etnies AE sean Ee mr STATE OF FLORIDA , AGENCY FOR HEALTH CARE ADMINISTRATION “ape fia AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2004010118 AHCA No.: 2004008633 v. Return Receipt Requested: 7004 1350 0000 5650 1654 VILLA MARIA NURSING AND 7004 1350 0000 5650 1661 REHABILITATION CENTER, INC. a/b/a VILLA MARIA NURSING CENTER, CS- Ob 19 Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), bY and through the undersigned counsel, and files this administrative complaint against Villa Maria Nursing and Rehabilitation Center, Inc. d/b/a Villa Maria Nursing Center (hereinafter syilla Maria Nursing 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 $2,500.90 pursuant to Sections 400.23(8) (b), Florida Statutes {AHCA No.: 2004008633) - ig an action to impose 4 conditional licensure 2. This rating pursuant to Section 400.23(7) (b). Florida Statutes (AHCA No. 2004010118] . JURISDICTION AND VENUE Section 3. This court has jurisdiction pursuant Lo atutes and Chapter 28-106, Florida 120.569 and 120.57, Florida St Administrative Code. 4. yenue lies in Miami-Dade County, pursuant f° Section 400.121 Florida Statutes and Chapter 28-106.207, Florida ive Code. Administrat PARTIES 5. AHCA is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part Il, Florida Statutes and Rule S59A-4, Florida Administrative Code. 6. villa Maria Nursing Center is a skilled nursing facility located at 1050 N.E. 125 Street, North Miami, Florida 33161 and is licensed under Chapter 400, Part Il, Florida Statutes and Chapter 59A-4, Florida administrative Code. peta Rs TS ES reps aa couNnT I VILLA MARIA NURSING CENTER FAILED TO ADDRESS THE RESIDENT’ S COMPLAINTS OF HAVING FALLEN IN ADDITION TO DEMONSTRATING SIGNS OF POSSIBLE INJURY FROM THAT FALL SUCH AS REPORT OF PAIN INA TIMELY AND APPROPRIATE MANNER CAUSING DELAY IN PROPER TREATMENT LEADING IN ACTUAL HARM. TITLE 42 SECTION 483.25, CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE RULE 59a-4.106 (4) (aa), 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 Villa Maria Nursing 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. aA recertification survey was conducted on August 19, 2004. Based upon interview, observation and record review, the facility neglected to address the resident's complaints of having fallen in addition to demonstrating signs of possible injury from that fall such as report of pain in a timely and appropriate manner causing delay in proper treatment leading to actual harm for 1 (one) out of 29 sampled residents, #16. The findings include the following: 10. Review of the clinical record revealed that resident #16 was re-admitted to the facility on 7/26/04 with the neem tA ANH ED diagnosis' of Parkinson's, CAD, COPD, dementia, psychosis, left hip fracture and osteopenia. According to the latest Minimum Data Extract (MDS) assessment dated 8/6/04 the resident makes poor decisions, requiring cues and supervision and has short- term memory problems. Further review of the assessment indicates that the resident requires limited assistance with one-person physical assist for bed mobility and transfers. Also, resident #16 is frequently incontinent of bowel but usually continent of bladder. 11. Review of the Fall Risk Assessment dated 5/19/04 revealed that the resident's score is 11 making the resident a high risk for falls. According to the scale on the forma total score of 10 and above represents high risk. Review of the Resident Assessment Protocol (RAP) for falls dated 12/8/03 indicates that the resident is at risk for falls/injury related to impaired mobility, decreased strength, endurance and poor safety awareness. Soft lap buddy applied to chair to prevent resident from standing. Call bell placed within reach when in room. Allowed to stand and repositioned q3-4h (every 3-4 hours) while in chair. Review of the care plan initially dated 11/8/03 for risk of falls secondary to history of falls, impaired mobility, and poor safety awareness. Approaches listed are: provide low bed, ensure eall light within reach at all times, answer call light promptly, ensure room is clutter-free, ensure a) ns wheelchair is locked during transfer, mattress on the floor and 2 half rails in ped as an enabler. According to the care plan the resident had a lap buddy when she/he was in wheelchair for safety but this was discontinued on 6/10/04. 42. During an interview with the Assistant Director of Nurses! (ADON) on 8/17/04 at 3:20 pM regarding the lap buddy the ADON stated the resident is not a safe walker. She/he gets Up on own, that's how she/he fell and proke her/his hip. Interview with the Risk Manager (RM) on 8/18/04 at 12:30PM regarding investigation into the resident's fall on 7/18/04 revealed that the resident ambulated with assistance. The resident was identified as being at high risk for falls and was on the Falling Star program. The resident was reported to have gotten out of bed without assistance and fell. According to the RM the resident stated, "I picked myself up." According to staff interviews no one witnessed the resident's fall nor did anyone assist with picking the resident up- 13. When the RM = was further questioned about the resident's fall and the pain that is usually involved, the RM stated that sometimes it takes a while for pain to occur. Continued interview with RM and review of the facility's investigation into the resident's fall reveals that on Saturday, 7/17/04 at 7:00 AM while the 11-7 and 7-3 CNA were washing the resident, the resident complained of pain to the leg when the sian LA A I wa CNA turned the resident on her/his side. When the 7-3 CNA asked the resident what happened, the resident stated, "I fell." The CNA than attempted to sit the resident up for breakfast but the resident refused stating, "T'm in pain." The RM also reported that the 7-3 CNA reported the resident's pain to the nurse and the resident was medicated for a migraine. However, according to the investigation statement there is no indication that the CNA told the nurse about the resident's statement that she/he fell. It does state that the 7-3 CNA checked the resident's legs and found no bruising or swelling. The resident refused lunch and remained in bed all day. 14. On 7/18/04 at 7:00 AM, the CNA checked the resident who was still in bed and complained of pain. The investigative documentation states that the nurse assisted the CNA putting the resident in the wheelchair. The resident did not put any weight bearing on the “----~ * leg but still complained of pain. Continued interview with the RM, the RM stated that “----- ‘, indicates the affected leg. The nurse did not medicate the resident for pain. The resident remained in the wheelchair throughout breakfast and lunch. The report further added that at approximately 3:30PM the resident was sitting in the dining room with her/his spouse and son when she/he yelled out. When the resident was asked what happened, the resident stated "I fell yesterday morning." She/he stated that when she/he tried to get out of bed she/he fell. When asked who picked you up, the resident stated, "I picked myself up." 15. Review of the nurses' notes dated 7/18/04 at 3:10 PM reveals the resident's family member stated that the resident had fallen yesterday morning. The note continues to indicate that after report was taken from the off going nurse, the nurse went to the resident's room to assess the resident's mobility. The resident complained of pain to left thigh, left knee and left ankle upon movement. The upper extremity was warm and the lower extremity was cold. After the physician was called and notified, a stat (immediately) x-ray was ordered of the left leg. According to the x-ray report dated 7/18/04 the resident was found to have a left femoral neck fracture with shortening. 16. During an interview with the Director of Nurses and the Director of Social Work on 8/19/04 at 1:05 PM, the Agency raised its concern with the facility. The concern being that despite the resident’s recurrent statements to staff that she/he had fallen, numerous complaints of pain during bathing, and inability to bear weight on the left leg, the staff never intervened. These symptoms are all indications of possible trauma to the leg. In addition, the resident was not assessed until the resident's son spoke with the nurse on Sunday at about 3:00 PM. The Director of Social Work’s response to the Agency wag that this is a very subjective issue since one didn't always ae A TR know if this resident was telling you something that actually happened or not. 23. Based on the foregoing facts, Villa Maria Nursing Center violated 483.25, Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, and Rule 59A-4.106(4) (aa), Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Villa Maria Nursing 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 1576096; Certificate No.: Effective date: 08/19/2004 Expiration date: 08/31/2004 & = Oe Toph, ~ by Wisc, FL 11935 ype» ‘2 « q By; a : FG eS: 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 Count I 2. Assess against Villa Maria Nursing Center an administrative fine of $2,500.00 for the violations cited above. 3. Assess against Villa Maria Nursing 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. bicypbe, @ haces) ia Lawton-Russell ssistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6804 Copies furnished to: Diane Castillo Field Office Manager Agency for Health Care Administration Manchester Building 8350 NW 52 74 Terrace - Suite 103 Miami, Florida 33166 (Interoffice 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) il CERTIFICATE OF SERVICE — ee ee I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to James Reiss, Administrator, Villa Maria Nursing Center, 1050 N. RE. 125 Street, North Miami, Florida 33161; Patrick J. Fitzgerald, 110 Merrick Wa Suite 3-B, Coral Gables, Florida 33134 on this 12 aay of fant, 2005. Wr £2, 7 Learee) ria Lawton-Russell, Esq. sccneemnemnen secas nme ap nS EM pepe ee eS ee STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION OF b EXPLANATION OF RIGHTS UNDER SEC. 420.569, FLORIDA STATUTES “y, os (To be used with Election of Rights for Administrative Complaint form — attagnedy. {5 In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (“AHCA” or “Agency”), Respondent must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint and your Election of Rights in this matter must be received by AHCA within twenty- one (21) days from the date you receive the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION’. = |f Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION 1 on the election of rights form. A final order will be entered setting forth the allegations as being deemed admitted and imposing the penalty sought in the Administrative Complaint. You will be provided a copy of the final order. OPTION2. ff Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the material facts alleged in the Administrative Complaint.), Respondent may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. _ [Ifthe Respondent disputes the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., Respondent's request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts disputed. If you select Option 3, mediation may be available in this case pursuant to Section 120.573, Florida Statutes, if all parties agree to it. PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: in order to preserve the right to a hearing, Respondent's original Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondent’s selected option is not received by AHCA within twenty-one (21) days from the date of Respondent's receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. 5)

Docket for Case No: 05-000699