STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, R E c AGENCY FOR HEALTH CARE EI VE D ADMINISTRATION, DEC 27 209 Petitioner, vs. Case No. 2004008867 ISLAND LAKE CENTER, LLC, — Nee d/b/a ISLAND LAKE CENTER, Od O}) x QA « _ “ wn, Respondent. Do, Bo / Pe fo gt _—_— Dt Ce w . eg ce) ADMINISTRATIVE COMPLAINT Boye % COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE” on 2 ADMINISTRATION (hereinafter referred to as “Agency” or “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against ISLAND LAKE CENTER, LLC, d/b/a ISLAND LAKE CENTER (hereinafter referred to as “ISLAND LAKE”), pursuant to §§ 120.569 and 120.57, Fla. Stat. (2003), and alleges NATURE OF THE ACTION This is an action to impose an administrative fine, pursuant to §§ 400.23(8)(b) and 400.102, Fla. Stat. (2003), in the amount of $2,500.00 against ISLAND LAKE based upon one cited State Class II deficiency which the Agency has determined compromised a 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. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §3 120.60 and 400.(62, Fla. Stat. (2003). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliaticn Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part Il, Florida Statutes; and, Fla. Admin. Code R. 59A-4, respectively. 4. ISLAND LAKE operates a 120-bed skilled nursing facility located at 155 Landover Place, Longwood, Seminole County, Florida, 32750, and is licensed as a skilled nursing facility under license number SNF 13460963. 5. ISLAND LAKE was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to 42 CFR § 483.25 and Fla. Admin. Code R. 59A-4.1288, ISLAND LAKE must provide each resident with 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. 8. The Agency conducted a re-certification survey at ISLAND LAKE during 8/23/04 through 8/26/04. 9. Based upon record review, observation and interview, ISLAND LAKE failed to ensure that one of its residents was provided the necessary care and services to prevent a fracture for | of 23 (Resident # 17) residents. 10. Resident # 17 was admitted to the facility on 4/01/03 with multiple diagnoses including Alzheimer's disease, cerebrovascular disease, unspecified osteoporosis, and unspecified essential hypertension. 11. Review of Resident # 17’s clinical record on 8/25/04 revealed that on 7/30/04, at 10:15 p.m., a certified nursing assistant (hereinafter “CNA”) reported to one of the facility nurses that when he was turning Resident # 17 in bed to perform activities of daily living (“ADL’s”), he heard a snap in Resident # 17’s left arm. 12. The resident’s arm had been positioned in between the side of the bed and the side rail, and the CNA failed to move the resident’s arm in a safe position prior to turning the resident. 13. Following the incident, according to the resident’s clinical record, assessment of the arm revealed a rising hematoma, which was the size of a golf ball. 14. According to the clinical record, staff applied an ice pack to the resident’s arm and notified a physician at 10:45 p.m. 15. A telephone order was documented at 10:50 p.m., in which the physician ordered an ice pack, which was to be applied to the left elbow, immobilization of the left arm, and an x-ray of the left humerus, forearm, and elbow. 16. The nurse, who was notified by the CNA about the incident, indicated that when she entered the resident’s room she heard the resident moaning and grunting. 17. An x-ray was not taken until 10:55 a.m. on 7/31/04, when an x-ray technician arrived at the facility. 18. Further review of the nurse's notes revealed that the x-ray results, received at 3:00 p.m. on 7/31/04, confirmed a displaced fracture to the left elbow. 19. However, the facility did not send the resident to the hospital until 4:45 p.m. on 7/31/04. 20. Review of the medication administration record (MAR) revealed that the resident was not given anything for pain until 7/31/04 at 1:30 p.m., the day after the incident occurred. 21. Agency interview with the director of nursing (DON) during the investigation revealed that the DON was not able to explain why Resident # 17 had to wait until 1:30 p.m. on 7/31/04, the day after the incident, to receive Tylenol when the resident was heard moaning and grunting prior to that time and when the resident had a rising hematoma the size of a golf ball on 7/30/04. 22. Review of the quarterly Minimum Data Set (MDS), dated 5/27/04, indicated that the resident was totally dependent and required one-person physical assistance with transfers. 23. The resident’s cognition was documented in his/her facility records as moderately impaired. 24. Resident # 17’s records also documented that the resident required full bed rails on all open sides of the bed, to be used daily. 25. According to the physician order sheet, Resident # 17 had an order for pads to bilateral side rails. 26. Review of the resident's care plan for impaired mobility indicated that the resident was to use side rails to assist with turning and re-positioning. 27. ISLAND LAKE staff documented on the resident’s care plan that staff should provide padded side rails to assist the resident with turning and re-positioning. 28. According to the DON, at the time of the incident, the side rail pads were not on Resident # 17’s bed as ordered by the resident’s physician and as documented to be used on the resident’s care plan. 29. Review of the CNA's personnel record revealed that the CNA had a prior incident to the one on 7/30/04. 30. The incident occurred on 7/10/04 and involved the treatment of a resident. 31. According to documentation in the CNA’s personnel file, another resident had reported that the CNA was "abusive verbally during care”. 32. The resident also reported that the CNA slammed him or her around and made inappropriate statements. 33. Agency interview with the DON on 8/25/04 revealed that the DON did not feel that this was an abusive incident. 34. The DON only gave the CNA a warning to guard against inappropriate staternents. 35. The DON indicated that she did not provide any in-service education to the CNA, nor any other staff members, after this incident regarding the proper handling of residents or the prevention of abuse and/or abusive behaviors. 36. On 8/26/04, the Agency conducted interviews with the administrator, the DON, and the risk manager. 37. | The DON was questioned again regarding if the CNA was re-educated on the proper handling of residents; and, again, she replied "No". 38. On 8/26/04, at about 12:00 p.m., Resident #17 was observed in the hallway sitting in his/her wheelchair with a cast on his/her left arm. 39. Resident #17 was observed to be unable to speak, 40. During observation of Resident #17’s bed, the side rail pads were observed to be placed behind the head of the bed. 41. The Agency determined that ISLAND LAKE did not provide the resident with the necessary care and services and had 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. These deficient practices were cited as an isolated State Class II deficiency. 42. The Agency provided ISLAND LAKE with a mandatory ccrrection date of 9/16/04. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against ISLAND LAKE, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). Respectfully submitted this gos day of December 2004. Kunberly M1 Deassondes—11 | ware Kimbedy M. Nicewonder-Murray Fla. Bar. No. 571628 Agency for Health Care Administration 525 Mirror Lake Drive, 330D St. Petersburg, FL 33701 727/552-1435 (office) 727/552-1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, 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 attention of: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by Certified Mail, Return Receipt No: 7003 1010 0003 0299 1815 on December Zap, 2004 to: David J. Powers, P.A., Registered Agent, Island Lake Center, 7777 Glades Road, Suite 300, Boca Raton, Florida 33434 and by U.S. Mail to: David P. Jones, Administrator, Island Lake Center, 155 Landover Place, Longwood, Florida 32750. Hn Ms rorduL' imberly M. Nicewonder-Murray Copies furnished to: David J. Powers, P.A. David P. Jones Kimberly Nicewonder-Murray Registered Agent Administrator Senior Attorney Island Lake Center Island Lake Center Agency for Health Care 771717 Glades Rd, #300 155 Landover Place Administration Boca Raton, Florida 33434 — Longwood, Florida 32750 = 525 Mirror Lake Drive, 330D (U.S. Certified Mail) (U.S. Mail) St. Petersburg, FL 33701 (Interoffice Mail)

Docket for Case No: 05-000118