; STATE OF FLORIDA AGENCY FOR HEALTH 'CARE ADMINISTRATION /, 1 AGENCY FOR HEALTH CARE Ou 2946 ADMINISTRATION, IY 229 . Petitioner, AHCA No.: 2004005065 Return Receipt Requested: 7002 2410 0001 4237 1253 7002 2410 0001 4237 1260 Vv. KEY WEST CONVALESCENT CENTER, INC., d/b/a KEY WEST CONVALESCENT CENTER, INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (YAHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Key West Convalescent Center, Inc., d/b/a Key West convalescent Center, Inc. - (hereinafter “Key West Convalescent Center, Inc.”), pursuant to Chapter 400, Part II, and Section 120.69, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $20,000.00 pursuant to Section 400.23, Florida Statutes (2003), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Monroe County, pursuant to Section 120.57, Fla. Stat. and Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities, pursuant to Chapter 400, Part II, Florida Statutes (2003), and Chapter 59A-4, Florida Administrative Code., S. Key West Convalescent Center, inc. operates a 120- bed skilled nursing facility located at 5860 W. Junior College Road, "Key West, Florida 33040-4392. Key West Convalescent Center, Ine. is licensed as a skilled nursing facility license number 1265096, with an expiration date of January 31, 2005. Key West Convalescent Center, Inc. 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 KEY WEST CONVALESCENT CENTER, INC. FAILED TO ASSESS THE SAFETY OF A RESIDENT SELF ADMINISTERING MEDICATIONS Title 42, Section 483.10(n), Code of Federal Regulations, as incorporated by Rule 59A-4, Florida Administrative Code (SELF ADMINISTRATION OF DRUGS) UNCORRECTED CLASS III VIOLATION 6. AHCA re-aileges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the licensure and re-certification survey conducted on 02/23-26/2004 and based on observation, interview and clinical record review, the facility failed to assess the safety of a resident self administering medications; failed to care plan for self administration and failed to obtain a physician's order for self administration for 1 (#4) of 23 sampled residents. ‘ 8. During the initial tour of the facility on 2/23/04 at 9:10 AM with the Licensed Professional Staff member, resident #4 was observed to have two tubes of medication at his/her bedside, Clotrimazole cream 1% and Bacitracin ointment . The resident stated at that time that he/she applies the Clotrimazole cream after he/she changes their incontinent brief and he/she applies the Bacitracin ointment to an area by the left ear. 9. Review of the latest Minimum Data Set (MDS) dated 1/16/04 at 9:20 A.M. on 2/23/04 revealed that the resident is coded as being independent for cognition; decisions are consistent and reasonable. Further review of the clinical record revealed that there is no physician's order for the resident to have medications at the bedside. Also, the 3 Clinical record revealed that the interdisciplinary team had not care pianned the resident to self-administer medications to ensure that the practice was safe. The interdisciplinary team failed to determine who would be responsible (the resident or the nursing staff) for storage and documentation of the administration of drugs, as well as the location of the drug administration (e.g.,. resident's room, nurses' station, or activities room) . 10. Interview with the resident's nurse on 2/23/04 at 9:20 AM confirmed that there was no physician order for the resident to have medications at the bedside and to self- ' administer. She also confirmed that there was no care plan for resident #4 tc self-administer his/her medications. Correction date: 3/30/2004 . 11. During the follow-up conducted on 4/12-13/2004 and based on observation, interview and clinical record review the facility failed to assess the safety of a resident self administering medications; failed to care plan for self administration and failed to obtain a physician's order for self administration for 1 (#6) of 13 sampled residents. 12. During the initial tour of the facility a licensed nurse was asked if any of the residents self-administered medications. The nurse stated that resident #6 had been doing so for some time. 13. On 4/12/04 at approximately 10:30am resident #6 was asked about self-administration of. medications. The resident stated he/she had médications at the bedside and showed this surveyor the following medications in the drawer of his/her bedside table: Nitroquick (nitroglycerin) 0.4mg sublingual tablets, Zinc Oxide topical and A & 2 ointment topical. Review of the medication administration record (MAR) for the month of April 2004 revealed the instructions for the nitroglycerin tablets were "give one tab (tablet) sublingually (under the tongue) every five minutes X (times) three doses as needed for chest pain; if no relief call MD. Interview with the resident on 4/12/04 at approximately 8:05pm revealed the resident takes the nitroglycerin for "heart pain" but could not do it the last time he/she had ‘the pain because he/she "could not move." 14. Review of the resident's interdisciplinary plan of care most recently updated on 1/23/04 reveals the following four problems listed and addressed by the care plan: (1) Impaired cognitive status; (2) Risk for falls; (3) Risk for skin impairment; and (4) Need for a therapeutic diet. Self- administration of medications is not addressed in the care plan. Review of the physician's orders revealed a telephone order dated 12/5/03 for Zinc oxide and A&D ointment to be kept at the bedside and applied to feet daily. The order noted that this was at "Pt (patient) request." The most t current "Physician Order Sheet" (April 2004) contained an order for the nitroglycerin tablets but did not specify that it was to be left at the bedside or that it was for self- administration. 15. Review of the policy supplied by the facility for "Patient /Resident Self Administration of Medications" states, "A review by the interdisciplinary team tc determine if they agree with the physician in that they feel the patient/resident is capable of self-administration (this includes physical, psychosocial, and mental health aspects) . If the interdisciplinary team agrees a progress note and a plan of care by the Resident Assessment Coordinator (RAC) or designated team member must be written and followed. This should be 100% in place before self-administration is begun. 16. At approximately ipm on 4/12/04 the Director of Nursing was advised of the findings and stated she would check into it. On 4/13/04 at approximately 3:30pm the Assistant Director of Nursing stated the resident had been assessed for his/her ability to self-administer that day and the care plan was being amended to address the resident's ability to self-administration. She admitted that these measures had not been in place prior to that time. Uncorrected deficiency from the 02/26/2004 survey. 17. Based on the foregoing, Key West Convalescent Center, Inc. violated Title 42, Section 483.10(r), Code of Federal Regulations, as. incorporated by Rule 59A-4.1288, : Florida Administrative Code, an uncorrected Class MII I deficiency, which carries, in'this case, an assessed fine of $2,000.00. COUNT II KEY WEST CONVALESCENT CENFER, INC. FAILED TO PROMOTE CARE FOR RESIDENTS IN A MANNER THAT MAINTAINS AND ENHANCES EACH RESIDENT’S DIGNITY AND INDIVIDUALITY Title 42, Section 483.15(a), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code (QUALITY OF LIFE) UNCORRECTED CLASS III 18. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 19. During the licensure and re-certification survey conducted on 02/23-26/2004 and based on opservation, interview and record review the facility failed to promote care for residents in a manner that maintains and enhances each resident's dignity and individuality for seven randomly observed residents. 20. Based on observation of the resident breakfast meal at approximately 9AM on 02/23/2004, resident’ #26 was observed in the second floor dining room, seated at the table with other residents as well as staff. Resident #26 was wearing a housecoat, which was high up on her leg, exposing the resident's thigh and incontinent brief. 21. On 02/24/2004 at approximately 11:55am this surveyor was standing outside of the first flocr shower room and overheard someone screaming "cover me, cover me" over and over again. This surveyor then knocked on the door and entered. Resident #27 was seen in a shower chair, naked and wet with a towel around his/her neck and shoulders by a certified nursing assistant (CNA). The CNA stated that the resident was a screamer and made no effort to cover the " resident as requested. After multiple requests to be covered the resident used foul language to refer to the CNA. The CNA stated, "I wish you would watch your language" but still did ; not make any attempt to cover the resident. Several minutes later the surveyor left the shower room and reported the event to the charge nurse who stated that was unacceptable and she would address the situation with the CNA. Review of the clinical record for #R27 reveals the resident is assessed as "severely cognitively impaired" on the Minimum Data Set with reference date 3/4/03. 22. An un-sampled resident was observed on 02/23/2004, at 10:30 a.m. sitting in the corridor ‘towards the front entrance. The resident's pants were soaked with urine and a pool of liquid was under the resident's wheelchair. Staff passed by the resident without attempting to take the resident to his/her room to get cleaned up. At this time the surveyor informed the Director of Nursing (DCN) of the resident's condition at which point the DON removed the i] I resident from the corridor and maintenance was called. 23. At 10:00a.m. on 2/26/04 four un-sampled residents were sitting outside of their rooms on the second floor still wearing their food protectors 2 hours after the breakfast meal or from 8:00 a.m. It was noted that oatmeal was on the food protectors, and one resident was chewing on the food protector. During this time members of staff were passing the area with the resident in clear view. However, no attempt was made to remove the soiled food protectors. Correction date: 3/30/04. . 24. During the follow up conducted on 4/12-13/2004 and based on observation, interview and medical chart review it was noted that the facility failed to provide care in an environment that maintains and enhances the resident's dignity by having a resident sleep out in the hallway for one of 14 sampled residents (#8) and allowing a resident to eat puree food by hand without providing any interventions for one un-sampled resident. ) 25. On the initial day of the follow-up to the annual recertification survey, 4/12/2004 at 5:55am, a low bed was observed in a public corridor between the activity room and the day room. Interview at this time with a Certified Nursing Assistant (CNA) revealed that the bed belonged to resident #8 and that he/she slept there during the night. Further interview with nursing at 8:10 pm on 4/12/04 as to why the resident was sleeping in the hallway at nights revealed that the resident talks non-stop and keeps his/her roommate awake. Continued interview with a different nurse at 9:45 am on 4/13/2004 confirmed that the resident slept in the alcove and that he/she disturbs his/her roommate. During a visit to the resident's assigned room the resident's roommate was asked why the room was so warm. The roommate stated, “We don't use air conditioning in here. I like the window open. ____ (name of resident), doesn't even sleep in ‘here anyway." Throughout the two days of the survey the resident was seen positioned in the hallway in a Geri chair and observed to be incapable of independent locomction. 26. On 4/12/2004 at approximately 12:00pm an un-sampled resident was observed in the main dining room on the first floor of the facility eating pureed food with his/her fingers. A direct care staff member waS overheard commenting to another staff member that the resident was eating with his/her fingers again. There was no effort on tne part of either staff member to assist or cue the resident. Again, on 4/13/04 at approximately 1:10pm the same un-sampled resident was observed in the main dining room eating pureed food with his/her fingers. Staff members were present but no one assisted or cued the resident. Uncorrected Deficiency from the survey of 02/23-26/2004. 27. Based on the foregoing, Key West Convalescent 13 1 Center, Inc. violated Title 42, Section 483.15(a); Code of | Federal Regulations, as incotporated by Rule 59A-4.1288, Florida Administrative Code, an uncorrected Class III deficiency, which carries, in this case, an assessed fine of $2,000.00. COUNT III ‘ KEY WEST CONVALESCENT CENTER, INC. FAILED TO PROVIDER EFFECTIVE HOUSEKEEPING AND MAINTENANCE SERVICES NECESSARY TO MAINTAIN A SANITARY, ORDERLY AND COMFORTABLE INTERIOR. Title 42, Section 483.15(h) (2), Code of federal Regulations, as incorporated by Rules 59A-04.1288, and 59A-4.106 (4) (k), and 59A-4.122(1), Florida Administrative Code (ENVIRONMENT ) UNCORRECTED CLASS III 28. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29. During the licensure and re-certification survey conducted on 02/23-26/2004 and based on the initial facility tour at approximately 9 AM on 02/23/2004, the following observations were made: (a) The bathroom doorframes had chipped paint in the following rooms: 57 and 48. (b) There was damaged/scuffed paint in the following rooms: 48 and 53{(behind the "B” beds), 51 (behind the "A" bed), and room 49. (c) One of the resident's armoires in room 270 was missing a door. (d) Room 49 had a strong fecal odor in the room, as did the bathroom for room 47. A dirty incontinent brief was in the garbage can in the bathroom for room 47. (e) A bedside table drawer jn room 51 was missing some laminate, leaving a rough surface exposed. 30. Other environmental observations include: (a)) At 2:30 PM on 02/23/2004 it was noted the feeding pump/pole for resident #7 had splatters of dried 4 formula on the surface. The vertical blinds next to the "B" bed in this resident's room were missing slats, so they could not provide complete privacy. The paint on the door of the bathroom adjacent to this resident's room was also chipped. (b) at 2 PM on 02/25/2004 a surveyor observed the bedside table provided to resident #19 had laminate peeling off one corner, resulting in the exposure of a rough ' surface. 31. The following findings were observed during the initial tour of the facility on 02/23/2004 between 9:20 and approximately 11:30am: (a) Room #2A a gouge in the floor tile, water damage to the dresser and exposed rusty screws on the base of the commode, privacy curtain missing many hangers. (bo) In the shower room on the first floor the first shower stall had a privacy curtain that left a 3 to 4 foot gap when closed. In the same shower room an "EZ shampoo" plastic inflatable device, a tray like aide for washing hair, on which the tesident's neck and head are rested, lay on the floor containing a used glove and soiled Band-Aid. This finding was reported to the Director of Nursing (DON) who was in nurses! station just outside the shower room, at that time. The DON had the device removed immediately and stated it should not have been there. (c) Room #8 had multiple holes patched but not painted in the walls over the beds. (a) Room #9 has water damage under the sink. (e) Room #11B feeding pump and pole have dried pn debris. (£) Bathroom between rooms 2 and 4 has exposed rusty screws on the base of the commode. (g) Bathroom between rooms 1 and 3 has exposed rusty screws on the base of the commode and water damage to the floor tiles. (h) Bathroom between rooms 5 and 7 has exposed rusty screws on the base of the commode. (i) Bathroom between rooms 10 and 12 nas exposed rusty screws on the base of the commode. (j) Bathroom between rooms 9 and 11 nas exposed rusty screws on the base of the commode. ‘ (k) Bathroom between rooms 14 and 16 has exposed rusty screws on the base of the commode. (1) Bathroom between rooms 19 and 21 has exposed rusty screws on the base of the commode. Toilet paper on the floor with fecal material on it. (m) Bathroom between rooms 20 and 22 has exposed rusty screws on the base of the commode. (n) Bathroom in room 18 has exposed rusty screws 4 on the base of the commode and a puddle of water on the floor. (0) Bathroom between rooms 23 and 25 kas exposed rusty screws on the base of the commode. (p) Bathroom between rooms 24 and 26 has exposed rusty screws on the base of the commode and wheelchair leg/foot extenders are lying on the floor. (q) Bathroom between rooms 27 and 29 has exposed rusty screws on the base of the commode. (r) Bathroom between rooms 30 and 28 has exposed rusty screws on the base of the commode. (s) Room 38: Window Bed- Pump pole encrusted with dry/old feeding residue. (t) Room 41: Window Bed-Foot Board rim covering loose. (au) Room 45: Window Bed-Foot Board (frame) wood/metal piece broken. (v) Room 46: Door bed - side railing off and vesting by the head of the ‘bed/wall. 32. On 02/25/2004 at approximately 10:35am broken wooden molding was observed around the top of the front of the nurse’s station on the first floor. There were several areas with jagged wood exposed. This was reported to the charge nurse at that time. The charge nurse acknowledged the fact that it posed a potential for injury' and immediately reported it to maintenance. ; 33. On the morning of 02/25/2004 the following was observed in room 54: 1) a broken hinge on the becside table at the foot of the bed, water damage in the bathroom. Also observed a telephone wire that had apparently been extended ‘using a broken faceplate and exposed wiring. This last finding was immediately reported to a maintenance person who was on the floor at that time ‘who stated he didn't know what had been done to it but he would repair it immediately. Correction date: 3/30/04 34. During the follow up conducted on 4/12-13/2004 and Based on observation and interview the facility failed to provide a sanitary environment in the two of