Ui [sé s STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION aN oy or AGENCY FOR HEALTH CARE ADMINISTRATION, a, Petitioner, vs. Case No. 2004001319 2004001841 EVANS HEALTH CARE ASSOCIATES, LLC, d/b/a EVANS HEALTH CARE Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against EVANS HEALTH CARE ASSOCIATES, LLC, d/b/a EVANS HEALTH CARE, (hereinafter “Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine against Respondent, in the amount of two thousand five hundred dollars ($2,500) pursuant to Sections 400.102(1) (a) and (d), 400.19 and 400.23(8) (b), Florida Statutes (2003) [AHCA Case No. 2004001319]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes (2003) [AHCA Case No. 2004001841]. 3. The Respondent was cited for the deficiencies set forth below as a result of an Annual Licensure and Recertification survey conducted January 29, 2004. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2003). 4, Venue lies in Lee County, Division of Administrative Hearings, pursuant to Section 120.57, Florida Statutes (2003), and Chapter 28-106, Florida Administrative Code (2003). PARTIES 5. AHCA, Agency for Health Care Administration, is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes (2003), and; Chapter 59A-4, Fla. Admin. Code (2003), respectively. 5. Respondent is a nursing facility located at 3735 Evans Avenue, Fort Myers, FL 33901. Respondent is licensed to operate a skilled nursing facility pursuant to license #SNF130470992. At all relevant times, Respondent was a licensed facility required to comply with all applicable regulations, staturtes and rules under the licensing authority of AHCA. COUNT I RESPONDENT FAILED TO ENSURE THAT RESIDENTS RECEIVED THE NECESSARY CARE AND SERVICES TO PREVENT THE DEVELOPMENT OF PRESSURE SORES. Fla. Admin. Code R.59A-4.1288(2003), INCORPORATING BY REFERENCE 42 CFR 483.25(c) (2003) CLASS II DEFICIENCY ISOLATED 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about January 29, 2004, AHCA conducted an Annual Licensure and Recertification survey at Respondent's facility. 9. Based on observation, record review, staff interview and review of facility policies and procedures, the facility failed to develop and implement interventions to prevent i (Resident #4) of 21 active sampled residents from developing an avoidable pressure sore and, once developed, did not accurately assess, care plan or consistently treat the resident to prevent recurrence and/or deterioration of pressure sores. This is evidenced by: Resident #4 was admitted to the facility without pressure sores, developed pressure sores which healed, then reoccurred and worsened. fs OS te 2 1. Review of the clinical record for Resident #4 on 1/27/04 revealed that the, ie Py b: resident was admitted to the facility on 6/05/01, discharged, then readmitted) the, ; 00 facility on 9/09/03 with a diagnosis including but not limited to Dysphasia, apt. dS) ie ; y Aphasia, and effects from a past CVA (Cerebral Vascular Accident). There is no! Nees Oy nursing documentation to support the resident's skin condition after return (9/09/03) from the recent hospital stay. The findings include: Review of the nursing progress notes revealed that 9/14/03, the resident was noted to have a small, unopened blister on the left upper buttocks. There is nothing further noted about this blister. However, the Skin Grid sheet which the facility uses to identify "other skin problems" did not indicate that this area was on the left; rather, the facility indicated that this area on this form was on the right. There was conflicting documentation and assessment regarding this wound from the nurse's notes (9/14/03) versus the Skin Grid Sheet (dated 9/15/03). This area had been documented as healed, however, there was no date indicating which area had healed (right or left). Review of the Quarterly MDS (MDS - Minimum Data Set) Assessment with an assessment reference date 9/29/03 revealed the resident has both short and long term memory problems ((B2a=1, b=1), has severely impaired decision making skills (B43=3) and is totally dependent on staff for bed mobility (Gla=4/2). The resident was also assessed as requiring total assistance of 2 people for transfers (G1b=4/3) and totally dependent on staff for eating (G4h=4/2). The resident is non-ambulatory and also required total assistance for bathing, grooming, and dressing. The resident is totally incontinent of both urine and bowels (Hla=4, H1b=4). The resident's bowel elimination assessment did not indicate that she had diarrhea. The area of "stability of conditions" on this MDS was checked "none of the above", no change in the resident's condition. The facility indicated that the resident was receiving a tube feeding and was on a planned weight change program. This resident was assessed as having a "Stage 2" wound (M1=b). However, “type of ulcer" was not indicated. Review of the nurse's note, dated 9/30/03, (1 day after the most recent Quarterly MDS assessment) revealed, "the resident developed a small open area noted on lower left buttock....treatment obtained." This is a new and different area of development since the nurse's note of 9/14/03. Review of the "Skin Grid Pressure" form dated 9/30/03 revealed the resident had an in house acquired Stage II pressure area, lcm x .5 cm, superficial, left lower buttock. However, on the body diagram where the nurses are to indicate the location of the ulcer, the "open area” was illustrated as on the "right" lower buttock area. (This is a conflict of where the ulcer was located.) This area was documented as "healed" on 10/29/03. On 10/02/03, it is recorded that there is a small skin tear on the fold of the right buttock (new area?). On 10/16, two weeks after an identified skin tear was noted, nursing notes state only that the dressing to the buttock is intact. F urther, on 10/17, 10/18 and 10/20/03, nursing notes continue to indicate that the dressing to the buttock is intact. Nursing notes dated 10/21/03 states that the right buttock is almost healed; on 10/22 it is documented as healing well with the dressing intact. There is no further documentation of this wound until 10/28/03 and 11/02/03, which states that the open area on the right gluteal fold is healed. On 11/17/03, the Skin Grid Pressure Form indicates that a new pressure wound, Stage LI, 2em x 1 cm with "0" depth has developed on the resident. This form does not indicate location of wound. However, further down the form there is an entry dated 11/17/03 by the same nurse, indicating that a Stage II pressure area, measuring 8(I) x .3(w) x .1(d) with no drainage or odor is present. This is in conflict from the same dated assessment on the top part of the form. On 12/08/03, the "Weekly Skin Sweep" form indicates the resident has a new skin impairment and the diagram illustrates "Stage II." There is no description as to the type of wound identified. On 12/17/03 (approximately 9 days after a wound on 12/08/03 had been identified), there is an entry in the nurse's notes stating that the treatment to the coccyx and ischium done as ordered; 12/19/03 documentation reveals that the resident has 2 Stage II decubiti, one on the right ischium and one on the coccyx. There is no documentation on the Skin Grid Pressure form relating to the nurse's notes of "coccyx and ischium." The next reference to the pressure sores is 12/24/03 documenting a dressing change. The 12/30/03 entry states that the wound is not healing and the doctor was called for a wound care consult. On 1/02/04, the note revealed treatment to the coccyx - Stage IT. Review of the resident's Quarterly MDS with an assessment reference date of 12/28/03 indicated there were no changes in the resident's cognitive or ADL (Activities of Daily Living) status (from the previous assessment). Further, this assessment revealed that the resident did not have "diarrhea", and remained totally incontinent of bowel and bladder. The section "Stability of Conditions" indicates "none of the above", no change in condition. Section M1b indicates the resident has a Stage II pressure area. On 12/30/03, an entry made by a nurse included: "...called (MD) office for consult to wound care..." There was no documentation in the chart that the referral had been done and that the resident had received an evaluation by a wound care center. Documentation on 1/07/04 states that the resident has 2 open areas on the coccyx; the upper wound is noted to be a Stage III and the lower wound a Stage IT and there is yellowish-green drainage. Documentation on 1/20/04 states that the upper wound is a Stage III with 0 depth and some yellowish-green drainage-the other area appears red with a smal! amount of drainage. Review of the laboratory reports revealed that, although the resident's impairment in skin integrity was identified on 9/14/03 and progressed from a blister to a Stage (II pressure sore with yellowish - green drainage on 1/07/04, there were no laboratory tests obtained to assess the resident's nutritional status and needs 1.e.: Prealbumin, Serum Albumin and Total protein levels. There were also no wound cultures requested or obtained to determine if the yellowish green drainage was indicative of infection. Dietary/nutrition review completed on 9/29/03 made no reference to the fact that the resident had wounds or developed pressure ulcers. There was no reassessment related to the resident's ongoing wounds until 12/31/03 (approximately 3 months). There are no guidelines for how the nutritional status of the resident will be monitored. Review of the care plans revealed that a plan for pressure ulcer prevention, "High Risk" was developed on 4/07/03. There were no changes in interventions to prevent skin breakdown or promote wound healing except an update to the care plan on 10/08/03 "Moderate Risk" (down grading the resident's pressure ulcer risk factors) for the staff to "Evaluate for bowel and bladder continence program as indicated.” Two months later, the facility devised a new care plan on 12/20/03 at which time the following interventions were developed: 1) Turn and position every 2 hours. 2) Up in Geri chair each day. 3) Check for incontinence every 2 hours and provide peri-care after each episode. 4) A skin assessment will be completed and wound measurements will be recorded weekly in the TAR (Treatment Administration Record). These interventions were the same since the 4/07/03 initial care plan. Multiple observations of the resident from 1/26/04 through 1/29/04 revealed that the resident's shoulders and upper body were often repositioned, however, her lower body is always positioned flat on her buttocks. The resident was never observed to be up in a chair or positioned up off of her buttocks while in bed. Review of the Skin Sweep reports and the Skin Grid-Pressure sheets reveal that, although the large pressure sore on the resident's coccyx was recorded as a Stage II in the progress notes, the Skin Grid records it as a Stage II with no depth on 1/07, 1/20 and 1/23/04. Review of facility policies and procedures for wound care states that the facility will obtain a dietary consult for assessment of the nutritional needs of residents at risk for or with actual impairment of skin integrity; this assessment shall include laboratory measurements of the resident's protein status to include any or all of the following: Prealbumin, Serum Albumin or Total Protein. This was not done until 12/31/03, when it was noted by the facility of the increase in the wound size. The technique to measure the depth of a wound is also detailed in this policy. The facility did not follow their policy. During an interview with the DON (Director of Nursing) and the A Wing UM (Unit Manager) on 1/29/04 at approximately 10:30 A.M., both confirmed that no labs had been done for the resident to assess her nutritional needs or to identify possible infection of the wound. When asked why the drawings in the clinical documentation are not consistent as to the location of wounds 1.e.: upper, lower, left, right, the UM stated that the drawings and documentation were not always accurate. When asked why documentation indicated 2 decubitus, one a Stage II and one a Stage II and further documentation only indicates one decubiti, she stated that the 2 wounds had become one; she verified that this was not apparent in the clinical documentation. The DON or UM did not indicate what new interventions on behalf of the resident were done to promote wound healing or prevention of skin breakdown. There was no mention of changing the turning schedule from 2 hours to 1 hour, there was no mention whether any other discipline (Occupational Therapy or Physical Therapy) were involved to establish a turning and repositioning program for this resident, or a special chair that could be utilized to enable the resident to get out of bed. Further, there was no indication that therapy was consulted to evaluate whether a special cushion could be utilized for the resident. in her recliner chair. Observation of the resident on 1/28/04 at approximately 4:30 P.M., revealed the resident laying on her left side. The resident was lying on a folded draw sheet. On top of the draw sheet were 3 incontinent pads. In between her thighs and vaginal area was a thickly folded sheet that was yellow stained. Observation of the coccyx wound reveals the wound to have a yellow base, Stage II in appearance and approximately | to 1.5 cm. in depth. A pad was against the wound and stained yellow. When the UM was asked if she would agree with the documented wound assessments describing the wound at 0 depth, she stated that she didn't know but that it was getting better. When asked if she thought that a Stage IIT decubitus could be 0 cm. in depth, she did not reply. When asked if she would assess a wound as improving if it went from no depth to the current depth of 1 to 1.5 cm, she stated that she was not sure of how to accurately measure wound depth and that facility nursing staff could use an in-service in accurately assessing and measuring wounds because everyone does it differently and uses different terminology. When asked to describe how the development of pressure sores in this resident was unavoidable, the DON and UM stated that the resident's family was adamant that the resident be up in the Geri chair every day. The facility did not indicate that they had spoken to the family regarding the specific sk factors associated with pressure ulcer development. (There was no documentation in the clinical record as well.) The facility stated that, due to the resident's size, it was hard to reposition her off of her buttocks in the chair. When the resident had developed pressure sores that were not responding well to treatment, the facility became more firm with the resident's family and convinced them to allow the resident to stay in bed, where she could be more adequately repositioned. When asked what the facility could have done differently to prevent pressure sores in this resident, the DON replied: better nursing care, repositioning more often and initially being firmer with the resident's family. 10. Respondent was provided a mandated correction date of February 29, 2004. 11. The above actions or inactions are a violation Rule 59A-4.1288, Florida Administrative Code (2003), incorporating by reference 42 Code of Federal Regulations 483.25(c) (2003), which requires the facility to provide each resident the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. As it relates to pressure sores, based on the comprehensive assessment of a resident, the facility must ensure that: (1) a resident who enters the facility without pressure sores, does not develop pressure sores, unless the individual's clinical condition demonstrates that they were unavoidable and (2) a resident having pressure sores, receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 12. Pursuant to Section 400.23(8) (b), Florida Statutes (2003), the foregoing is an “isolated” class II deficiency and as such, has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 13. A civil penalty is authorized and warranted in the amount of $2,500, as this violation constitutes an isolated” Class II deficiency. 14. Pursuant to Section 400.23(7) (b), Florida Statutes (2003), the Agency is authorized to assign a conditional licensure status to Respondent’s facility. WHEREFORE, CLAIM FOR RELIEF the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: a. Enter actual and legal findings in favor of AHCA on Count I of the complaint; Impose a $2,500 civil penalty against Respondent ; Assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Florida Statutes (2003); Uphold the conditional licensure status pursuant to Section 400.23(7) {b) (2003); and Grant any other general and equitable relief as deemed appropriate. NOTICE The Respondent is hereby notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. L) Ae Wayn . Knight, quire, AHCA, Senior Attorney Fla. Bar. No. 0136440 Counsel for Petitioner 525-Mirror Lake Dr. N., #330L St. Petersburg, FL 33701 (727) 552-1525 (office) (727) 552-1440 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail Return Receipt No. 7003 1010 0002 4667 0210, to CT Corporation System, Registered Agent for Evans Health Care, 1200 S. Pine Island Road, Plantation, FL 33324, dated on April g , 2004. lls £2 Hig i Copies furnished to: CT Corporation System. Registered Agent for Evans Health Care 1200 S. Pine Island Roa Plantation, FL 33324 (U.S. Certified Mail) Elizabeth Ann Mackewich Administrator Evans Health Care 3735 Evans Avenue Fort Myers, FL 33901 (U.S. Mail) Wayne D. Knight AHCA - Senior Attorney 525 Mirror Lake Drive, St. Petersburg, FL 3370 d Suite 330L 1 POOC/OE/IT ‘ALVA NOILVUldXd ASNAOTT p007/62/10 ‘ALVC AALLOSSA NOLLOV AONVHD SO.LV.LS SdH 0¢1 “TVLOL TO6€€ ‘Id “SUAAW LYOA ANNAAV SNVAG SELE WaVO HLTVdH SNVAD :BUIMOT[OJ Oy) aeIodo 0} pazLOYINE ST dasudol] OY) SB puk ‘saynjeIg EPLOLy ‘[] Wed ‘OOP Jodeyo ul pozoyyne ‘uOneNsIUIMpY aed Yeap 10,j Aouasy ‘epuoy.y Jo ae1S ay Aq pordope suoneingar pue sopnr oy yum parfduioo sey OTT ‘SALVIOOSSV FAVO HLTVAH SNVAZ Jeu) WYyUOD 0} st Sty, "IVNOILIGNOO ALYUOVA ONISUON GATIDIS AFONVANSSV ALITVNO HLTVaH AO NOISIAIC NOLLVULLSININGY dav HLITVdH YOA AONADV BPLIOL] JO 938)¢ COGOLPOCTANS ‘# ASNAOIT PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , which represents payment of the Administrative Fine imposed by AHCA. Facility Name AHCA No.

Docket for Case No: 04-001596