OF 5 14 STATE OF FLORIDA G3 . AGENCY FOR HEALTH CARE ADMINISTRATION Oe AGENCY FOR HEALTH CARE 1G, vg ADMINISTRATION, fy ; . MeL A LS Petitioner, AHCA No.: 200202953P ‘* AHCA No.: 2002029541 v. Return Receipt Requested: 7000 1670 0011 4847 2710 BROOKWOOD EXTENDED CARE CENTER OF 7000 1670 0011 4847 2727 HOMESTEAD, LLP d/b/a BROOKWOOD 7000 1670 0011 4847 2734 GARDENS CONVALESCENT CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Brookwood Extended Care Center of Homestead, LLP d/b/a Brookwood Gardens Convalescent Center (hereinafter “Brookwood Gardens Convalescent Center”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (“Fla. Stat.”), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose administrative fines totally $81,000 pursuant to Section 400.23(8), Fla. Stat. (2001), for the protection of the public health, safety and welfare. 2. This is an action of Notice of Intent to Assign Conditional Licensure Status to Brookwood Gardens Convalescent Center pursuant to Section 400.23(7) (b), Fla. Stat. JURISDICTION AND VENUE 3. AHCA has jurisdiction pursuant to Chapter 400, Part II, Fla. Stat., (2001). 4. Venue lies in Dade County, pursuant to Section 400.121(1)(e), Fla. Stat., and Rule 28.106.207, Florida Administrative Code. PARTIES S. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Fla. Stat., (2001), and Chapter 59A-4 Florida Administrative Code. 6. Brookwood Gardens Convalescent Center operates a 120-bed skilled nursing facility located at 1990 S. Canal Drive, Homestead, Florida 33035. Brookwood Gardens Convalescent Center is licensed as a skilled nursing facility, license number SNF1064096; certificate number 8550, effective April 12, 2002 through February 28, 2003. Brookwood Gardens Convalescent Center was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I BROOKWOOD GARDENS CONVALESCENT CENTER FAILED TO ENSURE SUFFICIENT NURSING STAFF WAS AVAILABLE ON A DAILY BASIS TO PROVIDE NEEDED CARE AND SUPERVISION FOR WANDERING RESIDENTS TITLE 42, SECTION 483.30, CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE RULE 59A-4.106(4) (r), FLORIDA ADMINISTRATIVE CODE. (NURSING SERVICES) CLASS I 7. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 8. Based on annual survey conducted on April 12, 2002 and based on observation, interview and record review, the facility failed to ensure that there was sufficient staff to provide nursing and related services to attain or maintain the highest practicable, physical, mental and psychosocial well-being of each resident, as required by Title 42, Section 483.30, Code of Federal Regulations. Because of this, the facility did not prevent identified abusive residents from causing and/or from being likely to cause serious injury, harm, impairment, or death to the residents receiving care in the facility. 9. During a group interview on 4/10/02, 4 out of 10 residents voiced concerns about being physically and psychologically abused by other residents. Resident #27, R#26 and R#25 reported that sample resident #15 had been repeatedly hitting them and other residents over the past two months. a. Resident #15’s nurse’s notes reveal the following information: 2/6/02 “As reported by maintenance person... he witnessed (Resident 15) slapped and bang with her hands on {another resident’s) head several times before making the attempt to choke him. Both residents was(sic) immediately separated”. On 2/5/02 Nurse’s Notes reveal “Resident fighting with staff in day room”. On 2/7/02 “Resident going in other resident room and yelling and trying to hit other residents - take her out from resident room and take her to her room but she insist to go back”. 2/10/02 6:00 pm “It was reported by a male resident that this resident had hit him on the face and top of head. This resident was found standing in front of male resident while he was sitting on W/C in hall”. 2/11/02 11:00 p.m. “Resident has had increased agitation and aitercations with other residents. 2/16/02 10:15 am Resident ambulating and hitting staff when they stop her from doing that...” 3/5/02 1:45 pm “staff reported that resident is agitated she is hitting visitors on their back...” 3/13/02 6:00 pm “noted yelling _ (illegible) floor..istart to ambulate in 200’s section of hallway..wondering to rooms, redirect to hallway” b. Resident #25 reported to have been punched, pushed, and hit by sample resident # 3 on at least three occasions. Resident #3’s record reveals the following: Psychiatric Evaluation Report dated February 13, 2002 reveals the following under the history of present illness: “Patient struck a nurse and another resident regarding food related issues’. On an Initial Psychological diagnostic form dated 2/18/02, it is noted that Resident #3 would not be receiving psychological services any longer for problem area of aggressive inappropriate behavior due to significant short term memory impairment. c. Resident #16 was described as hitting everyone. Review of Resident #16’s Nurse’s Notes revealed the following: 2/10/02 Resident was very loud this day and defiant. Mrs. ss had =6tto) «6be” redirected continuously...” 2/11/02 at 11:40 am, “Resident sitting in w/c hit a resident & resident in turn hit her. Mrs. did not sustain any injury. Mrs. is becoming increasing hostile toward other residents. She does not have eny safety awareness...” “.. She is able to move around _ the facility in her w/c by pushing her feet...” d. On 4/10/02 at approximately 1:00 p.m. Resident #16 was observed by AHCA personnel to remove the yellow barrier in front of room 409 in the North wing and attempted to enter the room. 10. During the Survey residents reported to AHCA personnel that the facility is aware of the problem caused by wondering residents but has not been able to correct the problem. 9 out of 10 residents reported that the facility has not been able to prevent wandering residents from going into their rooms uninvited. a. Review of the resident council minutes on 4/11/02 revealed that the facility was aware of the wandering behavior. On 3/19/02, residents voiced concern about resident # 10 entering other resident rooms Review of Resident #10’s Nurses’ notes reveal an entry with the following information: 2/19/02 “Called to room 401, observed resident lying on his back...assist up off the floor”. (Resident 10’s room number was at that time #411A). b. The Residents reported that the facility's intervention of placing yellow barrier strips in front of all residents' doors has not been effective in deterring wanderers from entering other resident's rooms uninvited. The wanderers were reported being able to go under the yellow barrier or push it aside. Cc. Two of the residents (R#27 and R#30) in the group reported that resident #11 had entered their rooms and had incontinent episodes on their bed. Review of Resident #11’s record reveals that the Social Services reassessment Form 320 dated 1/29/02 has the following information: “Mr. continues to walk throughout the facility independently, at times he gets into other resident’s rooms. Needs supervision and redirection, specially during meal times...” Review of Resident #27’s Nurse’s Notes reveals the following entry: 1/15/02 at 6:00 am “Resident in hallway screaming. States someone urinated on his bed and he wants to die, Resident advised to calm down and stop screaming. Resident states he is a SOB and can’t breathe. Medicated with (illegible) with relief noted. d. In addition, sampled resident R#27 reported that sampled resident R#29 wanders into his/her room day and night "like we have a welcome sign on the door". 11. Most of the comments made by the residents in the group meeting on 4/10/02 were substantiated through observation, interview and record review during the survey. a. On 4/10/02 at approximately 4:15 p.m., Resident #17 was observed attempting ta enter room 219, beginning to use foul language and repeatedly hitting the male nurse who was trying to re-direct him/her. The resident began to remove the stop sign barrier in front of the room and propelled his/her wheel chair into the room. The resident then got up from the wheel chair and laid on the bed and refused to get up. After licensed staff instructed the resident to get up, the resident began to yell and stated that it was his/her bed and for the staff to get out of the room. Resident # 17's room was located in the 300's hallway. Entries on the Resident’s Nurses Notes revealed the following: 4/10/02 “Resident trying to enter RM 219, instructed resident that the room belonged to another resident, resident refuse to listen, yelling & slapping my arm, using some profanti(sic) towards me, request CNA to call supervisor nurse.. trying to redirect without effective results” and again the same date another entry reads as follows: “Entering Rm 219, resident refused to leave. On 4/7/02: “Winders(sic) from room to room .. combative hitting spitting”. On 4/7/02 10:00 p.m. the Nurse’s Notes reflect the following: “When meds offered by this nurse resident hit nurse hand knocking meds out of med cup”. b. On 4/10/02 at approximately 4:10 p.m. sample resident #14 was observed entering into room 219 (South wing). However, resident's room was located in the 400's hallway in the North wing. Review of resident #14 medical record revealed that he/she was described as being a wanderer and to physically and verbally abuse staff and other residents. The psychiatrist had reported that the resident needed close staff supervision. A review of Resident’s 14 Social Services Reassessment Form dated 1/2/02 reveals the following comments: ‘“Resident.. restless and wonders throughout the facility... gets physically abusive when re- directed and when other residents get in her room”. A review of Social Services Reassessment Form dated 4/2/02 reveals the following comments: “Resident...gets physically abusive at other residents and staff when redirected or when other residents try to go in her room or closer to her room...” Review of Social Service Progress Notes reveal an entry dated 3/29/02 with the following information: ‘“Resident...moved to room 311B as she becomes physically abusive at other residents that get in her room or walk closer to her room as she thinks is her territory.” On 4/9/02 another entry states as follows: “Resident was moved back to room 401 last night as she did not get along with her roommate, was blocking her to enter the room, to use the bathroom or to sleep”. The Nurses Notes for Resident #14 reveal the following information: 3/21/02 “Resident bending towards her and she hitting him with small stuff(sic) toy. Pt. Asked not to hit anyone”. On 3/26/02 “Aggressive behavior last week”. The resident’s care plan dated 1/2/02, to continue as of 4/2/02 reveal the following under the heading of problem “Combative with other residents and staff at times”. Under approach there is an entry to “Redirect resident when wondering into other rooms”. c. On 4/10/02. at approximately 4:20 p.m. interview with sample resident R#25 revealed that resident #10 had entered his/her room about 4 months ago and asked to go to bed with him/her. About two months ago resident #10 was reported to be in the resident's room waiting for the resident. The resident had to summon the nursing staff to take resident #10 out of the room. Review of Resident #10’s Nurses’ notes revealed the following: 2/19/02 “Called to room 401, observed resident. lying on his back...assist up off the floor”. Resident 10’s room number was at that time #411A, On the Resident’s council meeting of 3/19/01 there is a note under new business “ (Resident #10) entering room”. d. Resident R#25 also reported that sample resident #3 pushed him/her in the dinning room during coffee about two months ago. £. On 4/11/02 at approximately 9:45 a.m. sample resident #10 was observed wandering in the North hallway. A CNA came to take the resident back to his/her room but was unable to redirect him/her. The resident kept walking and attempted to enter other residents' rooms. At about 9:50 a.m., the resident was observed wandering alone and entered a room located in the 400's hallway. 10 g. On 4/11/02 at approximateiy 3:40 p.m. a Certified Nursing Assistance (CNA) was observed to leave room 407 without placing the yellow barrier in place. Interview with the staff revealed that she had forgot. Review of the resident status” report, dated 3/19/02, revealed that all staff were instructed to replace the yellow barriers upon entering and leaving residents rooms. h. On 4/12/02 at about 8:50 a.m. resident #18 reported that at least once a week, sample resident #11 wanders into his/her room. Resident 11’s Social Service Reassessment Form dated 1/29/02 reveals that the resident: “Continues to walk throughout the facility independently, at times he gets into other resident’s rooms” i. Interview with administrative staff on 4/10/02 at approximately 8:00 p.m. revealed that the facility was aware of the wandering residents and those who were physically and verbally abusive by providing list of names of these residents. However, based on above findings, the facility failed to ensure that these residents received adequate care and supervision to deter them from wandering into other resident rooms uninvited and causing physical and psychological harm to residents. 12. Based on the foregoing Brookwood Gardens Convalescent Center violated Title 42, Section 483.30, Code 11 of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code and Rule 59A-4.106(4) (r), Florida Administrative Code herein classified as a Class I deficiency pursuant to Section 400.23(8) (a), Fla. Stat., which carries, in this case, an assessed fine of $25,000. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). COUNT II BROOKWOOD GARDENS CONVALESCENT CENTER FAILED TO ASSESS APPROPRIATE INTERVENTIONS AND IMPLEMENT PROCEDURES TO PROTECT RESIDENTS FROM OCCURRENCES OF NEGLECT AND LACK OF SUPERVISION OF RESIDENTS WITH WANDERING AND AGGRESSIVE BEHAVIORS RULE 59A-4,1228, FLORIDA ADMINISTRATIVE CODE 483.15(e) (1), CODE OF FEDERATION REGULATION (STAFF TREATMENT OF RESIDENTS) CLASS I 13. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 14. Based on annual survey conducted on April 12, 2002 and based on observations, interviews with residents and facility staff and clinical record review, the facility failed to assess appropriate interventions and implement procedures to protect residents from occurrences of neglect and lack of supervision of residents with wandering and aggressive behaviors who have access to all areas of the facility. Findings include the following: 12 15. Group interview: During the group interview on 4/10/02 at approximately 10:30 a.m. and 3:00 p.m., 4 out of 10 residents voiced concerned about being physically and psychologically abused by other residents who reside in both north and south wings of the facility. a. Randomly sampled resident #25, 26, 27 reported that sample resident #15 had repeatedly been hitting other residents over the past two months. Resident #15’s nurse’s notes reveal the following information: 2/6/02 “As reported by maintenance person... he witnessed (Resident 15) slapped and bang with her hands on (another resident’s) head several times before making the attempt to choke him. Both residents was(sic) immediately separated”. On 2/5/02 Nurse’s Notes reveal Resident fighting with staff in day room”. On 2/7/02 “Resident going in other resident (sic) room and yelling and trying to hit other residents ~ take her out from resident room and take her to her room but she insist to go back”, 2/10/02 6:00 pm “It was reported by a male resident that this resident had hit him on the face and top of head. This resident was found standing in front of male resident while he was sitting on W/C in hall”. 2/11/02 11:00 p.m. “Resident has had increased agitation and altercations with other residents. 2/16/02 10:15 am Resident ambulating and hitting staff when they stop her from doing that...” 3/5/02 1:45 pm “staff reported that resident is agitated she is hitting visitors on their back...” 3/13/02 6:00 pm “noted yelling — (illegible) flcor..start to ambulate in 200’s section of hallway..wondering to rooms, redirect to hallway” 13 b. Resident #25 reported to have been punched, pushed, and hit by sample resident # 3 on at least three occasions. Resident #3’s record reveals the following: Psychiatric Evaluation Report dated February 13, 2002 reveals the following under the history of present illness: “patient struck a nurse and another resident regarding food related issues’. On an Initial Psychological diagnostic form dated 2/18/02, it is noted that Resident #3 would not be receiving psychological services any longer for problem area of aggressive inappropriate behavior due to significant short term memory impairment. 16. 9 out of 10 residents (sample resident #20, randomly sampled residents # 24, 25, 26, 27, 28, 29, 30, 31) reported problems with wandering residents. These residents reported that the wanderers are going under the yellow wander barrier strips by pushing the strips aside. The residents reported that the facility is aware of the situation but has not corrected the problem. The facility staff identified all the residents in the group as being alert and oriented times three. Review of the resident’s medical record revealed that the residents were assessed as not being impaired in cognition. 14 17. Review of the facility's plan of correction from the re-certification survey of 2001 revealed that yellow wandering strips were placed on doors of all residents except those who requested otherwise to prevent wanderers from entering rooms other than their own. a. The following include more examples given by residents during the group meeting on 4/10/02 regarding the physical and psychological harm inflicted by other residents in the facility: b. Sample resident 420 reported that a month ago a wandering resident came into his/her room, pushed the chair and sat down and would not leave. The resident stated, "He avoids them". c. Randomly sampled resident # 24 (R#24) was hit by a resident 2 months age and informed facility staff. d. Randomly sampled resident #25 (R#25) reported that one month ago in the dining room, he/she was hit and pushed by sampled resident #4, who still resides in the facility. R#25 stated that resident #4 had hit a nurse just a few days ago. R#25 stated that he/she was also hit on the arm 2 months ago by sampled resident # 15. While R425 was speaking, sampled resident #16 was observed to enter the conference room where the group interview was in 15 progress. At this time, R#25 stated that sampled resident #16 “hits everybody" and backs into people with his/her wheelchair in the hallways and dining rooms. e. Randomly sampled resident #26 reported being hit on the shoulder by sample resident #15 about 6 weeks ago. R#26 reported that he/she hit sample resident #15 back, then reported this incident to the C.N.A. R#26 does not know the status of the incident. R#26 stated the wandering residents come from north wing to the south wing. R#26 stated, “You wake up at night and you have people standing over you." R#26 expressed annoyance at wanderers going in and out of his /her room both day and night. f. Randomly sampled resident #27 (R#27) stated that sample resident #16 doesn't have control of his/her wheelchair and runs into people and walls. R#27 further reported that a female wandering resident came into his/her room and got into his/her bed. R#27 stated that he/she closes his/her room door at all times in an attempt to avoid this from happening again. R#27 reported being hit by sample resident #15 two months ago which was witnessed by both R#25 and a licensed practical nurse (LPN) who failed to intervene other than calling out "Watch out behind you". R#27 stated this attack resulted in a very painful injury. Interview further revealed that sample resident #15 still 16 resides in the facility. Furthermore, R#27 stated that a resident of the opposite sex recently entered his/her room while he/she was in the bathroom. The wandering resident laid down on his/her bed and was unable to be removed from the bed by both staff and R#27. In addition, R#27 reported that R#2S also wanders into his/her room day and night, "Like we nave a welcome sign on the docr". g. Resident #27's Social Services reassessment Form dated 3/20/01 reveals that the resident likes to work on model airplanes in his room and converse of his army days. Nurse’s notes entries reveal the following information: 1/15/02 at 6:00 am “Resident in hallway screaming. States someone urinated on his bed and he wants to die, Resident advised to calm down and stop screaming. Resident states he is a SOB and can’t breathe. Medicated with (illegible) with relief noted. 2/1/92 “..Staff member reported that (Resident # 15) from south side hit pt several times in back of head and tapped pt on head. Pt. Assessed no swelling or redness noted. Pt. Denies pain. Dr. Wong in house made aware and examined patient. Message left for ..”2/2/02 at 9:05 pm “Resident... Also states he thinks resident that struck him may have ruptured a vessel in his neck. No visible sign of such. Resident states he don’t want the doctor called because he don’t want to go to the hospital. 2/11/02 at 12:05 pm reveals the following: “Resident hit by another resident - no injury noted. Resident is alert and oriented, able to verbalize needs. We informed resident that we would make every effort to redirect other residents away from him” h. Randomly sampled resident # 28 (R#28) reported that a wandering resident entered his/her room approximately 10 days ago. The wandering resident went into the bathroom, locked the door and refused to come out. R#28 called the certified nursing assistant (C.N.A.), and the C.N.A. stated, "just leave her, she will come out". No other attempts were made by the facility staff to remove the wandering resident. i. Randomly sampled resident #30 (R#30) who was admitted one month ago reported that he/she has complained about sampled resident # 11 who wanders into his/her room at least once a week. R#30 reports that sampled resident #11 enters his/her room, lays on his/her bed, drools and has incontinent episodes. R#30 reports that the latest incident occurred 4/10/02 at approximately 1:00 p.m. when sampled resident #11 removed the yellow wander barrier strip, iaid on the bed and took a nap without any facility staff interventions. In addition, R#30 reports that since his/her admission, R#31 has wandered into his/her room at least 3 times. 18 3. Randomiy sampled resident #33 (R#33) stated that he/she "just kindly leads them out" when he/she can; however R#33 stated for other wandering residents, he/she has to get staff to help remove the residents from his/her room, 18. Surveyor observations and clinical record review: On 4/10/02 at approximately 1:00 p.m., revealed the following: a. Resident #16, from the south wing, was observed to remove the yellow wander barrier strip in front of room 409 in the north wing and attempted to enter the room. Two of the staff in room 409 redirected the resident to leave the room without any further interventions. b. On 4/10/02 at about 3:00 p.m., Resident #32 was observed to enter the nursing station in the south hallway. One of the nursing staff attempted to remove the resident, but the resident started to yell. The staff pushed this wheelchair-bound resident out of the nursing station. The resident grabbed the staff's I.D. badge and would not let go. c. On 4/10/02 at approximately 3:45 p.m., R#32 was again observed this time hitting another resident in the south hallway. The staff had difficulty redirecting the resident. d. On 4/10/02 at approximately 4:10 p.m., sampled resident #14 was observed to wander in and out another resident's room, 219. However, resident's room was located in the 400's hallway in the North wing. Review of resident #14's medical record revealed that he/she was assessed as being severely impaired in cognition with short and long term memory problems. Review of the nursing progress notes revealed that ‘the resident had demonstrated wandering behavior and had been verbally and physically abusive to staff and residents. For example, review of the nursing progress note dated 4/2/01 revealed that the resident had pushed one resident sitting on 4 wheel chair into another resident. On 4/19/01 the resident was described by the nurse as removing the yellow barrier in front of room 405 causing the resident who resided in the room to become angry. e. On 4/20/01 the resident pushed sample resident # 10 sitting on a wheel chair causing it to spin around. The resident was also described in the nursing progress notes dated 5/17/01 as becoming very aggressive when other residents enter the resident's side of hallway. When staff intervenes, the resident becomes physically and verbally abusive toward them. Similar aggressive behavior was described in July, August, September, December 2001. Recent 20 episode was reported to have occurred on 3/21/02 where the resident had hit another resident with a small stuff toy. f. On 4/10/02 at approximately 4:15 p.m-, sample resident #17 was observed to wander into room 219 and started to hit the male nurse who was attempting to re- direct. This resident was observed removing the stop barrier sign from the doorway and entered the room. This resident got up from his/her wheelchair and proceeded to lay on the bed and refused to get up. The resident then started yelling at staff " This is my bed, get out". Resident #17's room was located in the "300 hallway". Based on interview with the administrative staff during the tour of the facility on 4/9/02 at approximately 12:30 p.m., resident #17 was admitted about 1 week ago and continually displayed verbal and physical abusive behavior toward staff and other residents. The Administrative staff added that resident #17 is known to hit, wander from room to room, not easily re-directed, and refuses medications. Staff noted that the doctor is aware of the resident's behavior and has instructed staff to keep trying to administer the medications for behavior problems. This nurse reported that resident #17 does not like anyone in his/her space and has been assigned to a private room. 21 g. Observation on 4/11/02 at 9:45 a.m. revealed sample resident #10 wandering alone in the north hallway. A C.N.A. was observed trying to redirect this resident to his/her own room but was unsuccessful. Resident #10 was observed to continue walking and attempted to enter another resident's room. At 9:50 a.m., resident #10 was observed again to be wandering alone in the "400 hallway”. h. After the facility had implemented short-term interventions in response to the identified immediate jeopardy on 4/10/02, it was observed that on 4/11/02 at approximately 10:10 a.m., resident # 10 wandered into room 416 without any staff interventions. Interview with the administrator on 4/11/02) at approximately 1:20 p.m. revealed that the staff assigned to the wing had left the area to alleviate an altercation between another resident and sampled resident #14. However, review of the ‘short term plan of wandering residents’ letter revealed that "when any monitor needs to leave their post for any reason, they will obtain relief coverage from a nurse or CNA before leaving the floor". i. Further investigation into the altercation of 4/11/02 revealed that despite knowledge of sample resident #14's aggressiveness and inability te get along with other residents (as noted in the resident's clinical record and 22 staff interview), resident #17 had been transferred to sample resident # 14's room that day, resulting in not only the altercation of these two residents but the lack of supervision for wandering sampled resident #10. 3. The facility also failed to adequately assess the adverse consequence of transferring resident #17 to resident #414's room. During the tcur of the facility, the nurse reported both sample resident #14 and #17 needed to be in private rooms due to not being able to get along with other residents and wanting to have their space. In addition, review of the sample resident #14 and #17's clinical record revealed that both residents were described as being aggressive and not able to get along with other residents. Interview with the admission director on 4/12/02 at about 9:30 a.m. revealed that resident #17 was not able to get along with resident #14 and was sent back to his/her own room the same day the altercation took place (4/11/02). Review of sample resident #17's medical record further revealed that the altercation had contributed to the bleeding of a pre-existing hematoma to the back of the head. Moreover, review of sample resident #14's medical record on 4/11/02 revealed that the facility was aware of resident's aggressive response to other residents who come in his/her room. For example, review of the nursing 23 progress note dated 8/30/01 revealed that the resident had pointed his/her finger in front of a new roommate. The new roommate was transferred to another room since he/she "was afraid to.stay there". Review of the social services progress notes dated 3/28/02 revealed that the resident was moved to another room. However, on 4/9/02 the resident was moved back to his/her own room due to not getting along with the roommate. k. On 4/11/02 at approximately 2:45 p.m. the yellow barrier strips were observed to be down in front of rooms 208 and 212. Two residents were observed to be in the room sleeping. Facility staff was not in the area, although according to the short-term plan developed on 4/10/02 for monitoring wanderers, staff monitors were assigned to monitor the area. The plan was to have 2 monitors in the hall of rooms 201-220. In addition, on 4/11/02, review of the resident status report, dated 3/19/02, revealed that all staff were instructed to replace the yellow barriers upon entering and leaving residents rooms. l. On 4/11/02 at 5:45 p.m., R#32 was observed to self-propel his/her wheelchair into the nurses’ station and started to remove the charts without any staff redirection. 19. Resident / staff interviews: Further review of resident #3's clinical record revealed that he/she was re- 24 admitted on 1/22/02. The mental health services symptoms checklist and request for referral dated 1/30/02 revealed that the resident was combative and aggressive. Review of the resident assessment protocol (RAP) for behavior problems dated 2/3/02 revealed that the resident is mentally retarded. The plan was to refer to psychologist and to develop a care plan to prevent behavior problems. The resident was described as needing constant supervision. Review of the clinical record revealed that there was no care plan in place as of 4/12/02 for the behavior problems of sample resident #4. Interview with the social worker on 4/11/02 at about 10:45 a.m. revealed that a care plan for the resident was not developed although the resident was known to be aggressive. Review of the psychologist note dated 2/13/02 revealed that the resident had "struck a nurse and another resident regarding food related issues". a. During interviews on 4/10/02 at 4:20 p.m. and 4/12/02 at 4:10 p.m. with random resident R#25, it was disclosed that on two separate occasions sampled resident #10 entered his/her room. The first occasion was approximately four (4) months ago when sampled resident #10 entered R#25's room and reportedly asked to go to bed with him/her. R#25 stated that the request made him/her "feel bad". Then approximately two (2) months ago, R#25 stated 25 they were "scared" after opening the door to enter his/her room to find sampled resident #10 already inside the room. On both occasions R#25 had to summon facility staff to remove sampled resident #10 from his/her room. R#25 also reported that sampled resident #3, with documented history of aggressive behavior, pushed him/her in the dining room about 2 months ago. R#25 reported another resident entered his/her room and took his/her bedspread. Review of R#25 Social Services reassessment form dated 2/19/02 reveals that this resident is alert and oriented to time, place and person. b. Interview with nursing staff on 4/10/02 at approximately 5:15 p.m. revealed that he/she does not want to be a nurse anymore as he/she is tired of being hit, punched and kicked by physically aggressive residents. c. Interview with R#31 on 4/12/02 at about 8:50 a.m. revealed that sampled resident #11 wanders into his/her room at least once a week. d. Based on above findings, the facility failed to ensure that interventions were functional and appropriate to protect residents from occurrences of neglect and to provide adequate supervision of residents with wandering and aggressive behaviors who have access to all areas of 26 the facility, placing other residents at risk for physical harm and mental distress. 20. Based on the foregoing Brookwood Gardens Convalescent Center violated Section 483.25, Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class I deficiency pursuant to Section 409,23(8) (a), Fla. Stat., which carries, in this case, an assessed fine of $25,000. This violation also gives rise to a conditional license rating pursuant to Section 400.23(7) (b), Fla. Stat. COUNT III BROOKWOOD GARDENS CONVALESCENT CENTER FAILED TO USE ITS RESOURCES EFFECTIVELY AND EFFICIENTLY TO DETER WANDERING RESIDENTS IDENTIFIED BY THE FACILITY FROM GOING INTO OTHER RESIDENTS’ ROOMS UNINVITED AND TO PREVENT IDENTIFIED ABUSIVE RESIDENTS FROM PHYSICALLY AND MENTALLY ABUSING OTHER RESIDENTS. SECTION 483.15(e) (1), CODE OF FEDERATION REGULATION RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE CLASS I 21. AHCA xre-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 22. Based on the annual survey conducted on April 12, 2002 and based on observation interview and record review, the facility failed to use its resources effectively and efficiently to deter 17 wandering residents identified by 27 the facility from going into other resident rooms uninvited and to prevent 10 facility identified abusive residents from physically and mentally abusing other residents. The findings include the following: 23. Interview with residents in the group meeting on 4/10/02 at 10:30 a.m. and 3:00 p.m. revealed that the residents voiced displeasure about facility's failure in providing a safe and home like environment to residents. As alleged in Counts I and II, residents voiced concerns and the facility’s own record support that residents were being physically and psychologically abused by other residents. The facility failed to implement a plan to stop the resident's aggressive behavior toward others. a. In addition, 9% out of 10 residents reported problem with wandering residents going into their rooms uninvited as alleged in Count I and II. The residents reported that the facility's intervention of placing yellow barrier strips in front of all residents' doors has not been effective in deterring wanderers from entering other resident's rooms uninvited. The wanderers were reportedly being able to go under the yellow barrier or push it aside. b. In addition, residents were still observed to wander into other resident rooms even after the facility implemented a new "short term pian for wandering 28 residents’. The plan was to assign staff to monitor for wandering residents and/or residents annoying other residents, at all wings. The monitoring was to have been continued throughout the week for all shifts. However, resident # 10 was observed wandering into room # 416 unattended on 4/11/02 at approximately 10:10 a.m. The monitor who was assigned to the area was not in the hallway monitoring the area. Interview with the administrator on 4/11/02 at approximately 1:20 p.m. revealed that the reason for the assigned staff's disappearance was to take care of a situation. The administrator stated that sample resident #17 was transferred to sample resident # 14 room on 4/11/02, but there was an altercation between the two residents. However, review of the ‘short term plan of wandering residents' letter revealed that "when any monitor needs to leave their post for any reason, they will obtain relief coverage from a nurse or CNA before leaving the floor". c. In addition, 9 out of 10 residents in the group meeting on 4/10/02 reported problem with wandering residents going into their rooms uninvited. The residents reported that the facility's intervention of placing yellow barrier strips in front of all residents' doors has not been effective in deterring uninvited wzndering residents 29 from entering their rooms. The Wanderers were reported being able to go under the yellow barrier or push it aside. Sampled resident #16 was observed on 4/10/02 at approximately 1:00 p.m. to remove the yellow barrier in front of room 409 in the North wing and attempted to enter the room. Also, on 4/10/02 at approximately 4:15 p.m., sample resident #17 was observed attempting to enter room 219 and began to use foul language and repeatedly hit the male nurse who was trying to re-direct him/her. The resident began to remove the stop sign barrier in front of the room and propelled his/her wheel chair into the room. The resident then got up from the wheel chair and lied on the bed and refused to get up. d. In addition, the facility also failed to follow its policy in usina the yeliow barrier strip. A letter provided by the facility dated 4/11/02 regarding facility's "lack of interventions to prevent individual from creating an environment of fear", states, "Velcro strips are placed across doors of all resident rooms." However, on 4/10/02 at approximately 2:50 p.m. the yellow barriers were not put in place in front of rooms 215, 214, 213, 212, 2lland 208 located in the south wing. During the tour of the facility on 4/9/02, however, the barriers to these rooms were placed in front of the doors. Interview with licensed staff 30 during the tour at approximately 17:00 p.m. revealed that the barriers are placed in front of the doors of every room at all times, except during mealtime or medication pass. At the time of observation on 4/10/02, neither activity was taking place. The barriers were placed in front of the door of the rooms mentioned above on 4/10/02 at approximately 3:30 p.m. In addition, on 4/11/02, review of the resident status report, dated 3/19/02, revealed that all staff were instructed to replace the yellow barriers upon entering and leaving residents rooms. e. The facility had also failed to implement an effective program to deter wandering residents from going into other residents’ rooms uninvited, causing mental harm. As alleged in Counts I and II, besides the allegations made by the residents, the facility’s own resident records reflect the memorialization of several incidents. Additionally, on 4/11/02 observation was made on 4/11/02 at approximately 10:10 a.m. of sample resident #10 wandered into rocm 416 unattended. This incident happened even after the facility had developed a short-term plan on 4/10/02 to monitor wandering residents by assigning staff monitors on each wing. However, a monitor was not in the area. Interview with activity staff who was passing in the hallway on 10:15 a.m. revealed that the resident should not 31 be in the room. interview with the administrator on 4/11/02 at approximately 1:20 p.m. revealed that the reason for the assigned staff's disappearance was to take care of a situation. The administrator stated that sample resident #17 was transferred to sample resident # 14 yroom on 4/11/02, but there was an altercation between the two residents. However, review of the "short term plan of wandering residents’ letter dated 4/10/02 revealed that "when any monitor needs to leave their post for any reason, they will obtain relief coverage from a nurse or CNA before leaving the floor”. g. On 4/11/02 at approximately 2:00 p.m. the administrator provided a letter dated 4/11/02, after the immediate jeopardy was announced, a list of interventions to prevent individuals from creating an environment of fear. One of the interventions included providing cognitively impaired residents receive appropriate activities. A schedule for two new activities (exercise club and walking club) was attached to the letter. According to the administrator, the new activities were designed to increase involvement of wandering and abusive residents. h. In addition, interview with the Activities Director on 4/12/02 at 11:00 am revealed that residents 32 with cognitive impairment receive Sensory Stimulation activities twice per week. According to the Activities Director, if able, cognitively impaired residents attend the coffee social given 7 days per week, with no further activities provided to wandering/aggressive residents to deter them from inappropriate behavior. Interview with the Director further revealed that the amount of activities offered to these residents were inadequate. The two new activities program described by the administrator were planned to be implemented on the last day of survey (4/12/02). i. Based on above findings, the facility failed to ensure that interventions were appropriate and adequate to prevent residents identified as having wandering and abusive behavior from physically and mentally abusing other residents. 24. Based on the foregoing, Brookwood Gardens Convalescent Center violated Section 483.15(e) (1), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code herein classified as a Class I deficiency pursuant to Section 400.23(8)(a), Fla. Stat., which carries, in this case an assessed fine of $25,000. This violation also gives rise to a conditional license rating pursuant to Section 400.23(7) (b), Fla. Stat. 33 COUNT IV SURVEY FEE SECTION 400.19(3), FLA. STAT. COUNT III § 400.19, Florida Statutes (2001), provides that a survey shall be conducted every 6 months for the next two year period when the facility has been cited for a class I deficiency and that in addition to any other fees or fines the agency shall assess a fine of $6,000, one half to be paid at the completion of each survey. Based on the Class I deficiencies identified on Counts I, II and III of this complaint, the Agency is hereby assessing a fine of $6,000 against Brookwood Gardens Convalescent Center. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Brookwood Gardens Convalescent Center shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit NAY 34 CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Brookwood Gardens Convalescent Center on Counts I through III. 2. Assess against Brookwood Gardens Convalescent Center an administrative fine of $75,000 on Counts I through III for violations as reflected above. 3. Assess against Brookwood Gardens Convalescent Center a conditional license in accordance with Section 400.23(7) (b), Florida Statutes. 4, Assess against Brookwood Gardens Convalescent Center a survey fee of $6000 pursuant to Section 400.19, Florida Statutes. S. Assess against Brookwood Gardens Convalescent Center a total amount due of $81,000 [$75,000 on Counts I through III plus $6000 survey fee]. 6. Assess costs related to the investigation and prosecution of this matter, if applicable 7. Grant such other relief as the court deems is just and proper on Counts I through IV. 35 Respondent is notified that it has a right to request an administrative hearing pursuant tc Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the ‘attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 N. W. 53rd Street, Miami, Florida, 33166; Attn: Alba M. Rodriguez. 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. 5 , Clibe., ee Boda 2a Alba M. Rodriguez ran a Assistant General Counsel Agency for Health Care Administration 68355 N. W. 53 Street Miami, Florida 33166 Copies furnished to: Diane Castillo Field Office Manager Agency for Health Care Administration 8355 N. W. 53rd Street Miami, Florida 33166 (U.S. Mail) Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 37 EXHIBIT “A” Conditional License License # SNF 1064096; Certificate No.: Effective date: 04-12-02 Expiration date: 02-28-03 38 93 Lee ~9 £859). Ady a os HEA ja iy “i if

Docket for Case No: 03-004512