04 AUG 16 PH 4: 13 STATE OF FLORIDA AGENCY FOR HEALTE CARR ADMINISTRATION AGENCY FoR HEALTH CARE ADMINISTRATION, Petitioner, Va. Case No, 2004002549 2004003333 LEESBURG REGIONAL MEDICAL f. ( JU CENTER, INC., d/b/a LRMC NURSING 'o —~ : CENTER, The Respondent, ee f nee ADMINISTRATIVE COMPLATNT ER SC OMPLAINTE COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATI iN {“AHCA”), by and through the undersigned counsel, and fil gs this Administrative Complaint against LEESBURG REGION... MEDICAYS, CENTER, INC, d/b/a LRauc NURSING CENTER, (“LRMC”), pursuant to Section 120.569, and 120.57, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION ACTION 1. This is an action to impose an administrative fine in the amount of $2,500 against LRMC, Pursuant to Section 400.102, Florida Statutes, (2003) and assign a conditional jicense, as Provided by Section 400.23(7), Florida Statutes (2003). The original Condition license certificate is attached hereto as Exhibit ‘ar, Exhibit A 2. Count I of this action [AHCA No. 2004002549), is agency action, pursvant to Section 400.102(1) (ad) and 400.23(8) (b), Florida Statutes (2003), to impose an administrative fine upon the facility in the amount of $2,500 for a Class II deficiency. ‘the deficiency finding relates to the facility’s alleged failure to furnish necessary and appropriate care to a particular resident in a Manner in conformance with 42 CFR 483.13(c) (2003), as incorporated by reference by 59A-4.1288, F.2.C. (2003) that resulted in further deterioration of the patient's condition and weli-being. AHCA alleges that the alleged failure to properly care for this resident compromised the vesident‘s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being at the Respondent’s facility. Count If of this action [AHCA No. 2004003333] consists of agency action to assign a conditional xating licensure status upon the Respondent's jicensure based upon the presence of the Class If deficiency. JURISDICTION AND VENUE 3. The Agency (AHCA) has jurisdiction over the Respondent pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). 4. Venue shall be determined pursuant to Rule 28- 106.207, Florida Administrative Code (2003). 2 rt an PARTIES 5. Pursuant to Chapter 400, Part II (sections 400.012 through 400.334), Florida Statutes (2003), AHCA igs the licensing and enforcing authority with regard to nursing home facility laws and State administrative rules adopted within Chapter 59A-4, Florida Administrative Code (2003), AECA also has the legal authority to enforce applicable federal regulations (Code of Federal Regulations), governing nureing home facilities pursuant to the Omnibus Reconciliation Act of 1387, Title iV, Subtitle C (as amended) . 6. LRuc, doing business ag LRMC Nursing Center, is a Florida Non Profit company with a principal addresa of 600 &. Dixie Avenue, Leesburg, Florida 34748-5925, 7. URMC is a skilled nursing facility whose 120-bed nursing home is located at 700 WN. Palmetto Street, Leesburg, FL 34748. LRMC is licensed to operate a skilled nursing facility license #SNF12990961;- certifiaate number 33508 effective May 30, 2003, through September 30, 2004, At all relevant times, LRMC was a licensed facility xeguired to comply with all applicable regulations, state and federal statutes and rules under the licensing authority of AHCA, COUNT T LEMC FAILED TO ENSURE THAT ONE (#26) OF 26 RESIDENTS REVIEWED WAS TRANSFERRED UTILIZING STANDARD TECHNIQUE TO PROTECT THE RESIDENT'S COMPROMISED LEFT LEG, CAUSING THE LEG TO FRACTURE ABOVE A PREVIOUS KNEE REPLACEMENT. Sections 400.102(1){d), 400.022(1)(1), and 400.23(8) (b), Florida Statutes (2003), 59A-4.1288, F.A.C. (2003), 42 CFR 483.13(c) (2003) 8. AHCA re-alleges and incorporates paragraph numbers (1) through (7) as if fully set forth herein. 9, AHCA conducted an annual survey of LRMC on or about March 12, 2004. Investigation revealed the following Class II deficiency: A. AHCA staff interviewed the Director of Nurses (DON), Administrator, and Risk Manager on 3/11/04 at 12:10 PM and discussed the matter xrespecting resident #26's fracture on or about February 28, 2004, of his/her left leg, on the femur bone above a previous knee replacement. The DON explained that the resident had his/her leg brace off for the shower and the resident's legs crossed during the resident's assisted transfer from a shower chair to the resident's bed. The DON stated the resident could have the brace off for "Hygiene". B, AHCA’s review of medical records for this resident revealed the resident was admitted on 1/06/04 following a left femur Open Reduction Internal Fixation (ORIF). The resident's left hip had a Surgical incision site and a previous left knee replacement and the resident's records included orders: "Bed chair/wheelchair transfers only - Strict Non Weight Bearing - Left Lower Extremity in knee immobilizer at all times except for daily dressing change and hygiene when staples discontinued". wNo Range of Motion was to be performed or allowec. Cc. The Nursing Aide Care Plan dated 1/C6/04 documented the resident as having special precautions for "Strict Non Weight Bearing - Left Lower Extremity" and was to have an “assist of one person and set-up for bed baths-3 times per week". The Respondent's Nursing Monthly Resident Assessment dated 2/06/04 documented the resident as requiring the assistance of one person for bathing three times per week. The document failed to indicate type of bathing activity could be utilized with the resident. D. AHCA’s review of the patient’s records revealed a Nursing Note dated 2/29/04 for the 3-11 shift at 11:00 AM documented the resident as complaining ef “pain to left knee, now swollen" and the Doctor was notified. Physician progress note dated 2/29/04 documented that an X-ray was required to "Rule 5 Out Fracture, highly doubtful, dislocation". The Facility acquired X~ray photography cf the resident's left leg Performed on 2/29/04 ang again on 3/01/04, confirming the leg was fractured on the "Distal left femur®". Review of the X-ray reports failed to produce any documentation that the resident's attending Physician had reviewed it. Interview with the Administrator on 3/12/04 at 12:30 PM revealed the Nursing Home and the Hospital have a System of Pulling up the X-rays and the %-ray reports by computer *on line’, for review. AHCA'’s follow up interview with the Administrator on 3/12/04 at 3:45-py revealed a Standard procedure that any Physician involved would document this review in their progress notes after reviewing the "on line" x-ray reports. E. Review by AHCA Surveyors revealed there were no “nursing notes” or “physician Progress notes" or orders documented in the Patient’s medical chart or records for the veriod from 2/29/03 to 3/04/04 in response to the fxacture and patient’s care asa result thereto. aA Physician Progress note dated 2/17/04 documented the resident as having a follow up appointment scheduled with his/her orthopedic surgeon on 3/04/04. On 3/04/04 the nursing notes decumented the resident was delivered to this scheduled 6 ee ET A I appointment with the Orthopedic Surgeon, where it was determined that the resident needed to be a "direct admit to LRMC South" (Hospital). The Orthopedic Physician contacted the LRMC Nursing Home facility with the order to direct admit to the hospital on 3/04/04. F. In reaction to these events, the Respondent's staff prepared written statements from statements offered by two Certified Nursing Assistants (CNAs) on 3/05/04 who were involved with the resident's transfer event on 02/28/04. CNA #1 documented she had given the resident a showex on 2/28/04 and had CNA #2 assist her in putting the resident back in bed. CNA #1 documented the resident had expressed pain when they "picked him/her up and turned him/her." CNA #1 documented the nurse medicated the resident for pain and the resident expressed pain again on 2/29/04. CNA #1 further documented she and CNA #2 told a RN what happened with the resident. CNA #2 documented that on 2/28/04 she helped CNA #1 "put resident into bed from shower chair". CNA #2 documented that the resident's right foot went under the left foot and the nurse in charge was notified and pain medication was given by the nurse. 2 TT G. Interview with the Respondent's attending Physical Therapy Assistant {PTA) on 3/11/04 at 2:45 pM revealed resident #26 had received therapy in their Gepartment from 1/07/04 to 2/04/04. The resident was discharged to the Restorative Program after he/she declined to make further Progress due to pain in the patient's unaffected or right leg. Regarding the event on February 28, 2004, the pra Stated the resident was trained to hold on to a walker to distribute weight off his/her leg during any transfer activity, The resident was trained to stand on his/her right {or Strong) leg, lean weight on the walker, have the CNA hold the left leg brace and leg up while pivoting on the right leg using a small hop motion. The PTA stated that it is standard practice to locate the wheelchair next to the transfer location and use the strong leg closest to the transfer location for a pivot. Further interview with the pTa revealed that the resident’s legs should not have crossed if transferred in the trained method, H. Resident #26 wag transferred from the Hospital and readmitted to the LRMC Nursing Home: on 7/08/04. AHCA further interviewed stars at the Therapy Department on 3/11/04 at 2:45 PM who revealed that, since readmission on 3/08/04, they had not been 8 an a a TO contacted by the Respondent's poy to provide in- service training to this resident's CNAs on proper transfer techniques for thig resident. 10. The Administrative rule pertinent to the above findings is Rule S9A-4.1288, F.A.c. (2003), which incorporates by reference Section 42 CFR 483 (2003) Provides: 59A-4.1288 Exception. Nursing homes that participate in Title XVIH or XIX must follow Certification rules and r i i Non-certified facilities must follow the Contents of this rule and the Standards contained in the Conditions of Participation found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, il. Regulations found in 42 C.F.LR. 483, Requirements for Long Term Care Facilities, September 26, 1991, provide as follows: Sec, 483.25 Quality of care. Each resident must receive and the facility must Provide the necessary Cate 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. (8) Activities of daily living. Based on the comprehensive assessment of a resident, the facility must ensure that -- (1) A resident's abilities in activities of A daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to-- (i) Bathe, dress, and groom: (li) Transfer and ambulate; (ili) Toilet; (iv) Eat; and (v) Use speech, language, or other functional communication systems, (2) A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section: and (3) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Section 400.23(2) (f), Florida Statutes, authorizes ANCA and other state agencies to adopt rules (Florida Administrative Code Rule 59A-4.1288) which give effect to thle Federal regulation. 12. Furthermore, Section 400.022 (1) (1), Florida Statutes (2003), mandates that the Respondent will provide the xesidents of its facilities with ‘adequate “and appropriate healthcare” consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the 10 agency and additionally, Florida Administrative Code Rule 59A-4.1288, that incorporates by reference 42 CFR § 483.25 xequiring that the Respondent must provide 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. 13. Further, Rule 59A-4.106(4) (aa), Florida Administrative Code, entitled “Facility Policies” provides: (4) Each facility shal! maintain policies and procedures in the following areas: (aa) Specialized rehabilitative and restorative services. 14. Based on all of the foregoing, LRMC violated: the provisions of 42 CFR 5§ 483.25(a)(1)~(3) and Rule s9a- 4.106(4) (aa), Florida Administrative Code, by failing to ensure that one (#26) of 26 residents reviewed was transferred utilizing the prescribed Standard technique to protect the resident's compromised left leg, causing the leg to fracture above a previous knee replacement. This event and the accompanying untimely action to have the resident's x ray be reviewed by the attending physician caused this patient to experience pain and discomfort without appropriate timely medical relief, and ultimately resulted in this resident's transfer to the hospital for several days of care from March 4, 2004, to March 9, 2004, Section 400.102(d), Florida Statutes, establishes that a li ANCA against the Respondent. 15. The statutory Provisions relevant to the determination of the Classification of the Scope and severity of the violation and mandating the @88@ssment of the administrative fines Bought in Count Ir of this Administrative Complaint are Contained in Section 400.23 (8), Florida Statutes {2003}, which Provides: 400.23 Rules, evaluation and deficiencies; potential to atfect a large portion of the facility’s tesidents. The agency shall indicate the Classification on tho face of the Notice of the deficiencies reach his or her highest Practicable physical, mental, and psychosocial well-being, as defined by an accurate and One or more class | or Class |] deficiencies during the tast annual inspection or any inspection or complaint investigation since the last annual inspection. A tine shall be levied notwithstanding the correction of the deficiency, 16. Pursuant fo Section 400.23 (8), F.S., this finding constitutes a Class IF deficiency because thi compromised the resident's ability to Maintain or reach hig or her highest Practicable physical, mental, and PSychosocial well-~being, @S defined by an accurate and comprehensive resident assessment, plan of Care, and Provision of services. 17. Pursuant to subsections 400.102 (1) (a) and 400.23(8) (b), Florida Statutes (2003), the Agency is authorized to impose a fine in the amount of not less than two thousand and five-hundreg Gollars ($2,500), for this isolated Class 1 deficiency violation. AHCA intends to impose an administrative skilled nursing facility in the State of Florida, pursuant to Section 400.102, Fla. Stat. (2003) COUNT rr RESPONDENT WAS NOT In SUBSTANTTAT, COMPLIANCE WITH 42 CFR 483.25 as INCORPORATED BY REFERENCE PURSUANT TO RULE 59A~4.1288, P.A.C, (2003) AT TEE ANNUAL SURVEY, RESULTING IN THE CITATION or AN ISOLATED “CLASS ir7 : DEFICIENCY AGAINST THE FACILITY §400.23(7) (b) and (8), Florida Statutes (2003) Section 400.022(1) (2), Florida Statutes (2003) 42 CFR 483.25 (2003) Rule S9A-4.1288, Fla. Admin, Cade (2003) set forth herein. 19. The statutory Provisions relevant to the imposition of conditional licensure Status sought this Count are contained in Section 400.23(7) (b), Florida Statutes (2003), which Provides; » Surveys, interviews, assign a licensure Status of standard the facility has no Class |, class {I or class {Hi deficiencies at tha time of the follow-up Survey, a standard licensure status may be assigned, 20... The Respondent’ s Conduct, actions and inaction in this matter establish both: {a) the Presence at the time of the subject survey of a violation by the Respondent oF Section 400,022 (1) (1), Plorida Statutes (2003) and algo of 42 CFR 483.25 (2003) as incorporated by reference by Rule 59A-4.1288, Fac, (2003) by its failure to give 14 (b) that this thus -proven violation ig a Class II violation that is “isolated” in Scope, as defined by Florida law. 21, By statutory definition, the Respondent thus wag not in substantial compliance with the criteria (regulations) pertaining to nursing homes on March 12, 2004. ANCA properly and correctly assigned the conditional licensure status to the Respondent, effective March 12, 2004, pursuant to § 400.23(7) (b), Florida Statutes (2003). WHEREFORE, AHCA requests this Court to order the following relief; A, Make factual and legal findings in favor of AHCA on Count Tf. B. Uphold the assignment of the conditional licensure status imposed upon Respondent effective March 12, 2004, as reflected on the license attached hereto as Exhibit “a”. . Notice Respondent is 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 Agency for Health Care Administration, 15 and delivered to the Agency for Realth Care Administration, Building 3, mgc #3, 2727 Mahan Drive, Tallahassee, Florida, 32308; Attention: Clark of Agendy Proceedings, & ALLEGED IN THE COMPLAIN? AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respect fully submitted on this waa 2004. day of uly Robert F, Langf Assistant Generg cCunsel Agency for Health Care Administration 2727 Mahan Drive Bldg. 3, msc#3 Tallahassee, Fr, 32308 (850) 922.5873 (office) (850) 413-9373 (fax) CERTIFICATE oF SERVICE —— ee BSERVICE I HEREBY CERTIFY that true and correct copies of the foregoing has been served by certi — day of _ UJ 2004 fied mail on this ? to: Wilma Green, LRMC Nursing Center, 700 w, Palmetto Street, Leesburg, ¥F1, 34748 and uy, D. Robuck, ur., PA, Registered Agent, Leesburg Regional Medical Center, Inc., 610 g&. Main Street, Leesburg, FL 34748,

Docket for Case No: 04-002869