his meal. w. Review of the Nursing Aide Care Plan (nurse's aide flow sheet) for 03/02, revealed that the Dietary section coded the resident as needing assistance with eating. The Nutrition section listed the resident's diet, which included the thickened liquids. It was checked that the resident was at risk for malnutrition and dehydration and the form stated to record fluids on the reverse side of the form. The following approaches were checked: offer/assist fluids each contact; measure fluid intake; measure fluid output and weigh monthly. The back of the care plan where the aides recorded meal and fluid percentage intake and number of times fluids offered was blank for all days and all shifts for the month when reviewed on 03/04/02. x. Review of the form on 03/05/02, revealed the form had been completed during the previous night for all days for the 3 P.M. - 11 P.M. shift and the 11 P.M. - 7 A.M. shift with the 7 A.M. - 3 P.M. shift remaining blank for 03/01/02 through 03/04/02. y. Observation of the resident's room on 03/05/02 at 4:00 P.M., revealed that the cooler was on the over bed table next to the resident's bed with a stack of plastic cups to the side. The cooler was closed and could not be opened by the resident. Z. Observation of the resident at dinner in the East Wing Dayroom on 03/05/02 at 5:40 P.M., revealed he drank 4 ounces of 42 i thickened water and 4 ounces of thickened milk with his meal and left the dining room. Interview with a staff member revealed that he had taken away the resident's iced tea because it was not sent thickened. The staff person was not observed obtaining a thickened tea from the kitchen for the resident. aa. Review of Nurse's Notes on 03/06/02, revealed that the Director of Nursing had recorded in the resident's record on 03/05/02 at 5:45 P.M., that he had sent a staff person to the kitchen to obtain a cup of tomato soup for the resident because he could not eat the sliced tomatoes. It was documented@*that the soup was thickened and given to the resident. There was no documentation of the amount of soup that the resident ate. bb. Observation of the snack tray sent to the East Wing on 03/06/02 at 10:05 A.M., revealed that it contained a cup of pudding for the resident with no beverage. cc. Review of the Nursing Aide Care Plan sheets on 03/06/02, revealed that the day shift had not recorded the resident's fluid and food intake and additional offerings of fluid since 02/28/02. dd. Observation of the resident's room on 03/06/02 at 11:00 A.M., revealed the cooler that contained the resident's thickened water was on the bedside table for the other bed in the room, behind the curtain, out of view and reach of the resident and staff. The resident was observed in the hall in his wheel chair, he was lethargic and responding slowly to the staff. The staff 43 nurse sent the resident to the hospital emergency room with complaint of chest pain. ee. Review of the 03/06/02 lab data upon return from the emergency room revealed that the resident's BUN/Cr ratio remained elevated at 25.4 and the resident had a low Hematocrit level. These labs may be indicative of a mild dehydration status. f£. Review of the facility's policy and procedure on Hydration/Risk for Dehydration revised 08/10/99 revealed the following: 3. "If identified "at risk", initiate care plan addressing triggered areas with appropriate interventions. Communicate approaches to C.N.A.'s and other staff as needed.”... 4. "The dietician will initiate a timely full assessment after admission, re-admission and with significant change to identify potential for risk, correlate resident information with MDS/RAP trigger for hydration and guide development of the interdisciplinary care plan as needed." 5... "Care planning with appropriate interventions will be implemented." 7. "The resident's hydration status will be monitored through identified approaches in the care plan.”... 13. "If a resident is at risk for dehydration, fluids will be offered at least every 2 hours..." 44 4a. Resident #23 RAP summary triggered for being at risk for Nutrition. The resident was not care planned for Nutrition Status. Refer to F279. The facility maintained a CNA Nutrition and Fluid intake sheet for the resident. The resident is at risk for Nutrition due to senile delusions. The resident's care plan further states the resident has senile dementia. b. In January 2002, there was no documentation of fluid intake on 12 of 186 opportunities to document fluid intake. Additionally, the resident was documented on 51 other occasions as either refusing to take fluids or "0" was entered on the CNA records. Cc. In February 2002, there was no documentation of fluid intake on 51 of 168 opportunities to document fluid intake. Additionally the resident was documented on 19 other occasions as either refusing to take fluids or "0" was entered on the CNA records. d. In March 2002, there was no documentation of fluid intake on 17 of 45 opportunities to document fluid intake. Additionally the resident was documented on 1 other occasion as either refusing to take fluids or "0" was entered on the CNA records. 5a. Resident #11's RAP summary triggered for being at risk for nutrition and dehydration. The resident was care planned on 8/23/01 to "encourage PO (by mouth) intake of fluids." The care plan was updated and the monitoring of the resident's fluid 4S intake was to be continued. A review of the Certified Nursing Assistant (CNA) Nutrition and Fluid intake sheet for November 2001 revealed a lack of documentation of fluid intake on 34 of 153 opportunities to document fluid intake. Additionally, the resident was documented on 13 other occasions as either refusing to take fluids or "0" was entered on the CNA records. b. In December 2001, there was no documentation of fluid intake on 32 of 186 opportunities to document fluid intake. Additionally the resident was documented on 6 other occasions as either refusing to take fluids or "0" was entered on the CNA records. c. In January 2002, there was no documentation of fluid intake on 33 of 186 opportunities to document fluid intake. Additionally, the resident was documented on 2 other occasions as either refusing to take fluids or "0" was entered on the CNA records. 48. Tag 490 Requirement: 49. Based on observation of residents and staff throughout the facility, clinical record review, interview with residents on an individual basis and in the Resident Group Council, interviews with the Administrator, DON (Director of Nursing), facility's Consultant RD (Registered Dietician), MDS (Minimum Data Set) Coordinator, QA (Quality Assurance) Consultant and facility's staff nurses, the Administrator failed to monitor staff and intervene in a timely matter resulting in harm to 3 active residents (Residents #19, #22 and #27) 46 and the struggle for all residents to attain and maintain their highest level of well-being. 50. This is evidenced by: 1. Failure to assure that the facility had sufficient nursing staff to care for all residents. 2. Pailure to follow the facility's Quality Assurance plan for correction of F241, F281, F353, F364, F426 and F490 resulting in a recitation of these tags at both the annual standard, and follow- up survey to the complaint dated 1/17/02. 3. Failure to follow policies and procedures resulting in harm to residents as exhibited by resident's who had clinical and physical signs of dehydration, weight loss and pressure sores. 4. Failure to follow facility's policies and procedures to prevent dehydration and weight loss and pressure sores. 5. Failure to assure that nursing and dietary staff accurately assess residents, and in a timely manner, initiated changes when there has been a decline in resident condition in relationship to hydration and nutrition. 6. Failure to assure that staff developed and up-dated Care Plans with specific and progressive interventions to prevent dehydration, weight loss and pressure sores. 47 TTS hs ee ve SENN SOP 7. Failure of MDS staff and facility's interdisciplinary Care Plan team to assure timely RAIs (Resident Assessment Indictors). 8. Failure to assure accurate resident clinical records as evidenced by falsification of records. 9. Failure of the Administrator to effectively and efficiently oversee and manage the facility led to a residents severe weight loss and dehydration (Resident #27) and development of pressure sores (Resident #19). 51. The findings include: 1. The Administration did not require the Director of Nurses or other facility staff to accurately assess residents and to develop specific and progressive care plans for these residents. Refer to F278 G Class II - accuracy of assessments for Residents #19, #27 and #28. Refer to F279 G Class II - Accurate and Comprehensive Care Plan for Resident #21, #23 and #27. This failure by the Administration to require accurate assessment and, specific and progressive care planning on each resident contributed to development of pressure sores, dehydration and weight loss to residents. Refer to F314, F325 and F327. 2. The Administration failed to increase staffing on the units to assure that adequate staff was available to monitor, care for, and protect residents from harm. This failure to increase staffing contributed to the facility's inability to 48 eevee caspases tee ( ! properly assess, develop and up-date Care Plans with specific and progressive interventions, and to care for, and monitor residents. Refer to F353, F278, F279, F314, F325 and F327. 3. The Administrator failed to assure that facility's Policies and Procedures were routinely implemented by nursing and dietary staff, which resulted in weight loss, dehydration and pressure sores. Refer to F314, F325 and F327. 4. Administrator failed to assure that the facility's Plan of Correction for the complaint survey ending on 1/17/02 was successfully implemented and completed. This is evidenced by the recitation of the following: F241 E Class III - Dignity of Residents, F281 D Class III - Professional Standards of Nursing Care, F353 E Class III - Staffing to meet the needs of all residents, F364 E Class III - Palatability of food, F426 D Class III - Accurate administration and distribution of drugs and biologicals and F490 K Class I - Inadequate Administration. 5. Failure of the Administration to use its recourses effectively and efficiently to attain the highest practice physical, mental, and psychological well being of all resident this facility as evidenced by falsification for records and citation of Immediate Jeopardy at F325 J Class I and F327 K Class I. 52. Tag 493 Requirement: 53. Based on observation, review of clinical records, review of the facility Policy's and Procedures, including Nursing, and 49 i TE f ( Administration, the Governing Body of the facility failed to assure that the Policy and Procedures to prevent weight loss, dehydration and pressures sores were implemented and that the Plan of Correction established by the facility for a complaint survey ending on 1/17/02 was implemented and successfully completed. 54. This is evidenced by: 1. Failure of the Administrator and the facility's supervisory personnel to follow the facility's Quality Assurance plan for correction of F241, F281, F353, F364, F426 and F490 resulting in a recitation of these tags at both the annual standard, and revisit survey to the 1/17/02 complaint. 2. Failure of the Administrator and the facility's supervisory staff to assure that facility Policy and Procedures were implemented to prevent harm to residents as outlined by absent, inaccurate or incomplete assessments of residents, resulting in G Class II Deficiencies at F278 and F279. 3. Failure of the Administrator and facility supervisory staff to assure that Policy and Procedures were implemented to prevent harm to a resident, development of an avoidable pressure sore, resulting in F314 ataG Class II level. 4. Failure of the Administrator and facility supervisory staff to assure accurate documentation by staff which 50 resulted in falsification of records and a citation of F492 at a G Class II level. 5. Failure of the Administrator and supervisory staff to prevent Immediate Jeopardy as outlined in F325 at a J Class I level (Weight Loss), F327 K Class I level (Hydration) and F490 K Class I level (Administration) . 5S. The findings include: 1. The Governing Body of this facility did not ensure the Administration effectively directed staff resulting in harm to residents. This is exhibited by failure of the supervisory staff to ensure accurate assessments of residents and the lack of development of specific, progressive care plans to monitor residents. Refer to F278 G Class II - plan for Resident #19, #23, #27 and #28. Refer to F279 G Class II - Accurate and comprehensive care planning for Resident #21, #23, and #27. This failure contributed to the development of pressure sores, dehydration and weight loss to residents. Refer to F314, F325, and F327. 2. The Governing Body of the facility did not ensure the Administration and supervisory nursing staff increased staff on nursing units to ensure adequate nursing staff was available to monitor, care for, and protect residents from harm. This failure to increase staffing contributed to the facility's inability to properly assess and implement updated care plans with specific, 31 to F353, F278, F279, F314, F325 and F327. 3. The Governing Body of the facility did not ensure the Administration, Nursing, and Dietary Supervisory staff were utilizing the facility's written Policies and Procedures which resulted in weight loss, dehydration and pressure sores. Refer to F314, F325, and F327. 4. The Governing Body of this facility failea to ensure the facility's Plan of Correction for the 1/17/02 complaint wag successfully implemented and completed by the Administration and nursing Supervisory staff. This is evidenced by the reciting of the following: F241 E Class III - Dignity of Residents, F281 D Class III - Professional Standards of Care, F353 EB Class III - Staffing to meet the need of residents, F364 E Class III - Palatability of Food, F426 D Class III - accurate administration and distribution of drugs and biologicals, and F490 K Class I - Inadequate Facility Administration. 5. The Governing Body of the facility did not ensure the Administration, Nursing, and Dietary Staff used its resources effectively and efficiently to attain the highest practicable physical, mental, and Psychological well-being of all residents in this facility as evidenced by falsification of records and Citation of Immediate Jeopardy at F325 [ Class I and F327 K Class I. 56. The above actions or inactions constitute a violation of (1) 52 Section 400.121 (3) (d) Fl. Stat. (2002), which states that the Agency shall revoke or deny a nursing home license if the licensee or controlling interest operates a facility in this state that is cited for two class I deficiencies arising from separate surveys or investigations within a 30-month period. 57. The above referenced violations constitute the grounds for the one (1) imposed Class I deficiency. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A, Make factual and legal findings in favor of the Agency on Counts I and II; B. Impose a license revocation for the violations cited in Counts I and II, against the Respondent under §400.121(1) and (3) (d), Florida Statutes; c. Assess costs related to the investigation and prosecution of this case pursuant to § 400.121 (2) Fl. Stat. (2002) and; D. All other general and equitable relief allowed by law. NOTICE DESOTO HEALTH & REHABILITATION, L.L.C., d/b/a DESOTO HEALTH AND REHABILITATION is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). 53 rey insinménnive a: ( All requests for hearing shall be made and delivered to: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida 32308. Attention: Lealand McCharen, Agency Clerk. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully s Eileen O’Hara Gar¢dia, Esquire AHCA - Senior Atforney 525 Mirror Lake/Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (FAX) I HEREBY CERTIFY that a copy hereof has been furnished to Philip Castleberg, Registered Agent for Desoto Health & Rehabilitation, L.L.C., 1002 North Brevard Avenue, Arcadia, Florida 34266, by U.S. Mail and Administrator, Desoto Health and Rehabilitation, 1002 North Brevard Avenue, Arcadia, Florida 34266 by U.S. Certified Mail, Return Receipt No.7002 2030 0007 8499 7086 o Eileen O’ Hara Garcia, Esquire 54 Copies furnished to: Philip Castleberg Registered Agent for Desoto Health and Rehabilitation, 1002 North Brevard Avenue Arcadia, Florida 34266 (U.S. Mail) Administrator Desoto Health and Rehabilitation, 1002 North Brevard Avenue Arcadia, Florida 34266 (U.S. Certified Mail) Eileen O’Hara Garcia, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701 (Interoffice) 5S a eer . = XUVYIvw wire . FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: 5 JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY September 25, 2003 Certified Article Number Administrator Desoto Health & Rehab, L.L.C 7k60 3901 5844 4609 4575 1002 N. Brevard Avenue SENDERS RECORD Arcadia, FL 34266 NOTICE OF INTENT TO DENY (#2003006976) It is the decision of this Agency that the Nursing Home License sénewal plication for Desoto Health & Rehab, L.L.C. is DENIED. Pursuant to Section 400.121(3)(d), Florida Statutes (F.S.), the agency shall revoke or deny a nursing home license if the licensee or controlling interest operates a facility in this state that is cited for two class I deficiencies arising from separate surveys or investigations within a 30 month period. You were notified by Administrative Complaint on July 16, 2003 that Desoto Health & Rehab, L.L.C. was in violation of this section of the Florida Statutes. . EXPLANATION OF RIGHTS Pursuant to Section 120.569, Florida Statutes, (F.S.) you have the right to request an administrative hearing. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS Sincerely, e/a CaraLee S. Stames Program Manager Long Term Care Unit cc: Agency Clerk, Mail Stop 3 Wendy Adams, Mail Stop 3 Fort Myers Field Office ‘ K. Munn, Long Term Care Unit Legal File, Long Term Care Unit EXHIBIT Visit AHCA online at www. fdhe. state. fl.us 2727 Mahan Drive « Mail Stop #33 Tallahassee, FL 32308 STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. DESOTO HEALTH AND REHABILITATION, L.L.C., d/b/a DESOTO HEALTH AND REHABILITATION, The Respondent. oe AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. DESOTO HEALTH AND REHABILITATION, L.L.C., d/b/a DESOTO HEALTH AND REHABILITATION, The Respondent. —_ ) ) ) ) } ) Case No.: 03-3323 J ) ) ) ) } ) ) ) ) ) ) ) ) Case No.: 03-4011 ) ) ) ) ) ) ) ) STIPULATION AND SETTLEMENT AGREEMENT — OE LEMENT AGREEMENT Petitioner, Agency for Health Care Administration (“Agency”) through their undersigned representatives and DeSoto Health and Rehabilitation, L.L.C. d/b/a DeSoto Health and Rehabilitation (“DeSoto”), pursuant to Section 120.57(4), Florida Statutes (2001) each individually, a “party” collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: EXHIBIT iZ WHEREAS, DeSoto is a nursing home licensed pursuant to Chapter 400, Part Il, Florida Statutes (2002) and Chapter 59A-4, Florida Administrative Code (2002): and WHEREAS, the Agency has Jurisdiction by virtue of being the regulatory and licensing authority over nursing homes pursuant to Chapter 400, Part I, Florida Statutes; and WHEREAS, the Agency served DeSoto with an Administrative Complaint intending to revoke DeSoto’s license: and WHEREAS, DeSoto requested a formal administrative hearing as to the revocation requested above; and WHEREAS, the Agency served DeSoto with a Notice of intent to deny DeSoto’s licensure renewal application; and WHEREAS, DeSoto requested a formal administrative hearing as to the notice of intent to deny its licensure renewal application; and WHEREAS, DeSoto has Presented factors in mitigation of revocation and denial of its license; and WHEREAS, the Agency has determined that the factors in mitigation are appropriate; and WHEREAS, the parties have agreed that a fair, efficient and cost effective resolution of this dispute would avoid the expenditure of substantial sums to litigate the dispute; and WHEREAS, the parties have negotiated and agreed that the best interests of all the parties will be served by a settlement of this proceeding; NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals are true and correct and are expressly incorporated herein. 2. Both parties agree that the “whereas” clauses incorporated herein are binding findings of the parties. 3. Upon full execution of this Agreement, DeSoto agrees to a withdrawal of its Petitions for a Formal Administrative Hearing; agrees to waive any and all appeals and proceedings; agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), a formal proceeding under Subsection 120.57(1), appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court (DOAH) of competent jurisdiction. 4. DeSoto agrees to participate in a six-month survey cycle commencing from March 2003. DeSoto shall pay the Agency $3,000.00 in Survey fees, to be paid at the completion of the next survey occurring after the execution of this settlement agreement. The Agency shall withdraw its Administrative Complaint and its intent to deny DeSoto’s licensure renewal application based on the mitigating factors presented by DeSoto. 5. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Florida and shall be subject to all applicable Provisions for interest, attorney’s fees, expenses and costs for the prevailing party. 6. DeSoto neither admits nor denies the allegations in the Administrative Complaint and the allegations in the notice of intent to deny. The Agency agrees that it will not impose any further penalty or sanction against DeSoto as a result of the Surveys of March 6-7, 2003, however, no agreement made herein shall preclude the Agency from imposing a penalty against DeSoto for any deficiency/violation of statute or rule identified in a future survey of DeSoto, which constitutes a cumulative fine or an uncorrected deficiency from the Surveys of March 6-7, 2003. 7. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and dismissing the above-styled case. 8. Each party shall bear its own costs and attorneys’ fees. 9. This Agreement shall become effective on the date upon which it is fully executed by all the parties. 10. DeSoto, for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs and executors or administrators, does hereby discharge the Agency for Health Care Administration and its agents, representatives and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this Agreement, by or on behalf of DeSoto or related facilities. 11. This Agreement is binding upon all parties herein and those identified in the aforementioned paragraph twelve (12) of this Agreement. 12. The undersigned have read and understand this Agreement and have authority to bind their respective principals to it. 13. This Agreement contains the entire understandings and agreements of the parties, 14. This Agreement supercedes any prior oral or written agreements between the parties 15. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement by DeSoto or related facilities, its successor or any resulting organization shall be void. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement: ficothe te debe DEPUTY SECRETARY AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive Tallahassee, FL 32308 Date signed: IP JBP7 o3 VALDA C. CHRISTIAN, ESQUIRE GENERAL COUNSEL AGENCY FOR HEALTH CARE ADMINISTRATION 2727 Mahan Drive Tallahassee, FL 32308 Date signed: cee JONATHAN S. GRO! GOLDSMITH, GROUT & LEWIS, P.A. 2180 Park Avenue North, #100 Post Office Box 2011 Winter Park, FL 32790-2011 407/740-0144 Attommeys for Respondent Florida Bar No. 296066 Date signed: LL “FACE “OR

Docket for Case No: 03-004011