STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Vv. EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY d/b/a KISSIMMEE GOOD SAMARITAN HEALTH CARE CENTER, Respondent. AHCA No.: 2004008349 AHCA No.: 2004007283 Return Receipt Requested: 7003 1680 0006 9825 9974 7003 1680 0006 9825 9981 7003 1680 0006 9825 9998 (E> YO | ADMINISTRATIVE COMPLAINT COMES NOW the (hereinafter “AHCA”), and files this Agency for administrative Health Care complaint against Administration by and through the undersigned counsel, Evangelical Lutheran Good Samaritan Society d/b/a Kissimmee Good Samaritan Health Care Center Care Center”) 60, Florida Statutes, (hereinafter pursuant to Chapter 400, “Kissimmee Good Samaritan Health (2004) and hereinafter alleges: NATURE OF THE ACTIONS Part II and Section 120- 1. This is an action to impose an administrative fine in the amount of $31,000.00 [$25,000.00 fine + $6,000.00 survey fee] pursuant to Section 400.23(8)(b), Florida Statutes and Section 400.19, Florida Statutes [AHCA No.: 2004007283]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes [AHCA No. 2003008929]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Osceola County, pursuant to Section 400.121 Florida Statutes and Chapter 28.106.207, Florida Administrative Code. PARTIES 5. AHCA is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Kissimmee Good Samaritan Health Care Center is a skilled nursing facility located at 1500 Southgate Drive, Kissimmee, Florida 34746 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I KISSIMMEE GOOD SAMARITAN HEALTH CARE CENTER FAILED TO ASSESS SKIN CONDITION WHEN USING A MOIST HOT PACK ON A RESIDENT THEREBY CAUSING A BURN. TITLE 42 SECTION 483.25, CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS II 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Kissimmee Good Samaritan Health Care Center participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. A recertification survey was conducted from July 12, 2004 through July 15, 2004. Based upon observation, interview and record review, it was determined that the facility failed to assess skin condition when using a moist hot pack, thereby causing a burn on 1 out of 24 sampled residents. The findings are as follows: 10. A review of Resident #5's clinical record indicated diagnoses of Alzheimer's disease, cerebral artery stenosis, cerebral atherosclerosis, cerebral vascular accident (CVA) and left sided paralysis. ll. A review of the 06/01/04 minimum data set (MDS) indicated that Resident #5 was moderately impaired cognitively, non-ambulatory and totally dependent on staff for all activities of daily living (ADL). 12. A review of the facility's Braden Scale for Predicting Pressure Sore Risk, dated 03/19/04, indicated a score of 14 and identified him/her at risk for skin breakdown. 13. A review of the physical therapy evaluation and plan of treatment dated from 06/02/04 to 07/01/04 indicated that Resident #5 was referred for a severe left knee and hip contracture. The plan of care identified hot/cold modalities, to increase left knee extension by 10-15 degrees, and to establish a restorative nursing program (RNP) for range of motion and splinting. At the end of the 4 weeks the resident would then demonstrate increased left knee extension up to 45-50 degrees, and tolerate the left knee brace up to 8 hours. 14. Therapy documentation revealed that Resident #5 received from the therapist a contrast bath (moist heat pack) seven (7) times along with left knee brace applications on 06/03/04, 06/04/04, and 06/07-11/04. The resident increased his/her tolerance in wearing the knee brace from 2 hours to 4 hours. 15. Further record review indicated that Resident #5 met most of the physical therapy goals. His/Her left knee extension was 25 degrees. He/She was able to tolerate the knee brace for 4 hours and was referred to RNP for lower extremity stretching and bracing. Eventually, Resident # 5 was discharged from therapy on 06/11/04. 16. A RNP (Restorative Nursing Program) was developed and initiated on 06/14/04. The treatment plan identified the following: 1. Provide patient with moist heating pad to the left knee prior to stretching 2. Gently stretch left knee towards extension for about 10-15 minutes 3. Apply left knee brace properly and keep for up to 4 hours. Increase time as patient tolerates. Check skin after removal of brace for any pressure areas and adjust brace as ROM (range of motion) increases. A review of the 06/04 RNP aides’ treatment sheet indicated Resident #5 received a moist heat pack for 10 minutes and that a splint was applied on 06/14/04. 17. A review of the 06/15/04, 11:00 a.m. interdisciplinary progress note (IPN) revealed that the RNP aides notified the nurse of a red area on the left knee. The heat pad had been applied. An open red area on the kneecap measured 5 centimeters (cm.) by 5 cm. with a second open area measuring 3 cm. by 2 cm. lateral to the knee. The IPN indicated at 4:00 p.m. that the left knee had an open area and was red with slight weeping of clear fluid. The 06/16/04 IPN indicated at 9:00 a.m. that the area on the knee continued to weep was red in color and measured 9 cm. by 7 cm. 18. A review of the physician's progress note of 06/16/04 identified a second-degree burn to the left knee sustained from a heat pad measuring 6 cm. by 7 cm. The 06/17/04 progress note identified a second-degree burn measuring 6 cm. by 9 cm. with serosanguineous (serum and blood) drainage. 19. An interview was conducted with the risk manager on 07/13/04 at 8:22 a.m. He/She stated that after conducting investigation and interviews, it was determined that the RNP aide failed to follow the physical therapy policy by not checking the skin every 5 minutes when a moist heat pad was applied. The risk manager stated that the RNP aide left the heat pad on 8 minutes, removed the pack, towels and noticed a reddened area. The risk manager stated upon assessment, Resident #5 received a burn and the top layer of skin came off the left knee. 20. An interview with the physical therapist on 07/13/04 at 4:39 p.m. revealed that the RNP aide applied the moist heat pack to the resident's left knee. The pack continued to drop off the knee. Therefore, it was reapplied and remained on the knee for 8 minutes. There was not any checking of the skin at 5 minute intervals as required according to Hydrocollator Pack Policy. Therefore, Resident #5 sustained a burn. The physical therapist stated that due to the burn, the knee brace had not been applied since 06/15/04 to allow for healing. The therapist stated that the resident had received prior heat pad application, even the day before on 06/14/04, without any incident occurring. 21. The RNP aide was interviewed on 07/14/04 at 10:15 a.m. He/She stated that the heat pad was applied and continued to fall off. So it was reapplied and remained on the knee approximately 6-8 minutes. The aide stated the skin was not observed at the 5 minute interval per the policy. When the pack and towels were removed, the skin was loose. 22. An observation of Resident # 5’s left knee on 07/13/04 at 10:34 a.m. revealed a distinct area, measuring approximately 6 cm. of intact, clean, pink tissue. 23. A review of the facility's Heat Application (Hydrocollator Packs) Procedure, dated 02/04 was conducted. Under Procedure #6, one is to visually inspect application site at least every 5 minutes for signs of burning or discomfort. 24. Based on the foregoing facts, Kissimmee Good Samaritan HealthCare Center violated 483.25, Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries, in this case, an assessed fine of $5,000.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7)(b), Florida Statutes. COUNT IT KISSIMMEE GOOD SAMARITAN HEALTH CARE CENTER FAILED TO CONSISTENTLY FOLLOW THE PLAN OF CARE AND SUPERVISE RESIDENT, WHICH RESULTED IN THE RESIDENT LEAVING THE FACILITY TWICE UNNOTICED FOR AN UNDETERMINED AMOUNT OF TIME. 483.25(h) (2), CODE OF FEDERAL REGULATION RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (RESIDENT SUPERVISION) CLASS fT 25. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 26. A recertification survey was conducted from July 12, 2004 through July 15, 2004. Based upon interview and record review, it was determined that the facility failed to consistently follow the plan of care and supervise 1 resident (#15) in a sample of 24 thereby allowing the resident to leave the facility twice unnoticed, for an undetermined amount of time and cross roads at busy intersections. The resident did not receive supervision resulting in findings of Immediate Jeopardy. The findings are as follows: 27. Resident #15 was admitted with a diagnosis of Alzheimer's disease in its, early stages. Record review revealed that the resident had documented episodes of wandering behavior. The resident's 9/11/03 care plan directed that the resident was to wear a "Code Alert" and that staff was to check for placement every shift. 28. On 12/27/03, the resident left the facility unnoticed, went through the gates surrounding the facility and walked to a grocery store across the street from the facility. At 2:50 p.m., facility staff realized the resident was not in the building. The resident was located at the grocery store and was returned by local police. 29. On 2/21/04 at 2:00 p.m., a nurse's progress note documented that the resident was found out of the building. A note faxed to the resident's physician on 2/21/04 at 2:00 p.m. noted that the resident was located at a local pharmacy, again outside the gates surrounding the facility and across the street from the facility. The resident was brought back to the facility by an employee. This progress note also documented that the resident "often takes off the code alert monitor". There was no documentation on how long the resident was gone from the facility. 30. Although the care plan directed staff to check for placement of the "Code Alert", it was not until the resident eloped a second time that nursing required staff to document that they check for placement each shift. It was not until 4/21/04 that staff began doing weekly function tests on the "Code Alert" bracelet. 31. Staff was supposed to document exit seeking behavior every shift on the Behavior Documentation log. On the day the resident eloped in December (12/27/03), the night shift failed to document any exit seeking behaviors on this sheet or elsewhere in the record. 32. Two (2) months after the first elopement, the resident eloped again. After the second incident, the intervention implemented was to have staff document that they check for placement of the "Code Alert" monitor each shift. Two (2) months later, 4/21/04, staff were directed to check weekly that the monitor was in working order. 33. On 7/14/04 at 1:04 p.m., the unit Manager (UM) was interviewed. The UM stated that staff were to check for the monitor. However, the UM did not know if the facility had an Elopement policy and procedure or where to find it. The UM had to ask two (2) nurses before the policy and procedure was located. 34. Based on the foregoing facts, Kissimmee Good Samaritan Health Care Center Nursing violated 483.25(h) (2), Code of Federal Regulation, as incorporated by Rule 59A-4.1288, Florida Administrative Code herein classified as a Class I violation pursuant to Section 400.23(8), Florida Statutes, which carries, 10 in this case an assessed fine of $20,000.00 due to demonstrated confirmed past non-compliance. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statute. SURVEY FEE Pursuant to Section 400.419, Florida Statutes, Kissimmee Good Samaritan Health Care Center qualifies for a 6-month survey cycle fee of $6,000.00. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Kissimmee good Samaritan Health Care 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 “A” EXHIBIT “A” Conditional License License # SNF 1267096; Certificate No.: Effective date: 07/15/2004 Expiration date: 07/31/2004 Conditional License License # SNF 1267096; Certificate No.: Effective date: 08/01/2004 Expiration date: 07/31/2005 Conditional License 11674 11675 License # SNF 1267096; Certificate No.: 11676 Effective date: 08/24/2004 Expiration date: 07/31/2005 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Counts I and II. 2. Assess against Kissimmee Good Samaritan Health Care Center an administrative fine of $25,000.00 fine for the violations cited above. 3. Assess against Kissimmee Good Samaritan Health Care Center a conditional license in accordance with Section 400.23(7), Florida Statutes. 4. Assess a 6-Month Survey Cycle fee of $6,000.00 against Kissimmee Good Samaritan Health Care Center pursuant to Section 400.419, Florida Statutes. 5. Assess costs related to the investigation and prosecution of this matter, if applicable. 6. Grant such other relief as the 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 120.57, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests 13 for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6800 Copies furnished to: Joel Libby Field Office Manager Agency for Health Care Administration 400 West Robinson Street - Suite $309 Orlando, Florida 32801 (U.S. Mail) Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 14 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE ——— eo eee I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Orin K. Eimers, Administrator, Kissimmee Good Samaritan Health Care Center, 1500 Southgate Drive, Kissimmee, Florida 34746; Evangelical Lutheran Good Samaritan Society, P. ©. Box 5038, Sioux Falls, South Dakota 57117; Chief Financial Officer, 200 E. Gaines Street, Tallahassee, Florida 32399 on this /4fh aay of , 2004,

Docket for Case No: 04-004507