STATE OF FLORIDA on ‘/ ne AGENCY FOR HEALTH CARE ADMINISTRATIO tog +) AGENCY FOR HEALTH CARE a - 7 a) ; ADMINISTRATION, : . MO Petitioner, AHCA No.: 2004003094 AHCA No.: 2004002850 v. Return Receipt Requested: 7002 2410 0001 4237 0935' KEY WEST CONVALESCENT CENTER, INC., 7002 2410 0001 4237 0942 . d/b/a KEY WEST CONVALESCENT CENTER, Respondent. ’ ADMINISTRATIVE COMPLAINT COMES, NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Key West Convalescent Center, Inc., d/b/a Key West Convalescent Center (hereinafter “Key West Convalescent Center”), pursuant to Chapter 400, Part II, and Section 120.60, Fla. Stat. (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $2,500.00 pursuant to Section 400.23(8), Fla. Stat. (2003), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Key West Convalescent Center, pursuant to Section 400.23(7) (b), Fla. Stat (2003). JURISDICTION AND VENUE i) 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat.'(2003), and Chapter 28-106, 4.. Venue lies in Monroe County, pursuant to Section 400.121(1) (e), Fla. Stat. ° (2003), and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part tr, Pla. Stat., (2003), ‘and Chapter 59A-4 Florida ‘Administrative Code. 6. Key West Convalescent Center is a 120-bed skilled nursing facility located at 5860 W. Junior College Road, Key West, Florida 33040-4392. Key West Convalescent Center is licensed as a skilled nursing facility; license number SNF1265096; certificate number 11360, effective 02/26/2004, through 01/31/2005. Key West 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. 7. Because Key West Convalescent Center participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule S59A-4.1288, F.A.C. couNT I KEY WEST CONVALESCENT CENTER FAILED TO PROPERLY ASSESS, IMPLEMENT AND EVALUATE CARE IN ORDER TO PREVENT THE DEVELOPMENT OF PRESSURE SORES AND ONCE DEVELOPED TO PROVIDE APPROPRIATE CARE AD SERVICES FOR THREE RESIDENTS. TITLE 42, SECTION 483.25(c), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code (QUALITY OF CARE) 4 CLASS II DEFICIENCY 8. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. * During an unannounced licensure and re- certification survey conducted February 23-26, 2004 and based on observation, interview and record review it was revealed that the facility failed to properly assess, implement and , evaluate care in order to prevent the development of pressure sores and once developed to provide appropriate cate and services for three (#11, #5 & #6) out of 20 sampled residents. 10. Clinical record review for resident #11 revealed that the resident was re-admitted to the facility on 7/31/03 and had the following diagnosis': atypical chest pains, gastritis, MS, neurogenic bladder. The "Resident Assessment - Data Collection Form dated 7/31/03 further revealed under "skin condition" that the resident's sacral area was free of any bruises, discolorations, abrasions or pressure ulcers. A Braden Scale for Predicting Pressure Sore Risk was in the clinical record behind the Resident Assessment form but was found to be blank. The complete assessment dated 8/4/03 indicates that the resident has a stage Il pressure ulcer. The assessment also indicates that the resident requires extensive assistance with bed mobility requiring two or more people assist. (a) Further review of the clinical record reveals that nurses’ notes dated 7/31/03, g/10/03, 8/11/03 and 8/27/03 did not document any skin breakdown/concern. The resident assessment protocol for pressure ulcers updated 8/13/03 indicates that the resident has impaired bed mobility, and is now incontinent of feces and has two stage II decubitus ulcers. The form also indicates that the ‘resident has the following risk factors for pressure ulcers: impaired transfer or bed mobility and quadriparesis. The form further indicates that the resident receives protective/preventive skin care evidenced by weekly skin checks, pressure relieving bed pad, pressure ulcer care to buttocks, turning/repositioning to be assisted as necessary and dietary supplements between meals. The resident has a care plan updated 8/13/03 for potential for skin impairment as evidenced by poor mobility related to disease process, Multiple Sclerosis. Some approaches listed are: skin checks per orders, assist resident to reposition in bed every two hours and as necessary and pressure relieving mattress for bed. (b) The Director of Nurses (DON) stated on 2/25/04 at 4:00 P.M. that she assumed that resicent #11l's wound was found during the weekly skin checks by the licensed staff. The DON further stated that the nurses perform weekly skin checks on all of the residents. The Certified Nursing Assistants (CNA) are to check the residents during personal care for any redness or bruises and report any findings to the nurse. The DON at this time confirmed that there are no nurses’ notes to indicate when the resident acquired the pressure ulcer. The treatment administration record (TAR) was found and reviewed with the DON. She confirmed that according to the TAR resident #11 did not receive weekly skin checks for 8/2/02, 8/9/03, 8/17/03 or 8/23/03. on 2/26/04 at 9:15 AM during an interview with the DON she stated that there was no documentation to indicate that the resident's are turned every two hours as ordered. She stated that she was implementing a form. (c) During review of the personnel files on 2/26/04 it was revealed that Certified Nursing Assistants (CNA) #1,2,3,4, and 5 all employed by the facility for over one year lacked the state mandated training regarding risk factors for pressure ulcers. un 11. On 8/07/03 resident #5 was re-admitted to the facility with diagnoses of dementia, psychosocial disorder, eczema and organic brain syndrome. The facility's Braden Scale- For Predicting Pressure Sore Risks assessed the resident at a moderate risk for developing pressure areas. On 8/15/03 the facility's weekly pressure sore record revealed that the resident had developed a stage 1 area. On 8/31/03 it was noted that the, resident had an unstagable area. This represents a significant change over a two-week period. (a) An interview with the MDS coordinator and the admissions director at 10:30 am on 2/25/04 revealed that jit is their policy that once a resident return from hospital a head ‘to toe skin assessment is done. However, when asked they could not provide any evidence that this was done for resident #5. (b) In addition, prompt dietary intervention was not demonstrated since the Registered Dietitian (RD) did not complete a nutritional assessment of the resident until 9/25/03, which was over a month after the development of the pressure area. The facility failed to assess and intervene in a timely manner, contributing to the rapid decline in the resident's condition. 12. Resident #6 with diagnosis of fracture left hip, dysrhythmia, hypertension and atrial fribilation, was ‘ admitted to the facility on 12/5/03 with a weight of 103 pounds (#) and the Resident Assessment Data Collection Form showed that the resident was free from pressure areas. Review of the Minimum Data Sets revealed that the resident was assessed as needing assistant with all Activities of Daily Livings (ADLs). Review of the Resident Assessment Protocol (RAP) Guide for Pressure Ulcers (#16) dated 12/19/03 revealed that the resident was assessed as having a stage IV pressure ulcer on the left heel with the size of the ulcer measured at 5cm X 4 cm. The size for 12/30/03 was indicated as 4cm X 8 cm stage IV necrotic and 1/28/04 it was 4.5 om X 4.cm stage IV necrotic. In addition, the RAP Guide dated 12/19/03 indicated under "summary/recommendation" that the resident's skin breakdown was "newly noted on the 14th but appears to have been present". (a) on 2/17/03 the registered dietitian (RD) assessed the nutritional needs for a pressure area, and indicated that the resident was to be supervised at meals, and encouraged by staff to eat during meals. Chart note also revealed that the resident's fluid needs were assessed below the minimum fluid requirement of 1500cc daily. The RD had recommended 1400cc daily. Observations of meals throughout the survey 2/23/04 at dinner and 2/24/04 at lunch revealed that the resident was not receiving any intervention, such as not being supervised and encouraged to eat/drink during meals. The resident percent intake during the meal | I observations was only about 25%. (b) The resident's lab values of 12/8/03 revealed abnormal albumin levels of 2.3 (3.9-5.0 is normal). On 1/13/04 an order was placed for lab work to be completed and nutritional notes revealed that once the lab work was received it would be evaluated. However, review of the chart revealed that there was no evaluation of the new labs by the RD and that the labs were not to be found in the chart until 2/25/04 after the RD was questioned. (c) A physician order dated 12/14/03 indicated that pressure relieving devices (heel blocks) under bilateral calf was to be used for the resident for elevating the heels off the bed at all times. However, on 2/24/04 at 7:40am and 2/25/04 at 10:15am the resident was observed to be lying in bed without any type of pressure relieving devices placed under the resident's calfs to elevate the heels. Interview with the wound care nurse on 2/25/04 revealed that the CNA could have used a pillow or blue boxes so that the resident's feet could be elevated. 13. Based on the foregoing, Key West Convalescent Center violated Title 42, Section 483.25(c), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as an isolated Class Il deficiency pursuant to Section 400.23(8)(b), Fla. Stat., which carries, in this case, an assessed fine of $2,500.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, Key West Convalescent Center shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are beirg admitted to the facility. The Conditional License is attached hereto as Exhibit wa" CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count B. Assess an administrative fine of $2,500.00 against Key West Convalescent Center on Count I. Cc. Assess and assign a conditional license status to Key West Convalescent Center in accordance with Section 400.23(7) {b), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 9 120.57, Florida Statutes (2003). Specific options for I I t 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, Lealand McCharen, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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. hi Charu ourdes A. Naranjo FL Bar No: 997315 Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 N.W. 52° Terrace Miami, Florida 33166' Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration Manchester Building 8355 N.W. 537° Street Miami, Florida 33166 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) ‘ EXHIBIT “A” Conditional License License No. SNF 1265096 Certificate No. Effective date: 02/26/2004 Expiration date: 01/31/2005

Docket for Case No: 04-002296