TislDE-FED C320 a.) GOLDSMITH & GROUT PA Paz We, 4077605187 PRD dos PAGE 82/13 * @3/22/2885 13:51 8139728066 STATE OF FLORIDA COAPR 26 PH 1, AGENCY FOR HEALTH CARE ADMINISTRATION ‘24 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VE. Case No. 2004003074 TR & SNF, INC., d/b/a THE NURSING CENTER _ _ AT UNIVERSITY VILLAGE OS [Dd 1b Respondent. eee f ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency™), by and through the undersigned counsel, and files this Administrative Complaint against TR & SNF, Inc., d/b/a The Nursing Center at University Village (hereinafter “The Nursing Center"), pursuant to §§ 120.569 and 120.57 Fla. Stat. (2004), and alleges: NA OF THE ACTIO This is an action to impose an administrative fine in the amount of Thirty Thousand Dollars ($30,000) and a survey fee of Six Thousand Dollars ($6,000) based upon The Nursing Center being cited for three State Class I deficiencies. JURISDICTION AND VENUR 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2004). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for liceusure of nursing homes and a] LATTTS-PRD TS-20 all GOLDSMITH & GROUT PA 3 93/22/2665 13:51 8139728864 NURSING CENTER @ Uv PAGE 83/13 enforcement of applicable federal regulations, state statutes and rules governing silled nursin g facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4. The Nursing Center operates a 240-bed nursing home located at, 12250 North 22" Street, Tampa, Florida 33612, and is licensed as a skilled nursing facility, license number SNF] 5690961. 5. The Nursing Center was at all times material hercto, 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 § 483.20(k)(3)(i) and Fla. Admin. Code R. SYA-4.1288 The Nursing Center must ensure the services provided. or arranged by the facility meet professional standards of quality. 8. On or about 03/17/04, the Agency conducted a complaint survey of The Nursing Center. 9. Based on observation, interviews and record review, the facility failed to meet professional standards of quality by not following facility policy and procedure for notifying the physician of a change in the resident's health status, by not having the resident assessed by a registered professional nurse (RN), or implementing cardiopulmonary resuscitation (CPR) in emergency situations for one of one residents who required immediate resuscitative intervention, but did not receive it. 10. On 01/04/04, at 1:00 a.m., the licensed practical nurse (LPN) on duty documented that 63/22/2885 13:51 8139728664 Po 092 21 ak GOLISMITH & GROUT PA NURSING CENTER @ LV Resident # 1 was found sitting on the side of the bed attempting to remove his/her clothing. 11. The LPN instructed the nursing assistant to place the resident in a wheelchnir “for better observation”. The LPN also noted that the resident had "3+ pitting edema" at that time. 12. At2:00 a.m. the LPN documented that she observed the resident was "mouth breathing” and that respirations were "shallow arid labored" with oxygen saturation (02 sat) measured at 80 percent (%). 13. The nurse's notes indicate that oxygen was administered to the resident at 2 Jiters per minute via nasal cannula and retumed to bed with the head of the bed elevated to 45 degrees. 14. Review of the clinical record for Resident # 1 did not reveal a physician's order for the administration of oxygen, however, the facility has a protocol for oxygen administration (no date) that states "Oxygen shall only be administered by a physician's order, except in an emergency. In an emergeticy situation, oxygen can be administered without physician's order, but the order must be obtained immediately after the crisis is under control”. 15. The facility's policy and procedure (P & P), Change in a Resident's Condition or Status, revised April 2001, states that "the nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been a significant change in the resident's physical/emotional/mental condition; A need to alter the resident's medical treatment significantly”, 16. Aninterview with the Director of Nursing (DON) and Risk Manager (RM) on 03/17/04, revealed that the LPN did not notify her nursing supervisor or the resident's physician of the oxygen desaturation or labored breathing of Resident # 1, nor did she request that a registered nurse (RN) assess the resident's condition, as is the facility's policy, and standard nursing practice. uw Q4/13 EESTEIUUEEED EN all GOLDSMITH & GROUT PA Pal Ya, 9077 93/22/2885 13:51 8139728864 NURSING CENTER @ UV PAGE @5/13 17, Nurse's notes indicate that at 3:00 a.m. on 01/04/04, the resident's O2 sat remained at 80% in spite of the administration of oxygen and that respirations continued to be shallow and labored. 18. The LPN documented the resident’s pulse as "weak" at a rate of 70 beats per minute (bpm) and the respiratory rate as 14 per minute. The resident’s blood pressure was not documented. 19. The nurse's notes entry for "4:00 a.m. - 6:00 a.m." documents "breathing labored and shallowed (sic), hands moist, pulse 56, respirations 12, 02 sat 69%”. 20. At 6:50 a.m., the LPN documented that 02 at 2 liters per minute was in place, but the resident is "unresponsive, no breath sounds, skin discolored". The LPN indicated that at that time she placed a call to the resident’s physician. 21. Review of the clinical record does not inditate the resident was assessed by an RN at any time on 01/04/04. 22. On 01/06/04, the LPN entered a late entry into the nurse's notes that on 01/04/04 at 5:00 a.m. that the resident’s O2 sat was 92%. 23, On 01/06/04 the LPN entered a late entry into the nurse's notes that an 01/04/04, at 2:00 am. "Upon discovering resident's O2 saturation at 80% chart checked for DNR. Found living will instructional directive sheet that led me, and the nurse (a LPN) on duty with me to believe the resident did not want to be resuscitated.” 26. An interview with the DON and RM on 03/17/04, revealed that per facility policy, the LPN should have reported the resident's condition to the RN supervisor on duty, who would have notified the resident's physician and instructed the LPN as to the appropriate measures of intervention. The DON and RM verified that the LPN neither notified her nursing supervisor or @3/22/23@5 13:51 8139728864 gedtereeas Pr 73:7) all GOLDSMITH & SEOUT PA Fas dle, ¢2774f8 155 BE NURSING CENTER @ UV PAGE 86/13 the resident's physician of the oxygen desaturation or labored breathing of Resident #1, nor did she request that an RN assess the resident's condition, as is the facility's policy, and standard nursing practice. 25, There is no documentation in the resident’s medical record that CPR was initiated or that emergency medical services was called for assistance. 26. There is no documentation in the resident's medical record that the resident had a Do Not Resuacitate (DNR) order, and therefore, according to facility policy CPR should have been initiated. 27. Review of the facility's policy and procedure for "Do Not Resuscitate Order”, revised April 2001, states that "the facility will not use CPR and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate order in effect". 28. Review of the clinical record and an interview with the DON and RM on 03/17/04, revealed that Resident # | was deemed a full code, as there was not a signed DNR order. 29. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Tho Nursing Center's non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care at The Nursing Center and cited this deficient practice as a State Class I deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against The Nursing Center, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Fla. Stat. (2004), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2004) COUNT I 30. The Agency re-alleges and incorporates paragraphs (1) through (5) and (7) through (29), strtepat oy li all GOLDSMITH & GROUT PA Fa 2 @3/22/2285 13:51 8139728864 NURSING CENTER @ Uv PAGE 87/12 as if fully set forth herein. 31. Pursuant to 42 CFR § 483.13(c)(1)(i) and Fla. Admin. Code R. 59A-4.1288 The Nursing Center must develop and implement written policies and procedures that prohibit mistreatment, neglect and abuse of residents and misappropriation of resident property. 32. Onor about 03/17/04 the Agency conducted a complaint survey of The Nursing Center. 33. Based on interviews and record review the facility did net meet the needs of the residents, through implementation of facility policy and procedure, by failing to notify the resident’s physician of a change in the resident’s health status, by failing to have the resident assessed by an RN, and by not providing prompt assistance to one of one residents (Resident # 1) who required immediate resuscitative interventions by staff who are certified in CPR. 34. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because The Nursing Center's non-compliance had caused, ot was likely to cause, serious injury, harm, impairment, or death to a resident recaiving care at The Nursing Center and cited this deficient practice as a State Class I deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against The Nursing Center, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Fla. Stat. (2004), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2004). COUNT IN 35. The Agency re-alleges and incorporates paragraphs (1) through (5). (7) through (29) and (31) through (34) as if fully set forth herein. 36. Pursuant to 42 CFR § 483.10(b)(11) and Fla. Admin. Code R. 59A-4,1288 The Nursing Center must iremediately inform the resident; consult with the resident's physician; and if CLE-FEL 22-22 a GOLDSMITH & GROUT PA policlTlisPhl TallD ak v PAGE @8/13 63/22/2085 13:51 8139728a64 NURSING CENTER @ U known, notify the resident’s legal representative or an interested family member when there is a significant change in the resident’s physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). 37. On or about 03/17/04 the Agency conducted a complaint survey of The Nuraing Center. 38, Based on interviews and record review, the facility failed to notify and/or consult with the resident’s physician when a deterioration of the health status of the resident occurred for one of three residents sampled (#1), which resulted in harm to the resident. 39. Per the history & physica! record, dated 11/28/03, Resident # 1 was diagnosed with congestive heart failure (CHF), which the physician described as "probably a new onset”, 40. After hospitalization, the resident was admitted to the facility on 12/08/03 and was on Lasix (diuretic) therapy as per the physician's orders dated 12/08/03, 41. Further, the physician had ordered fluid restrictions of 1200 ce's (cubic centimeters) per day from 12/08/03 until 12/29/03, when the fluid restrictions were discontinued. ‘42. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because The Nursing Center's non-compliance hed caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care at The Nursing Center and cited this deficient practice as a State Class I deficiency. 43. The Agency provided The Nursing Center with the mandatory correction date for this deficient practice of 04/17/04. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against The Nursing Center, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Fla. Stat. (2004), and assess costs related to the investigation and TL-LIL-FEI LE LL ad GOLDSMITH & GROUT PA 93/22/2085 13:51 8139728264 NURSING CENTER @ Lv PAGE 83/13 prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2004), COUNT IV 44. The Agency re-alleges and incorporates paragraphs (1) through (5), (7) through (29), (31) through (34) and (36) through (43) as if fully set forth herein. 45. The Nursing Center has been cited for three Class J deficiencies and therefore is subject to 4 six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400,19(3), Florida Statutes (2004). WHEREFORE, the Agency intends to jmpose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of $6,000.00 against The Nursing Center, a skiJled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2004). Respoctfolly submitted this ye/aY _ day of Iwurch 2005. Gerald L. Pickett Fla. Bar. No. 559334 Agency for Health Care Administration 525 Mixror Lake Drive, 330K St. Petersburg, FL 33701 727.552.1526 (office) The Nursing Center 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: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallabassee, Florida, 32308, (850) 922-5873. ns >. 2°22 ,8 GOLDSMITH & GROUT PA 63/22/2085 13:51 8139728064 NURSING CENTER @ LV PAGE 18/13 THE NURSING CENTER IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 2! DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSIJON 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 tmie and correct copy of the foregoing has been served by Certified Mail, Retum Receipt No: 7003 1010 0003 0299 1723 on March y/, {_,2005to: F& L Corporation, Registered Agent, The Nursing Center at University Village, The Greenleaf Building, 200 Laura Street, Jacksonville, Florida 32202 and U.S. Mail to: Richard J. Fenton, Administrator, The Nursing Center at University Village, 12250 North 22 Street, Tampa, Florida 33612. - ti nlt/ VA Gerald L. Pickett, Esquire Copies furnished to: F & L Corporation Richard J. Fenton Gerald L. Pickett, Esquire Registered Agent Administrator Senior Attorney The Nursing Center at The Nursing Center at Agency for Health Care University Village University Village Administration The Greenieaf Building 12250 North 22™ Street 525 Mirror Lake Drive, 330K 200 Laura Street Tampa, Florida 33612 St. Petersburg, Florida 33701 Jacksonville, Florida 32202 (U.S. Mail) (Interoffice) (USS. Certified Mail) l1i-fE) 23-20 ako GOLDSMITH & GROJT PA Fat Ne. 4077405; 87 Pil aes PAGE 11/13 43/22/2695 13:51 8139728864 NURSING CENTER @ Uv PAYMENT FORM Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ which represents payment of the Administrative Fine imposed by AHCA, The Nursing Center at University Vill 2004003074 AHCA Case No, Facility Name

Docket for Case No: 05-001516