{ Ao RAS FELIS OSE cm | ae STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CAR ADMINISTRATION, Qi ® “4 6 Petitioner, WO SAN . Lb, Ss 2 vs. - AHCA No. 2004008136 Bh Ay 2004007442 tee, OY. LEE HEALTH CARE ASSOCIATES, bys D/B/A LEE CONVALESCENT CENTER, on Respondent. () 5. OoUl | ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (‘AHCA” or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against LEE HEALTH CARE ASSOCIATES D/B/A LEE CONVALESCENT CENTER (“Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes (2004) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of TEN THOUSAND DOLLARS ($10,000.00), upon Respondent, pursuant to Section 400.23(8)(b), Florida Statutes (2004). JURISDICTION AND VENUE 2. The Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). 3. Venue shall be determined pursuant to Rule 28-106.207 Florida Administrative Code (2004). Page 1 of 15 PARTIES 4. AHCA 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 Il, Florida Statutes (2004), and; Chapter 59A-4 Fla. Admin. Code (2004), respectively. 5. Respondent, LEE HEALTH CARE ASSOCIATES, LLC, owns and operates a skilled nursing facility in the state of Florida. The facility, Lee Convalescent Center (“Facility”), is a 120-bed nursing home located at 2826 Cleveland Avenue, Fort Myers, Florida 33901-6097. Respondent is licensed as a skilled nursing facility, having been issued license #SNF1290096, effective September 14, 2004. The license is conditional as of July 15, 2004. Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and rules. COUNTI CLASS I VIOLATION FOR FAILURE TO PROVIDE NECESSARY CARE AND SERVICES 42 CFR 483.25 Section 400.23(8)(b), Florida Statutes Rule 59A-4.106(4)(aa), Fla. Admin. Code Rule 59A-4.1288, Fla. Admin. Code 6. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 7. The regulatory provisions of the Code of Federal Regulations that are pertinent to this alleged violation, read as follows: Page 2 of 15 ‘42 CFR 483.25 Quality of care. Each resident must receive and the facility 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. 59A-4.106 Facility Policies. ee (4) Each facility shall maintain policies and procedures is the following areas: (aa) Specialized rehabilitative and restorative services. 8. AHCA surveyors conducted an annual survey of Respondent's facility on or about July 15, 2004, which revealed the following: Based on resident record review and interview with staff, the facility failed to assure a resident received the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for 1 (Resident #10) of 20 actively sampled residents as evidenced by: 1.) The facility failed to coordinate the resident's care with his infectious disease physician. 2.) The facility failed to care plan the resident for the monitoring of the resident's antiviral medications and their side effects resulting in the resident on 7/15/04 having a critical low level white blood count (WBC) of 1.6 (normal for the lab used by the facility being 4.2 to 10.8) putting the resident into neutropenia and placing the resident at high risk for fungal infection, bacterial infection, and viral infections. WBC's play a role in assisting the body in fighting infections. The findings include: ” Review of the medical record for Resident #10 revealed the resident was admitted to the facility on 6/10/04 with diagnosis of, but not limited to, Human Immunodeficiency Virus (HIV), Hypotension, and Cardiomyopathy. Further review of the record revealed the resident was admitted for a "short-term stay" and to receive specialized rehabilitation for improving lower extremity strengthening and ambulation. The resident was discharged from specialized rehabilitation on 7/2/04 to restorative nursing. The resident could ambulate 120 feet, but was weak and tired easily. Review of the restorative nursing goals remained "improve lower extremity strengthening and ambulation 3 times a week," because that was all the resident Page 3 of 15 could tolerate. Review of the restorative note revealed restorative was started on 7/9/04 and the resident could ambulate 120 feet with one rest period, using the walker and gait belt. On 7/42/04, the resident had a 15-minute session with restorative for standing to sit. Interview with the resident revealed the resident does not get out of bed except to go to therapy. The resident stated, "| used to only walk with a cane at home and | came here to regain my ability to walk. | can't go home unless | am able to walk, but | get so tired.- | also noticed since | am here | get a pounding in my chest. | think that it is from my new cardiac medications." Further review of the record revealed the resident had blood work done the day before he/she was discharged from the hospital. Review of the blood work from the hospital revealed the resident had a WBC of 2.2 on 6/9/04 and the WBC had dropped from 2.9 on 6/8/04. The red blood count (RBC) on 6/9/04 was 3.21 (low), normal being 4.10 to 5.90; the hemoglobin (HGB) was 9.3 (low), normal being 13 to 18. Review of the resident's medications revealed that the resident was on 3 antiviral medications, Valcyte, Viread, and Epivir. Review of the side effects of these medications revealed all three of the medications can cause neutropenia. "Neutropenia" is the reduction of white blood cells. White blood cells assist the body in combating infections. Review of the care plan for the resident revealed the resident had no documented plan of care for the possible side effects of the antiviral medications. Interview with the unit manager on 7/13/04 at approximately 9:45 A.M. revealed she thought the resident was admitted to the facility for a short stay to rehab and gain strength back. When asked about the resident's medications she stated she knew the resident was on 3 antivirals, but was not sure of all the side effects. She reviewed the medications with the surveyor and noted the medications all had the potential to cause neutropenia. When asked about any lab work for the resident, she stated none had been ordered. After the surveyor showed the unit manager the hospital lab work that was in the resident's record, the unit manager stated, "I will have the nurse call his doctor and see if he wants any lab work ordered.” When asked if the facility had contacted the resident's infectious disease physician, the unit manager stated, "No, but | will ask his current physician if he wants us to call.” The facility had the blood work done on 7114104. On 7/15/04, the surveyor reviewed the lab work at approximately 12:30 P.M. The resident's WBC was down to 1.6 (critical low level); normal for the lab the facility uses is 4.2 to 10.8. The RBC was down to 2.59 (low), normal= 4 to5. The HGB was 7.7 (low), normal= 14 to 18. The "critical low WBC" results that the facility obtained based on the surveyor's questions as to whether the facility was monitoring the Page 4 of 15 medications and whether additional lab work was obtained to ensure monitoring of the medication side effects placed the resident at higher risk for any and all infections. The low HGB puts the resident at greater risk for increasing fatigue and weakness. Recent literature indicates for people with HIV, half of deaths occur due to infections. Interview with the nurse on 7/15/04 at 12:30 P.M. on the unit revealed the physician was notified and said no new orders. s The unit manager came to the surveyor on 7/15/04 at approximately 2:30 P.M. and said the facility was now trying to contact the resident's infectious disease physician about the critical WBC and the pounding the resident is having in his chest. 9. Respondent's failure to provide necessary care and services isa violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.25. 10. Respondent's failure to provide necessary care and services is a violation of Rule 59A-4.106(4)(aa), Fla. Admin. Code. 41. | AHCA classified the nature and scope of this violation as a class II violation. Pursuant to Section 400.23(8)(b), this classification constitutes grounds for the imposition of an administrative fine of FIVE THOUSAND DOLLARS ($5000.00). A class II violation is defined as one that “the agency determines 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.” COUNT Il CLASS I] VIOLATION FOR FAILURE TO PROVIDE NECESSARY CARE AND SERVICES 42 CFR 483.25(c) Section 400.23(8)(b), Florida Statutes Rule 59A-4.106(4)(aa), Fla. Admin. Code Page 5 of 15 Rule 59A-4.1288, Fla. Admin. Code 42. AHCAre-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 13. The regulatory provisions of the Code of Federal Regulations that are pertinent to this alleged violation, read as follows: 42 CFR 483.25 Quality of care. Each resident must receive and the facility 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. (c) Pressure sores. Based on the comprehensive assessment of a resident, the facility must insure that— (1) Aresident 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. 44. | AHCA surveyors conducted an annual survey of Respondent's facility on or about July 15, 2004, which revealed the following: Based on observations, resident record review, and interview with staff, the facility failed to provide necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 1 (Resident #5) of 20 active sampled residents as evidenced by: 1.) Staff allowing the resident to stay on his/her left side with the right knee resting on the side rail. 2.) Failure to have the tube feeding run continuously as ordered. 3.) Failure to update the care plan for prevention and healing of pressure sores after the facility identified the resident at high risk for pressure sores resulting in the resident developing 8 new areas of skin breakdown, 1 stage 2 on the left shoulder, 1 stage 2 on the right knee that was resting on the side rail, 5 open areas in the right groin, and 1 open area in the left groin. Page 6 of 15 Findings include: 4. Observation of resident #5 during a tour of the facility on 7/12/04 revealed the resident was lying on his/her left side with the right knee resting on the side rail. A total of 13 more observations were made over the next 2 days, at 1:00 P.M. on 7/12/04, On 7/13/04 the resident was observed lying in the same position at 5:00 A.M., 6:00 A.M., 7:45 A.M., 8:30 A.M., 12:00 P.M. and 2:00 P.M. The resident was observed on the left side with knee resting on the side rail on 7/14/04 at 8:00 AM., 8:45 A.M., 11:30 A.M., 12:00 P.M., 1:00 P.M. and 2:00 P.M. 2. Observation of the resident at 8:30 A.M. on 7/13/04 revealed the continuous tube feeding was not running. The nurse in the room stated, "The feeding tube pump thinks it has finished its program and it stops running.” The nurse was not sure how long the pump was off. The nurse and surveyor also noted the air mattress was unplugged and the mattress was flat for an unknown period. Observation of the resident on 7/14/04 at 8:45 A.M. revealed the resident's feeding pump was not running, the pump was reading the program was completed at 1235 cc infused. Observation of the label revealed the feeding was hung at 6 P.M. on 7113/04 and there was still 400 cc left in the container. Further observation revealed a nurse was present in the room doing wound care from 8:45 A.M. until 10:30 A.M. and did not notice the pump was not running. The surveyor continued to observe that the pump was not running at 12:30 P.M., 1:00 P.M. and 1:30 P.M. At 2:00 P.M. the surveyor told the facility the pump had not been running all day. After surveyor intervention, the resident's tube-feeding was restarted. 3. Review of the resident's medical record revealed the resident was admitted to the facility on 6/1/04 with diagnosis of, but not limited to, Peripheral Vascular Disease, Cerebral Vascular Accident, post PEG [jtube placement, and pressure sore. 4. Review of the orders for the tube feeding revealed the formula was to run at 90 cc an hour. Review of the amount left in the container and the time the formula was started revealed the resident was without nutrition for 7 and 1/2 hours. Further review of the record revealed the resident had a 12.7 % weight loss identified on 6/30/04 and the dietitian increased the tube feeding to 90 cc an hour to equal 2592 calories. The dietary note on 7/10/04 indicated the resident lost more weight and Arginaid was ordered twice a day to increase the calories by another 500 calories a day. On 7/1 4104, the resident did not receive 810 calories of the needed 2592 from the formula. This was confirmed by the Dietitian. Page 7 of 15 5. Observation of the resident's wound care on 7/14/04 at 8:45 A.M. revealed the resident had 6 pressure sores. During the wound care, the resident was lying on his/her left side and when the staff spread the resident's legs, a new stage 2 pressure sore was found on the inner aspect of the right knee (the knee that had been resting on the side rail). The resident was noted to have contracture of both legs: the legs are bent. Staff was observed to have difficulty spreading the resident's legs apart. There was a soft flat pillow between the ankle and calf; it did not extend to the knees. When staff went to turn the resident on to the right side the nurse found a hew stage 2 on the left shoulder. The nurse then assessed the resident for other skin breakdown and found 5 open areas in the right groin. The nurse stated, "They came from rubbing against the adult brief.” When she looked at the left groin, she found another open area. The nurse stated, "The resident had a history of breaking out in blisters and then they just come and go. Some of them open and become pressure areas.” 6. Review of the plan of care for prevention and healing of pressure areas - revealed it was dated 6/15/04 and the approaches were: 4. Assist with position changes. Air mattress to bed. Observe skin with daily care; report any areas of redness or irritation. Weekly skin check by nurse. Provide wound care as ordered. Vitamin C and Zinc to promote wound healing. AaRwWNn Further review of the record revealed the facility identified the resident at a team meeting that the resident was at high risk for pressure sores. The facility did not update the care plan after the facility identified the resident at high risk and they did not personalize the care plan for the resident. 7. Interview with the former Director of Nursing (DON) on 7/15/04 at approximately 12:40 P.M. revealed the facility identified the resident at high risk for pressure sores on 6/22/04. She further stated the resident likes to lay on his/her left side and if he/she is on the right side the resident would wiggle and tum to the left. She said the resident is to be out of bed in a chair once a day and even in the chair, the resident would wiggle to the left side. When asked if there were any interventions in place to keep the resident on his/her right side, she said they did not place pillows behind the resident so that he/she would not turn. The former DON stated, "We can't dispute the stuff you saw. What the nursing staff didn't do is an issue and | can't speak to that. They may need more education." Page 8 of 15 ‘15. Respondent's failure to provide necessary care and services is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.25(c). 16. Respondent's failure to provide necessary care and services is a violation of Rule 59A-4.406(4)(aa), Fla. Admin. Code. 17. AHCA classified the nature and scope of this violation as a class II violation. Pursuant to Section 400.23(8)(b), this classification constitutes grounds for the imposition of an administrative fine of FIVE THOUSAND DOLLARS ($5000.00). A class |! violation is defined as one that "the agency determines 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.” CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1. Factual and legal findings in favor of the Agency on Count I. 2. Imposition of an administrative fine of FIVE THOUSAND DOLLARS ($5000.00) for Count I, and an administrative fine of FIVE THOUSAND DOLLARS ($5000.00) for Count II for a total fine of TEN THOUSAND DOLLARS ($10,000). 3. Such other relief as this Court deems is just and proper. NOTICE Page 9 of 15 ‘Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569 and 120.57, Florida Statutes. 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, and delivered to: Agency Clerk Agency for Health Care Administration Building 3, MSC #3, 2727 Mahan Drive Tallahassee, Florida, 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE AGENCY MUST RECEIVE A REQUEST FOR HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT BY RESPONDENT. FAILURE TO COMPLY WILL CONSTITUTE AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND RESULT IN THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted this 77 _ day of Necemacn , 2004. pu — n Fowler, Esquire sistant General Counsel a. Bar No. 339067 Agency for Health Care Administration 2295 Victoria Avenue Room 346C Ft. Myers, Florida 33901 (239) 338-3203 (office) (239) 338-2372 (fax) Page 10 of 15 CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing Administrative Complaint, with an Election of Rights for Administrative Hearing form and an Explanation of Rights Under Section 120.569, F.S.A. form, have been forwarded by certified mail no. 7003 1010 0000 9716 0465, return receipt requested, to: Todd James Truax, Administrator, 3626 Woodmont Drive, Sarasota, Florida 34232, and by certified mail no. 7003 1010 0000 9716 0458, return receipt requested, to: Todd James Truax, Administrator, Lee Convalescent Center, 2826 Cleveland Ave., Fort Myers FL 33901-6097 this pote day of 5 Elem bere , 2004. Page 11 of 15

Docket for Case No: 05-000046