STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2005003066 AHCA No.: 2005003064 Vv. Return Receipt Requested: 7002 2410 0001 4234 4912 MIAMI GARDENS CARE CENTRE, INC., 7002 2410 0001 4234 4929 d/b/a MIAMI GARDENS CARE CENTRE, _ ; Respondent. CA DO) | ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Miami Gardens Care Centre, Inc., d/b/a Miami Gardens Care Centre (hereinafter “Miami Gardens Care Centre”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2004), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $2,500.00 pursuant to Section 400.23(8), Florida Statutes (2004), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Miami Gardens Care Centre, pursuant to Section 400.23(7) (b), Florida Statutes (2004). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and Chapter 28- 106, Florida Administrative Code. 4. Venue lies in Miami-Dade County, pursuant to Section 400.121(1)(e), Florida Statutes (2004), and Rule 28- 106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Florida Statutes, (2004), and Chapter 59A-4 Florida Administrative Code. 6. Miami Gardens Care Centre is a 120-bed skilled nursing facility located at 190 NE 191%* Street, Miami, Florida 33179. Miami Gardens Care Centre is licensed as a skilled nursing facility; license number SNF1352096; certificate number 12394, effective 01/21/2005 through 01/31/2005, and certificate number 12397, effective date 02/01/2005 through 01/31/2006. Miami Gardens Care Centre was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. 7. Because Miami Gardens Care Centre participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule 59A-4.1288, F.A.C. COUNT I MIAMI GARDENS CARE CENTRE FAILED TO ENSURE THAT A RESIDENT RECEIVED APPROPRIATE CARE AND SERVICES RELATED TO AN HYPOGLYCEMIC EPISODE THAT LED TO ACTUAL HARM FOR ONE RESIDENT Section 483.25, code of Federal Regulations, as incorporated by Rule 59A-4.1288, and 59A-4.106(4) (aa), Florida Administrative Code (QUALITY OF CARE) CLASS II DEFICIENCY 8. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. During the Licensure and Re-certification survey conducted on 1/18-21/2005 and based on record review and staff interview, the facility did not ensure that a resident received appropriate care and services related to an hypoglycemic episode that led to actual harm for one of 34 sampled resident (#30). 10. Admission review reveals that resident #30 was admitted to the facility on 12/31/04 and expired at the facility on 01/10/05. A review of the clinical record reveals diagnoses of diabetes, hypertension, and congestive heart failure among others. A review of the nursing notes reveals that on 01/10/05 at 6:00 a.m. the resident's blocd sugar level was 88 mg/dl (Normal range is between 80 to 120 mg/dl). The not further adds that the resident was given his/her medication with no acute distress. Review of the Mecication Administration Record (MAR) for January 2005 revealed that a standard order of insulin (Noveline-N 25 units subcutaneously every A.M.) was given to the resident at 6:30 a.m. An entry in the nursing notes at 7:15 pm reveals that at 4:30 pm the resident's blood sugar dropped to 60 mg/dl with orange juice and sugar given. At 7:15 pm the blood sugar 38 mg/dl and Insta Glucose (used to increase blood sugar) was given. There is no notation in the chart whether the treatment was effective, neither was there any indication that a repeat blood sugar level was done. There is also no notification that the resident's physician's was made aware of the low blood sugar level until 7:15 pm. At 7:45 pm the notes states "pt was open eyes, drink some milkshake approximately 40 cc." The 8:00 pm entry states, "Supervisor made aware of low BS blood sugar, entered resident room, found laying in bed without a pulse. Unable to get BP (blood pressure). CPR (cardio pulmonary resuscitation) initiated, 911 was called." The 8:10 pm entry notes, "911 at bedside. Resident ceased to breath. Call placed to family and Dr. (name given) ." Jl. The facility's Director of Nurses (DON) was interviewed on 01/21/05 at approximately 4:30 pm and was asked to review the resident's care prior to his expiration. She/he was also asked after review if she/was satisfied with the care that this resident received. The DON stated that he/she had some concerns, therefore, he/she asked the nurse to give a supplemental statement. However, the supplemental statement was not added to the resident's record. In the statement, the nurses stated that at 5:15 pm the resident's blood sugar level was 62 mg/dl, however, there is no record of this value in the nursing notes in the resident's record. The note further states that the resident was monitored every 30 minutes, however, this information is absent in the clinical records. The supplemental note further continues, "By 7:55 nursing supervisor notify of the low blood. I went on third floor to get the supervisor. Entering the room, resident was observed (with) no palpable pulse, no rising chest no auscultation of BP." The statement indicates that the respiratory therapist on duty initiated CPR, but the documentation in the nursing notes made by the nurse indicates that he/she was the one who performed the CPR. There is lack of consistency of documentation between the nursing notes and the supplemental statement that was given by the nurse. 12. Based on the information in the nursing notes, the DON was asked why the resident was left alone when it was apparent that his/her medical condition was deteriorating. She/he said that the nurse went to the third floor to get Insta Glucose, because it is not kept on the floor on which the resident was situated. The DON was also asked who was monitoring the resident during the time when the nurse was absent from the floor she/he was unable to respond. When asked for an explanation for the nurse's supplemental note, the DON stated that the nurse was very upset that the resident expired and forgot to correctly document on the chart. When asked if in-services were done with the staff after this resident expired, since she/he was concerned about the resident's care, the DON stated that he/she spoke with the nurse. When asked for evidence of the discussion, the DON stated that she/he did not document the encounter. The DON was also asked if he/she did a facility-wide in- service with the nursing staff, she/he stated that she/he spoke with the staff. When asked for evidence of documentation, the DON stated that she did not document the discussions. 13. The DON presented a copy of the facility's policy on Hypoglycemia/Insulin Reaction/Or Low Blood Sugar. The policy does not define an abnormally low blcod glucose level. The American Diabetes Association, in their Resource Guide 2005, indicates that an abnormally low blood glucose level is below 70 mg/dl. Under "Documentation," #E the policy states, "Notification of MD and resulting orders." It does not define when the MD should be called; neither does it specify critical blood sugar levels that wouid necessitate such a call. No portion of the policy addresses when the MD (medical doctor) should be called. According to the National Institutes of Health (NIH) National Diabetes Information Clearing House (NDIC), (