STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2004010029 AHCA No.: 2004009452 Vv. Return Receipt Requested: WASHINGTON MANOR HEALTH CARE 7004 1350 0000 5650 1616 ASSOCIATES, LLC d/b/a 7004 1350 0000 5650 1623 HILLCREST NURSING AND 7004 1350 0000 5650 1630 REHABILITATION CENTER, Respondent. ; QO < 0 sy vy ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this administrative complaint against Washington Manor Health Care Associates, LLC d/b/a Hillcrest Nursing and Rehabilitation Center (hereinafter “Hillcrest Nursing and Rehabilitation Center”) pursuant to Chapter 400, Part II and Section 120-60, Florida Statutes, (2004) hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine in the amount of $2,500.00 pursuant to Sections 400.23(8) (b), Florida Statutes [AHCA No.: 2004009452]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes [AHCA No. 2004010029]. 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 Broward 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. Hillcrest Nursing and Rehabilitation Center is a skilled nursing facility located at 4200 Washington Street, Hollywood, Florida 33021 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I HILLCREST NURSING AND REHABILITATION CENTER FAILED TO FOLLOW A PHYSICIAN'S ORDER TO OBTAIN AN ORTHOPEDIC CONSULT FOR A RESIDENT. TITLE 42 SECTION 483.13(c) (1), CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE SECTION 400.102 (1) (a), FLORIDA STATUTES SECTION 400.022(1) (1), FLORIDA STATUTES (STAFF TREATMENT OF RESIDENTS) CLASS II 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Hillcrest Nursing and Rehabilitation 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 complaint investigation survey was conducted on October 1, 2004. Based on record review and interview, it was determined that the facility failed to obtain an orthopedic consult for 28 days for 1 out of 18 sampled residents (Resident #1). The findings are as follows: 10. A review of Resident #1's clinical record revealed that the resident ambulated independently throughout’ the facility at the time of the injury (5/9/04). The resident was diagnosed with dementia and was resistant to care at times. Then the resident had an "injury of unknown origin" on 5/9/04. Nurses’ notes at 10:45am on 5/9/04 documented that the CNA (certified nursing assistant) observed the resident's fifth finger of the left hand to be swollen and painful to touch during morning care. Nurses' notes documented that the nurse was notified by the CNA. The resident was assessed and the physician was notified immediately following the injury. An x-ray was done on 5/9/04, which documented no fractures, but medial dislocation of the proximal phalanx of the left fifth digit. ll. On 5/12/04, the primary doctor ordered an orthopedic consult and to tape the 4th and 5th fingers together. 12. No orthopedic consult was done until 6/10/04. Diagnosis on the consult was "dislocation ......... left fifth finger". No new orders were noted on the record for that date. The facility has an "Appointment and Consult" log. The order dated 5/12/04 and consult dated 6/10/04 were noted on this form. The log states that the book is checked daily Monday through Friday. The date received for this entry is noted to be 6/7/04. Facility staff were unable to give a reason for the delay in obtaining the consult. No care plan was noted on the record regarding the monitoring of the taped fingers or dislocation of the finger. 13. Physician progress notes were noted on the record for 5/17/04, 6/29/04 and 7/27/04. The AHCA surveyor and facility staff were unable to decipher any reference to the finger. 14. The record documented an orthopedic follow up on 7/25/04, which noted chronic dislocation of left 5th digit. A preoperative checklist documented that the surgical procedure would be “attempt ORIF L 5th finger, possible amputation". An amputation of the little finger of the left hand above the PIP joint was done on 7/28/04. 15. The resident was noted to be confused at times and nurses' notes frequently documented removal of tape and postoperative bandages. 16. The patient was observed on the morning of 10/1/04 to be alert, but confused with garbled speech. He was noted to have a well healed amputation of the first joint of the fifth finger of the left hand. 17. Based on the foregoing facts, Hillcrest Nursing and Rehabilitation Center violated 483.13{c)(1), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Sections 400.102(1) (a) and 400.022(1) (1), Florida Statutes which carries, in this case, an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (bo), Florida Statutes. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Hillcrest Nursing and Rehabilitation 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 15840951; Certificate No.: Effective date: 10/01/2004 Expiration date: 11/30/2004 11923 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Assess against Hillcrest Nursing and Rehabilitation Center an administrative fine of $2,500.00 for the violations cited above. 3. Assess against Hillcrest Nursing and Rehabilitation Center a conditional license in accordance with Section 400.23(7), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if applicable. 5. 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 (2004). Specific options for 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 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. t General’Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6800 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive - Suite 101 West Palm Beach, Florida 334407 (U.S. Mail) Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE & ts ris : * Ooh. I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Maiti t/Return e Receipt Requested to Sandra Yersk, Administrator, Hillcrest Nursing and Rehabilitation Center, 4200 Washington Street, Hollywood, Florida 33021; Washington Manor Health Care Associates, LLC, 10210 Highland Manor Drive - Suite 250, Tampa, Florida 33610; CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on this 1441, day of Dee en , 2004, 10

Docket for Case No: 05-000548