STATE OF FLORIDA ron AGENCY FOR HEALTH CARE ADMINISTRATION _—“ > an STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA CASE NO. 2005002822 ~ Cs - 3484 PUNTA GORDA ELDERLY CARE CENTER, INC. 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 Punta Gorda Elderly Care Center, Inc. (hereinafter “Respondent”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2004) and alleges: NATURE OF THE ACTION 1. This is an action to impose administrative fines on Respondent in the amount of seventeen thousand five hundred dollars ($17500.00) pursuant to Section 400.419(1)(a) Florida Statutes (2004), and a survey fee of five hundred dollars ($500.00) pursuant to Section 400.419(10), Florida Statutes (2004). 2. The Respondent is cited for the deficiencies set forth below as a result of a survey conducted on or about May 5, 2005. The violations cited were three class I deficiencies, one of which was a repeat deficiency. t eeETUE EXHIBIT MAY 2M 2005 -ae ——— JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes (2004) and Chapter 28-106 Florida Administrative Code (2004). 4. Venue will be determined pursuant to Rule 28-106.207, Florida Administrative Code (2004). PARTIES 5. AHCA, Agency for Health Care Administration, State of Florida is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes (2004), and Rules 58A-5, Florida Administrative Code (2004). 6. Respondent is an assisted living facility located at 2295 Shreve Street, Punta Gorda, FL 33950. Respondent is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code. COUNTI THE FACILITY FAILED TO PROVIDE CARE AND SERVICES APPROPRIATE TO THE NEEDS OF RESIDENTS BY FAILING TO PROVIDE ADEQUATE SUPERVISION TO KNOW THE RESIDENTS’ WHEREABOUTS AT ALL TIMES, in violation of Rule 58A-5.0182(1), Florida Administrative Code (2004) CLASS I DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. Rule 58A-5.01 82(1), Florida Administrative Code provides: An assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. (1) SUPERVISION. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel independently in the community. (d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out. (e) A written record, updated as needed, of any significant changes in the resident’s normal appearance or state of health, any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. 9. A survey conducted on or about May 5, 2005 revealed: Based on observations, review of facility and resident records, and staff interviews, it was determined that the facility failed to provide care and services appropriate to the needs of 11 (Residents #1, #5, #7, #8, #9, #10, #11, #12, #13, #14, and #15) of 15 sampled residents by failing to provide adequate supervision to know their whereabouts at all times. These 11 residents were involved in 13 incidents outside the facility, six of which required transfer to the hospital for treatment. The facility also failed to have adequate supervision to prevent wandering residents from entering the rooms of 1 (Resident #2) of 15 actively sampled residents and 13 random resident rooms (Room #2, #3, #4, #10, #11, #14, #202, #206, #211, #302, #307, and #308). Their families requested the rooms be kept locked when the residents are not in their rooms. The failures of the facility present the possibility of placing all residents in imminent danger with a strong probability of physical harm or death. The findings include: 1. Observations on 5/5/05 at 10:30 a.m., revealed there were 15 locked resident rooms (#2, #3, #4, #10, #11, #13, #14, #202, #203, #204, #206, #209, #211, #302, #307, and #308). Room #13 had a sign on the door that states, "Please keep resident's door locked from 7:00 a.m. to 7:00 p.m." The residents were not in the locked rooms and staff explained that the rooms are locked at the resident's families’ request. Some of the locked rooms had a drawing of a key hanging over the door and staff said that this sign designates that the door is locked. Two of the rooms, #203 and #209, were locked at the resident's request and the residents did have a key to their room. During an interview on 5/5/05 at 1:00 p.m., a family member of one of the residents, not identified due to confidentiality, stated that the resident's door is locked at his request because there is not enough staff to keep other residents from wandering into his wife's room. He further stated that on tHree separate occasions he had found other residents in his wife's bed. He said that the residents were in bed under the blankets and he did not know what kind of diseases those residents might have and they might soil her bed. He stated that his wife had gotten scabies in the facility and thought that might have been the way she caught the scabies. He stated that his wife had lost personal items that had been found in other resident's rooms. He stated that his wife is out of the room from 7:00 a.m. until 7:00 p.m., and he wants to make sure that the room is locked when his wife is not in the room. Review of the record for Resident #14 revealed a complaint form dated 7/27/04, signed by the resident's Durable Power of Attorney (DPOA), that stated that the resident's door is to be kept locked from 7:00 a.m. to 11:00 p.m. and the resident is to receive a key. Up to three keys will be provided and the facility will "rethink" the action if all keys are lost. No one could ascertain whether Resident #14 had a key. 2. On 5/5/05 at about 11:40 a.m., an observation was made of the closed unit currently housing 18 dementia residents. This area has four exit doors. The main door coming from the front of the facility, which is locked, is an exit door to the outside fenced area from the end of two hallways and a central exit to another building, as well as to the outside fenced area. These doors are equipped with alarm equipment. When the three unlocked doors were opened during observation, no alarm was heard. During an interview with a staff member on this unit at this time, it was stated that the doors are alarmed and they are on timers. This unit has alarms active from 5:00 p.m. until 7:00 a.m. She was asked why the alarms were not active during the day and she stated that she did not know. She was asked how she knew when a resident was outside. She said that they just know because they are not in the common area. She further stated that they have a policy for hydration for residents when they are outside. She stated that they check on them and offer fluids every 8 to 10 minutes. Further interview revealed that she knows when the residents are outside because when she hears the alarms, she checks her watch and 8 to 10 minutes later, she will go and check on the residents and offer them fluids. Again, she was asked about what happens when the alarms are off. She stated that she just knows when her residents are outside. Observation of the exit doors in building two, which according to the staff houses the higher acuity residents numbering 16 at present, found the same alarm system and none of the three exit doors were active at 11:45 a.m. The residents on this unit are known to be roamers and go in and out of the building all day long. The residents have free access to the yard which encompasses about one acre. Interview with the Administrator at about 11:50 a.m., revealed that the alarms are turned off during the day because they are (the sound) an irritant to residents, staff and families. He further stated that family members had approached him on numerous occasions, because the alarms going off all day long bothered the residents. The back unit (building two) has the door alarms active 7:00 p.m. to 7:00 a.m. only. Also observed on this unit at about 11:45 a.m., nine random residents were noted to having no shoes on. They all did have socks on. Seven of the resident rooms were locked, rooms #2, #3, #4, #10, #11, #13 and #14. Shoes were not visible in the common area for these residents to put on. These same residents have full access to the yard at this time without the staff knowing they are out there. According to the nurse on the back unit, the staffing numbers for this unit on the night shift, 7:00 p.m. to 7:00 a.m., is one Certified Nursing Assistant. This information was validated by the Administrator and a review of the current staffing schedule for the month of May. 3. Resident # 1 was admitted to the facility on 11/1/04, with a diagnosis of high blood pressure, Alzheimer's, congested heart failure, Degenerative Joint Disease and Arterial Sclerotic Heart Disease. The resident has a DPOA, which is the daughter. Resident #1 receives assistance with medications and is on a No Added Salt (NAS) diet. On a tour of the facility at about 11:00 a.m. on 5/5/05, this resident was observed asleep, under the covers in bed, this observation took place in room #16. An interview with the staff on duty revealed that this resident's room number is #8. It was further stated, "Oh ---- gets tired after breakfast and just goes in the closest room and goes to sleep." A review on 5/5/05 of an Initial Adverse Incident 1 Day Report. revealed that on 4/30/05 Resident # 1 was found outside, sitting on the ground, where she sustained numerous ant bites. The report states that the adverse incident does represent a potential risk to other residents, it further stated, "It is possible for anyone to suffer ant bites." Therefore, the facility is contacting the extermination company to see if there is any new product on the market that can be used for ant control. As of 5/5/05, the ground had not been treated for ants. On 5/5/05 at about 4:15 p.m., a walking tour of the facility grounds, in the fenced in area, revealed a random sample of 29 different ant hills/areas of hills. The 29 areas/hills were currently active with very small red ants observed. Additional information contained in the report is as follows: "resident found outside by nurse aide ---- sitting on an ant pile. Resident brought in and immediately showered. Clothes changed. Buttocks and upper thighs reddened. Pt in no resp. distress. Pt's chart checked - allergic to PCN. Alcohol and moisture barrier was applied. Dtr notified at 2:00 P.M. (incident took place about 7:00 A.M.) - no distress noted. Info gave to PM nurse. Doctor's office notified at 2:30 P.M.. Service will have doctor call back. 2™ call placed to Dr's office at 4:00 P.M.. No return calls. Daughter gave Benadryl - 25mg PO at 5:00 P.M." A review of the nurse's notes dated 4/30/05 revealed the following: 4/30 - 7:00 a.m. (late entry) - "resident brought in from outside by nurses aide ---- stated (s)he was sitting on an ant pile. Resident showered, buttocks and upper thigh area noted to be reddened. Cleaned and dried, alcohol pads used over reddened areas to help alleviate the sting. No allergies on chart noted for ant bites, (PCN only). Will monitor.” 10:30 a.m.- "Pér nurse aide, pt not eating much breakfast. Laid down for nap. No distress noted.” 12:00 - "Resident up for lunch. Eating well. No change in behavior noted. No distress.” 1:45 p.m. - "Called dtr ----- to report resident sitting on an ant pile. Stated she would be in later on today or tomorrow." 4/30/05 - 2:00 p.m. - "Report from day nurse that resident was found sitting outside at breakfast time in ant hill. Resident has red areas on buttocks and both thighs. No respiratory distress noted. Daughter (-----) called and arrived at facility. Dr. ------- office called at 2:30 P.M.. "Message left with ans. Service. Dr. ----- on call today and call back requested." 3:30 p.m. - "Fluids encouraged. Daughter (unable to read) to visit. No call from MD - Daughter stated that she was going out to buy Benadryl and some cream as that was helpful in the past." 4:00 p.m. - "report called to answering service." 4:30 p.m. - "Resident eating - Ate 80% of meal. Up wandering in secured area. Attempted to go outside. Redirected to lounge chair in dining room.” 5:00 p.m. - "Daughter returned and gave resident Benadryl 25mg tablet. Resident continues to wander. Incont. of urine. Perineal area washed and protective skin barrier cream applied.” 7:00 p.m. - "resident continues to wander. Redirected to stay inside. Fluids encouraged. Resident given cookies and coffee. Took evening medications at 8 PM. Incont. of large amount of urine. No call back from MD office. Resident assisted with nightgown and put to bed. No distress noted." 5/1/05 - 10:00 a.m, - "Resident found sitting in ant bed on 4/30/05 has multiple ant bites all over buttocks, Peri area, and lower abdomen. Daughter is escorting her to ----- (Hospital) in Pt. Charlotte at this time. ER notified as well as Dr. ----(on call for----) Answering service also to fax info to Dr. ------- 's office." 10:15 a.m. - "resident was given Ativan 0.5mg PO before leaving at 10 AM for increased anxiety - ER notified when called." 4:45 p.m. - "received call from daughter "-----" at this time - resident admitted to ----(hospital). 7:40 p.m. (late entry) - "After making decision to send resident "out" this AM, I was going to call EMT's - daughter insisted on taking her because she "wanted to stay with her" - She also selected ---- (hospital). Also at 5:45 P.M. today I found out ringer on phone not working in nurses station because Dr. did call facility twice (Cable Co. being notified by owner of facility to repair) yesterday when nurse called him.” 5/3/05 - 5:50 p.m. - "Resident returned to facility. Daughter here. No D/C orders received from ~--- (hospital). Hospital called. Daughter returned to Hosp to pick-up orders. Ret at 7:00 p.m. Resident has scabbed areas over buttocks and thighs. Incont. of urine large amt. Diaper soaked. Daughter stated, "Resident was very combative in hosp and family stayed round the clock to sit with her. Stated that resident had not been out of bed. N.O. (new order) for Avelon 300mg qd (every day) for 7 days, Pepcid 20mg 1 BID (twice a day) and Zyrtec 10mg 1 PO (by mouth) QD - Faxed to PCP. Resident has skin intact except for scabbed areas.” 7:00 p.m. - "Became combative when checking skin unable to complete exam. Ate small amt of chix noodle soup. Ambulating in hall." Review of the hospital record obtained on 5/5/05 revealed the following: 5/1/05 - 11:13 a.m. - Arrived in Emergency Room with multiple ant bites to legs and trunk. "Emergency Department Course and Treatment” - in part - "Obviously, the reason this patient will be admitted at this point is due to her history of Alzheimer's dementia, the multiple ant bites that she had sustained, the risk for secondary infection, and the uncertainty of the adequacy of care at the facility that she came from. Dr. ------ is in agreement with this." "Emergency Room Nursing Record" revealed: Chief Complaint: "was found outside sitting on an ant hill. Bit by red ants on chest, vaginal area and buttocks.” "Additional Findings": Peri area, thighs, covered with ant bites too many to count. 11:42 Adult Prot Services notified @ 1-800-962-2873 ------ (name of person taking call) took report. On 5/2/05, an order for Case Management for placement was given by the physician. "Physicians Progress Notes" document the following: 5/2/05 - "Events noted. - Spoke with dtr (POA). She wants her to go back to ----(facility). She will talk to them about more supervision. I told her about the option of NH (Nursing Home) placement but she states she cannot afford it. Will discuss further with C.M. (Case manager) - the dtr will call my office in am with her final decision." 5/3/05 - "Spoke with dtr (POA). She decided to take her back to ----- (name of facility) ALF (Assisted Living Facility) - today she is sleeping because she did not sleep at all last PM. She spoke with the ALF and they will take care of the fire ants. 1 spoke with the nurses and they have been providing total care for her. Her dtr is aware of that and she will stay with her mom 24 hours a day at ALF until she is able to feed herself. She does not want her to go to SNF (Skilled Nursing Facility). She was told if her condition deteriorates she will bring her back to the hospital. See D/C (discharge) orders.” Telephone interview with the resident's daughter on 5/5/05 at about 12:45 p.m., revealed that this was the second time this resident had been bitten by ants in this facility and required treatment. She stated she was not sure of the date, but thought it was some time in January. , Review of the clinical record for Resident #1 found a physician's order, dated 11/29/04, for the treatment of ant bites. Further review of the nurse's notes and other facility documentation failed to find any record of this event. Review of the Incident/Accident reports failed to find a report regarding this episode of ant bites in November. Interview with the ECC Supervisor and the Administrator at about 3:00 p.m. on 5/5/05, failed to produce any additional information regarding the November ant bite incident. ECC Supervisor reviewed chart and was also unable to find any documentation discussing this issue. He further reviewed the Accident/Incident Log without success. Administrator stated, "I guess we missed that one. We made a mistake." 4. Resident # 5 was admitted to the facility on 4/25/05, with an admission diagnosis of Alzheimer's and Dementia. Listed on the 1823 (Health Assessment for Assisted Living Facilities) under Special Precautions - "Escape Precautions." The resident was admitted from a behavioral center. On 5/5/05, a review of the resident record revealed an admission note that included a notation "Is a flight risk." Additional notations in the record include: 4/26/05 10:00 A.M. - "Res. wandering throughout unit asking for directions "going to play soccer outside." 4/26/05 6:00 P.M. - "resident wandering continuously." 4/26/05 7:55 P.M. - "resident found in patio area in front of secure doors. Walked into kitchen. Brought back to secure area. Resident is flight risk. Staff continued to monitor resident so that (s)he does not follow visitors out the door." 4/28/05 7:00 A.M. - "Night shift reported res. Trying to go through middle doors last night. Redirection approach used. Staff continues to monitor res. Carefully." 4/29/05 9:00 A.M. - "Res. Adjusting fair. Pleasant but likes to go out by the fence. Looking for wife. Enjoys sitting on patio.” 5/1/05 11:00 A.M. - "Resident very restless trying to get out of building. Climbed over fence (short) around patio trying to get to front of building. Ripped back of pants. No injuries noted." 5/1/05 5:25 P.M. - "Staff have been searching building for approx 30 minutes. Last seen by staff right after eating supper at approx 4:50 PM - PGPD (Punta Gorda Police Department) notified and given description of resident. Owner of facility notified and he notified family." ? 5/1/05 8:45 P.M. - "resident returned to facility by PGPD. Resident ambulatory and no abrasions noted. Sneakers, socks and pant legs wet. Resident remains confused. No distress noted. Spouse notified of his return and appointment tomorrow with Dr.----- at 11:45 AM. Dr's office notified that he had returned.” 5/2/05 5:00 P.M. - "Resident becoming increasingly agitated. Running outside and back inside. Given Ativan Img PO." 5/2/05 8:00 P.M. - "Given Ambien - resident has sat in chair for short time. Remains confused. Has not attempted to climb fence. Has been cooperative and pleasant.” 5/2/05 8:25 P.M. - “Resident observed jumping fence and running west. 911 called. Responded stat. Resident found and returned to facility at 8:40 P.M. Administrator notified. Spouse called. Stated that resident was on Librium when he was at hospital and did sleep most of time. No distress or injury noted.” 8:50 P.M. Dr. ---- called. Returned call. Recommended that resident be admitted to ----- (hospital) for evaluation and medication adjustment. Resident's wife in agreernent. Review of 1-Day reports as follows: 5/2/05 Outcome of Incident: Elopement Circumstances as outlined above Actions: None noted on report Outcome of Incident: 1) Required Emergency Room Screening, 2) Event reported to law enforcement, 3) Elopement. 5/3/05 Circumstances as outlined above Actions: None noted on report 5. Review of the record for Resident #7 revealed he was admitted on 11/1/04. A nurse's note dated 11/1/04 at 2:00 p.m., documents that the resident is wandering in and out of several rooms. At 5:00 p.m., a note documents that the resident continues to wander and was found outside in secured area and was retumed to the unit. A nurse's note at 6:40 p.m. on 11/1/04 states, "Resident found lying on ground outside in secured area. Color dusky, no respirations noted. CPR (Cardiopulmonary Resuscitation) initiated. 911 called. Transported to ----- (name of hospital) via EMS." Review of an incident report dated 11/1/04 at 6:40 p.m., reveals documentation of the above nurse's note for Resident #7 revealed the resident was found outside the facility in the fenced area on 11/1/04 at 6:40 p.m. The resident was non responsive and had zero respirations. A nurse's note at 12:00 p.m., documents that the resident's spouse came to the facility and reported that the resident had died. During interview on 5/5/05 at 7:15 p.m., the facility Administrator and the ECC (Extended Congregate Care) Supervisor both stated they had no knowledge of this incident. When asked if an investigation had been done the ECC Supervisor stated," Why? He died at the hospital." The Administrator stated that he did not know if an Adverse Incident report had been completed and stated that they could not find the adverse incident reports that had been completed before the ECC Supervisor started doing them a few months ago. He stated, "I'll look for them.” No Adverse Incident Report could be found. 6. Further review of the facility's incident reports revealed Resident #8 had been found outside lying on the ground next to a rolling chair on 2/14/04 at 8:10 p.m., the resident had sustained hematomas above her right eye and was sent to the hospital for evaluation. 7. An incident report dated 2/7/04 at 4:00 p.m., for Resident #9 revealed the resident was found outside in the yard lying on her right side complaining of shoulder pain. The resident was sent to the hospital via EMS. The portion of the incident form for steps taken to prevent recurrence states, "watch resident closely." Another incident report dated 3/1/04 at 11:30 p.m., documented that the resident was found outside on the ground at the end of "C" hall. The section title "Brief description of incident states, "I found ------ (resident's name) outside on the ground after doing rounds. I did not know she was outside.” 8. Review of an incident report for Resident #10, revealed he was found outside on 6/12/04 at 7:45 p.m., the report stated, "Staff from back section wheeled ----- (resident's name) back to us saying he had found the resident on the ground outside. The resident was rain soaked and covered in dirt and sand." 9. Review of an incident report for Resident #11, revealed the resident was found outside on 12/20/04 at 5:15 p.m. The resident had a hematoma on her face and a skin tear on her right knee. 10. An incident report dated 3/20/04, revealed Resident #12 had fallen outside and sustained a laceration on his head. The resident was sent to the hospital for stitches. The portion of the form for "steps taken to prevent recurrence" stated, "check on more frequently than every 2 hours." 11. Review of an incident report dated 4/14/04, revealed Resident #13 was missing at lunchtime. The report stated, "Resident missing at lunch time." Area searched. Husband present. Police called. Then resident found on property in secured area at 12:20 p.m. Call to police cancelled as resident was found uninjured. The section titled, "Steps taken to prevent recurrence," documents that the area was searched for holes in the fence. 12. Review of an incident report dated 4/17/04 at 11:50 a.m. for Resident #14, revealed a person on a bicycle came to the facility to tell us the resident had walked to her street. Facility staff person drove to pick up resident. The resident had been out front with his wife and she left thinking the resident would go back into the facility. 13. An incident report dated 5/16/04 at 9:45 a.m. revealed Resident #15, was returned to the facility by the police after being found riding an electric wheel chair on the street after the police had received a phone call regarding the resident's safety. The "steps taken to prevent recurrence," stated that the resident was told never to leave facility by herself and she agreed. 10. This was a repeat deficiency as a survey conducted on or about February 10, 2005 also found: Based on a review of 9 clinical records, and interview with administrative staff, the facility did not ensure to provide care and services for 3 of the residents to meet their needs. There was a significant weight loss for Residents #1 and #3, and no interventions made by the facility, furthermore, Resident #6 had a deterioration of wounds without documentation of interventions by the facility. The findings include: 1. Resident #3 was readmitted to the facility's care on 11/1/04. Included on the 1823 form for health assessment are diagnoses of dementia, hypertension, and incontinence. On 11/2/04, the resident's weight was documented as being 127 pounds. The resident was weighed 2 more times in November and his/her weight remained stable. On 12/3/04, the resident's weight was documented as being 130. The next weight documented for this resident was on 1/5/04. At that time, the resident's weight was noted to be 114 pounds. This is a 16- pound weight loss in 32 days or a 12% weight loss. There was no intervention on this resident until 1/14/05, 10 days later at which time Ensure was added to the resident's dietary regimen. There was no documentation in the record indicating the facility initiated any measures to relieve this weight loss until 9 days post noting the weight loss. Administrative staff indicated they were unaware of the resident's loss of weight. 2. Resident #1 was admitted to the facility on 11/1/04. This resident's diagnoses included dementia, leg edema, and macular degeneration. On 11/2/04, the resident's weight was noted to be 102.5 pounds. On 12/3/04, the resident's weight was noted to be 91.5. This is a 10% weight loss in 1 month. On 12/24/04, the resident was weighed as 93 pounds. On 1/5/05, the next weight for this resident was noted to be 87 pounds. This was an additional 6 pounds and a 6% weight loss. Administrative staff on 2/10/05, at approximately 1:45 p.m. agreed there were no interventions done for this resident to reduce the weight loss. Administrative staff further indicated he was unaware of the resident's weight loss. 3. Resident #6 returned to the assisted living facility on 1/19/05 after hospitalization. At the time of return to the facility, the resident was noted to have a night heel with a dime size area of redness and closed skin. The Left heel also had a dime size area, however, it was black and closed. Further review of the "nurse's notes" revealed no further documentation about these areas until 2/1/05. There Was no documentation indicating the facility was monitoring the areas, and there were no interventions noted, such as off-loading the resident's heels from the bed. On 2/1/05, the nurse's notes indicated the resident's Hospice nurse was present (new admission to Hospice). At that time, the resident's heels were noted to be "both discolored, mushy, black left heel 6 cm round. Right heel yellow colored closed 5 cm round. These areas increased significantly in size between admission to the facility on 1/19/05 and 2/1/05, when the heels were evaluated and treatment initiated. 11. These observations were cited as a repeat Class I deficiency as the failures of the facility present the possibility of placing all residents in imminent danger with a strong probability of physical harm or death. This is a violation of Rule 58A-5.0182, Florida Administrative Code (2004) for which a fine of seven thousand five hundred dollars ($7500.00) is authorized pursuant to Section 400.419(1)(a), Florida Statutes (2004). COUNT II THE FACILITY FAILED TO HONOR RESIDENTS’ RIGHTS, in violation of Section 400.428(1), Florida Statutes (2004) CLASS I DEFICIENCY 12. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 13. Section 400.428(1), Florida Statutes (2004) provides: Resident bill of rights.-- (1) No resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a resident of a facility. Every resident of a facility shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. (c) Retain and use his or her own clothes and other personal property in his or her immediate living quarters,‘so as to maintain individuality and personal di gnity, except when the facility can demonstrate that such would be unsafe, impractical, or an infringement upon the rights of other residents. (d) Unrestricted private communication, including receiving and sending unopened correspondence, access to a telephone, and visiting with any person of his or her choice, at any time between the hours of 9 a.m. and 9 p.m. at a minimum. Upon request, the facility shall make provisions to extend visiting hours for caregivers and out-of-town guests, and in other similar situations. (e) Freedom to participate in and benefit from community services and activities and to achieve the highest possible level of independence, autonomy, and interaction within the community. (f) Manage his or her financial affairs unless the resident or, if applicable, the resident's representative, designee, surrogate, guardian, or attorney in fact authorizes the administrator of the facility to provide safekeeping for funds as provided in s. 400.427. (g) Share a room with his or her spouse if both are residents of the facility. (h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular and frequent intervals except when prevented by inclement weather. (i) Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, shall be imposed upon any resident. (j) Access to adequate and appropriate health care consistent with established and recognized standards within the community. (k) At least 45 days' notice of relocation or termination of residency from the facility unless, for medical reasons, the resident is certified by a physician to require an emergency relocation to a facility providing a more skilled level of care or the resident engages in a pattern of conduct that is harmful or offensive to other residents. In the case of a resident who has been adjudicated mentally incapacitated, the guardian shall be given at least 45 days' notice of a nonemergency relocation or residency termination. Reasons for relocation shall be set forth in writing. In order for a facility to terminate the residency of an individual without notice as provided herein, the facility shall show good cause in a court of competent jurisdiction. (1) Present grievances and recommend changes in policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the residents’ exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. 14. The survey conducted on or about May 5, 2005 showed: Based on interviews, observations and record reviews, A) The facility failed to honor residents rights by locking 13 of the 56 resident doors during day time hours, thus denying the residents access to their belongings and/or the ability to rest in their bed. B) The facility failed to provide a safe environment for 34 residents by not having a functioning alarm system during the hours of 7:00 a.m. to 7:00 p.m., by not having adequate lawn and/or pest control in the fenced area which is accessible to these residents, and by failing to have adequate supervision to know the whereabouts of the residents at all times. This is evidenced by 13 events occurring in the fenced area of which six events required emergency room visits for the residents. The failures of the facility present the possibility of placing the residents in imminent danger with a strong probability of creating physical harm or death. The findings include: 1. Observations on 5/5/05 at 10:30 a.m., revealed there are 15 locked resident rooms (#2, #3, #4, #10, #11, #13, #14, #202, #203, #204, #206, #209, #211, #302, #307, and #308). Room #13 has a sign on the door that states, "Please keep resident's door locked from 7:00 a.m. to 7:00 p.m." The residents were not in the locked rooms and staff explained that the rooms are locked at the resident's families’ request. Some of the locked rooms have a drawing of a key hanging over the door and staff said that this sign designates that the door is locked. Two of the rooms, #203 and #209, are locked at the resident's request and the residents have a key to their room. During an interview on 5/5/05 at 1:00 p.m., a family member for one of the residents, not identified due to confidentiality, stated that the resident's door is locked at his request because there is not enough staff to keep other residents from wandering into his wife's room. He further stated that on three separate occasions he had found other residents in his wife's bed. He said that the residents were in bed under the blankets and he did not know what kind of diseases those residents might have and they might soil her bed. He stated that his wife had gotten scabies in the facility and thought that might have been the way she caught the scabies. He stated that his wife had lost personal items that had been found in other resident's rooms. He stated that his wife is out of the room from 7:00 a.m. until 7:00 p.m., and he wants to make sure that the room is locked when his wife is not in the room. Review of the record for Resident #14 revealed a complaint form dated 7/27/04, signed by the resident's Durable Power of Attorney (DPOA) that stated the resident's door is to be kept locked from 7:00 a.m. to 11:00 p.m. and the resident is to receive a key. Up to three keys will be provided and the facility will "rethink” the action if all keys are lost. No one could ascertain whether Resident #14 had a key. 2. On 5/5/05 at about 11:40 a.m., an observation was made of the closed unit currently housing 18 dementia residents. This area has four exit doors. The main door coming from the front of the facility, which is locked, an exit door to the outside fenced area from the end of two hallways and a central exit to another building, as well as to the outside fenced area. These doors are equipped with alarm equipment. When the three unlocked doors were opened during observation, no alarm was heard. f 14 During an interview with a staff member on this unit at this time, it was stated that the doors are alarmed and they are on timers. This unit has alarms active from 5:00 p.m. until 7:00 am. She was asked why the alarms were not active during the day and she stated that she did not know. She was asked how she knew when a resident was outside, she said they just know because they are not in the common area. She further stated that they have a policy for hydration for residents when they are outside. She stated that they check on them and offer fluids every 8 to 10 minutes. Further interview revealed that she knows when the residents are outside because when she hears the alarms, she checks her watch and 8 to 10 minutes later, she will go and check on the residents and offer them fluids. Again, she was asked about what happens when the alarms are off and she stated she just knows when her residents are outside. Observation of the exit doors in building two, which according to the staff houses the higher acuity residents numbering 16 at present, found the same alarm system and none of the three exit doors were active at 11:45 a.m. The residents on this unit are known to be roamers and go in and out of the building all day long. The residents have free access to the yard, which encompasses about one acre. Interview with the Administrator at about 11:50 a.m., revealed that the alarms are turned off during the day because they are (the sound) an irritant to residents, staff, and families. He further stated that family members had approached him on numerous occasions, because the alarms going off all day long bothered the residents. The back unit (building two) has the door alarms active 7:00 p.m. to 7:00 a.m. only. Also observed on this unit at about 11:45 a.m., nine random residents were noted to having no shoes on. They all did have socks on. Seven of the resident rooms were locked, rooms #2, #3, #4, #10, #11, #13 and #14. Shoes were not visible in the common area for these residents to put on. These same residents have full access to the yard at this time without the staff knowing they are out there. According to the nurse on the back unit, the staffing numbers for this unit on the night shift, 7:00 p.m. to 7:00 a.m., is one Certified Nursing Assistant. This information was validated by the Administrator and a review of the current staffing schedule for the month of May. 3. Resident # 1 was admitted to the facility on 11/1/04, with a diagnosis of high blood pressure, Alzheimer's, congested heart failure, Degenerative Joint Disease, and Arterial Sclerotic Heart Disease. The resident has a DPOA, which is the daughter. Resident #1 receives assistance with medications and is on a No Added Salt (NAS) diet. On a tour of the facility at about 11:00 a.m. on 5/5/05, this resident was observed asleep, under the covers in bed, this observation took place in room #16. An interview with the staff on duty revealed that this resident's room number is #8. It was further stated, "Oh ---- gets tired after breakfast and just goes in the closest room and goes to sleep.” A review on 5/5/05 of an Initial Adverse Incident 1 Day Report. revealed that on 4/30/05 Resident # 1 w4s found outside, sitting on the ground, where she sustained numerous ant bites. The report stated that the adverse incident does represent a potential risk to other residents, it further stated, "It is possible for anyone to suffer ant bites." Therefore, the facility is contacting the extermination company to see if there is any new product on the market that can be used for ant control. As of 5/5/05, the ground had not been treated for ants. On 5/5/05 at about 4:15 p.m., a walking tour of the facility grounds, in the fenced in area, revealed a random sample of 29 different ant hills/areas of hills. The 29 areas/hills were currently active with very small red ants observed. Additional information contained in the report is as follows: "resident found outside by nurse aide ---- sitting on an ant pile. Resident brought in and immediately showered. Clothes changed. Buttocks and upper thighs reddened. Pt in no resp. distress. Pt's chart checked - allergic to PCN. Alcohol and moisture barrier was applied. Dtr notified at 2:00 P.M. (incident took place about 7:00 A.M.) - no distress noted. Info gave to PM nurse. Doctor's office notified at 2:30 P.M.. Service will have doctor call back. 2" call placed to Dr's office at 4:00 P.M., No retum calls. Daughter gave Benadryl - 25mg PO at 5:00 P.M." A review of the nurse's notes dated 4/30/05 revealed the following: 4/30 - 7:00 a.m. (late entry) - "resident brought in from outside by nurses aide ---- stated (s)he was sitting on an ant pile. Resident showered, buttocks and upper thigh area noted to be reddened. Cleaned it dried, alcohol pads used over reddened areas to help alleviate the sting. No allergies on chart noted for ant bites, (PCN only). Will monitor." 10:30 a.m.- "Per nurse aide, pt not eating much breakfast. Laid down for nap. No distress noted." 12:00 - “Resident up for lunch. Eating well. No change in behavior noted. No distress." 1:45 p.m. - "Called dtr ----- to report resident sitting on an ant pile. Stated she would be in later on today or tomorrow." 4/30/05 - 2:00 p.m. - “Report from day nurse that resident was found sitting outside at breakfast time in ant hill. Resident has red areas on buttocks and both thighs. No respiratory distress noted. Daughter (-----) called and arrived at facility. Dr. ------- office called at 2:30 P.M.. "Message left with ans. Service. Dr. ----- on call today and call back requested." 3:30 p.m. - "Fluids encouraged. Daughter (unable to read) to visit. No call from MD - Daughter stated that she was going out to buy Benadryl and some cream as that was helpful in the past." 4:00 p.m. - "report called to answering service." 4:30 p.m. - "Resident eating - Ate 80% of meal. Up wandering in secured area. Attempted to go outside. Redirected to lounge chair in dining room.” t 5:00 p.m. - "Daughter returned and gave resident Benadryl 25mg tablet. Resident continues to wander. Incont. of urine. Perineal area washed and protective skin barrier cream applied." 7:00 p.m. - "resident continues to wander. Redirected to stay inside. Fluids encouraged. Resident given cookies and coffee. Took evening medications at 8 PM. Incont. of large amount of urine. No call back from MD office. Resident assisted with nightgown and put to bed. No distress noted." 5/1/05 - 10:00 a.m. - "Resident found sitting in ant bed on 4/30/05 has multiple ant bites all over buttocks, Peri area, and lower abdomen. Daughter is escorting her to ----- (Hospital) in Pt. Charlotte at this time. ER notified as well as Dr. ----(on call for----) Answering service also to fax info to Dr. ------- 's office." 10:15 a.m. - “resident was given Ativan 0.5mg PO before leaving at 10 AM for increased anxiety - ER notified when called." 4:45 p.m. - "received call from daughter "-----" at this time - resident admitted to ----(hospital). 7:40 p.m. (late entry) - "After making decision to send resident "out" this AM, I was going to call EMT's - daughter insisted on taking her because she "wanted to stay with her" - She also selected ---- (hospital). Also at 5:45 P.M. today I found out ringer on phone not working in nurses station because Dr. did call facility twice (Cable Co. being notified by owner of facility to repair) yesterday when nurse called him." 5/3/05 - 5:50 p.m. - "Resident returned to facility. Daughter here. No D/C orders received from ---- (hospital). Hospital called. Daughter returned to Hosp to pick-up orders. Ret at 7:00 p.m. Resident has scabbed areas over buttocks and thighs. Incont. of urine large amt. Diaper soaked. Daughter stated, "Resident was very combative in hosp and family stayed round the clock to sit with her. Stated that resident had not been out of bed. N.O. (new order) for Avelon 300mg qd (every day) for 7 days, Pepcid 20mg 1 BID (twice a day) and Zyrtec 10mg 1 PO (by mouth) QD - Faxed to PCP. Resident has skin intact except for scabbed areas." 7:00 p.m. - "Became combative when checking skin unable to complete exam. Ate small amt of chix noodle soup. Ambulating in hall.” Review of the hospital record obtained on 5/5/05 revealed the following: 5/1/05 - 11:13 a.m. - Arrived in Emergency Room with multiple ant bites to legs and trunk. "Emergency Department Course and Treatment" - in part - "Obviously, the reason this patient will be admitted at this point is due to her history of Alzheimer's dementia, the multiple ant bites that she had sustained, the risk for secondary infection, and the uncertainty of the adequacy of care at the facility that she came from. Dr. ------ is in agreement with this.” "Emergency Room Nursing Record" revealed: Chief Complaint: "was found outside sitting on an ant hill. Bit by red ants on chest, vaginal area, and buttocks.” “Additional Findings": Peri area, thighs, covered with ant bites too many to count. 11:42 Adult Prot Services notified @ 1-800-962-2873 ------ (name of person taking call) took report. On 5/2/05, an order for Case Management for placement was given by the physician. "Physicians Progress Notes" document the following: 5/2/05 - "Events noted. - Spoke with dtr (POA). She wants her to go back to ----(facility). She will talk to them about more supervision. I told her about the option of NH (Nursing Home) placement but she states she cannot afford it. Will discuss further with C.M. (Case manager) - the dtr will call my office in am with her final decision." 5/3/05 - "Spoke with dtr (POA). She decided to take her back to ----- (name of facility) ALF (Assisted Living Facility) - today she is sleeping because she did not sleep at all last PM. She spoke with the ALF and they will take care of the fire ants. I spoke with the nurses and they have been providing total care for her. Her dtr is aware of that and she will stay with her mom 24 hours a day at ALF until she is able to feed herself. She does not want her to go to SNF (Skilled Nursing Facility). She was told if her condition deteriorates, she will bring her back to the hospital. See D/C (discharge) orders." Telephone interview with the resident's daughter on 5/5/05 at about 12:45 p.m., revealed that this was the second time this resident had been bitten by ants in this facility and required treatment. She stated she was not sure of the date, but thought it was some time in January. Review of the clinical record for Resident #1 found a physician's order, dated 11/29/04, for the treatment of ant bites. Further review of the nurse's notes and other facility documentation failed to find any record of this event. Review of the Incident/Accident reports failed to find a report regarding this episode of ant bites in November. Interview with the ECC Supervisor and the Administrator at about 3:00 p.m. on 5/5/05, failed to produce any additional information regarding the November ant bite incident. ECC Supervisor reviewed chart and was also unable to find any documentation discussing this issue. He further reviewed the Accident/Incident Log without success. Administrator stated, "I guess we missed that one. We made a mistake." 4. Resident # 5 was admitted to the facility on 4/25/05, with an admission diagnosis of Alzheimer's and Dementia. Listed on the 1823 (Health Assessment for Assisted Living Facilities) under Special Precautions - "Escape Precautions." The resident was admitted from a behavioral center. On 5/5/05, a review of the resident record revealed an admission note that included a notation "Is a flight risk.” Additional notations in the record include: 4/26/05 10:00 A.M. - "Res. wandering throughout unit asking for directions "going to play soccer outside." 4/26/05 6:00 P.M. - "resident wandering continuously.” 4/26/05 7:55 P.M. - "resident found in patio area in front of secure doors. Walked into kitchen. Brought back to secure area. Resident is flight risk. Staff continued to monitor resident so that (s)he does not follow visitors out the door." 4/28/05 7:00 A.M. - "Night shift reported res. Trying to go through middle doors last night. Redirection approach used. Staff continues to monitor res. Carefully.” 4/29/05 9:00 A.M. - "Res. Adjusting fair. Pleasant but likes to go out by the fence. Looking for wife. Enjoys sitting on patio." 5/1/05 11:00 A.M. - “Resident very restless trying to get out of building. Climbed over fence (short) around patio trying to get to front of building. Ripped back of pants. No injuries noted." 5/1/05 5:25 P.M. - "Staff have been searching building for approx 30 minutes. Last seen by staff right after eating supper at approx 4:50 PM - PGPD (Punta Gorda Police Department) notified and given description of resident. Owner of facility notified and he notified family. " 5/1/05 8:45 P.M. - "resident returned to facility by PGPD. Resident ambulatory and no abrasions noted. Sneakers, socks, and pant legs wet. Resident remains confused. No distress noted. Spouse notified of his return and appointment tomorrow with Dr.----- at 11:45 AM. Dr's office notified that he had returned." 5/2/05 5:00 P.M. - "Resident becoming increasingly agitated. Running outside and back inside. Given Ativan Img PO." 5/2/05 8:00 P.M. - "Given Ambien - resident has sat in chair for short time. Remains confused. Has not attempted to climb fence. Has been cooperative and pleasant." 5/2/05 8:25 P.M. - "Resident observed jumping fence and running west. 911 called. Responded stat. Resident found and returned to facility at 8:40 P.M. Administrator notified. Spouse called. Stated that resident was on Librium when he was at hospital and did sleep most of time. No distress or injury noted." 8:50 P.M. Dr. ---- called. Returned call. Recommended that resident be admitted to ----- (hospital) for evaluation and medication adjustment. Resident's wife in agreement. Review of 1-Day reports as follows: 5/2/05 Outcome of Incident: Elopement. Circumstances as outlined above. Actions: None noted on report. Outcome of Incident: 1) Required Emergency Room Screening, 2) Event reported to law enforcement, 3) Elopement. 5/3/05 Circumstances as outlined above. Actions: None noted on report. 5. Review of the record for Resident #7 revealed he was admitted on 11/1/04. A nurse's note dated 11/1/04 at 2:00 p.m., documents that the resident is wandering in and out of several rooms. At 5:00 p.m., a note documents that the resident continues to wander and was found outside in secured area and was retumed to the unit. A nurse's note at 6:40 p.m. on 11/1/04 states, “Resident found lying on ground outside in secured area. Color dusky, no respirations noted. CPR (Cardiopulmonary Resuscitation) initiated. 911 called. Transported to ----- (name of hospital) via EMS." Review of an incident report dated 11/1/04 at 6:40 p.m., reveals documentation of the above nurse's note for Resident #7 reveals the resident was found outside the facility in the fenced area on 11/1/04 at 6:40 p.m. The resident was non responsive and had zero respirations. A nurse's note at 12:00 p.m., documents that the resident's spouse came to the facility and reported that the resident had died. During interview on 5/5/05 at 7:15 p.m., the facility Administrator and the ECC (Extended Congregate Care) Supervisor both stated they had no knowledge of this incident. When asked if an investigation had been done the ECC Supervisor stated, "Why? He died at the hospital.” The Administrator stated that he did not know if an Adverse Incident report had been completed and stated that they could not find the adverse incident reports that had been completed before the ECC Supervisor started doing them a few months ago. He stated, "I'll look for them." No Adverse Incident Report could be found. 6. Further review of the facility's incident reports revealed Resident #8 had been found outside lying on the ground next to a rolling chair on 2/14/04 at 8:10 p.m., the resident had sustained hematomas above her right eye and was sent to the hospital for evaluation. 7. An incident report dated 2/7/04 at 4:00 p.m., for Resident #9 revealed the resident was found outside in the yard lying on her right side complaining of shoulder pain. The resident was sent to the hospital via EMS. The portion of the incident form for steps taken to prevent recurrence states, "watch resident closely." Another incident report dated 3/1/04 at 11:30 p.m., documented that the resident was found outside on the ground at the end of "C" hall. The section title "Brief description of incident states, "I found ------ (resident's name) outside on the ground after doing rounds. I did not know she was outside.” 8. Review of ah incident report for Resident #10, revealed he was found outside on 6/12/04 at 7:45 p.m., the report stated, “Staff from back section wheeled ----- (resident's name) back to us 20 saying he had found the resident on the ground outside. The resident was rain soaked and covered in dirt and sand." 9. Review of an incident report for Resident #11, revealed the resident was found outside on 12/20/04 at 5:15 p.m. The resident had a hematoma on her face and a skin tear on her right knee. 10. An incident report dated 3/20/04, revealed Resident #12 had fallen outside and sustained a laceration on his head. The resident was sent to the hospital for stitches. The portion of the form for "steps taken to prevent recurrence" states, "check on more frequently than every 2 hours." 11. Review of an incident report dated 4/14/04, revealed Resident #13 was missing at lunchtime. The report stated, "Resident missing at lunch time." Area searched. Husband present. Police called. Then resident found on property in secured area at 12:20 p.m. Call to police cancelled as resident was found uninjured. The section titled, "Steps taken to prevent recurrence,” documents that the area was searched for holes in the fence. 12. Review of an incident report dated 4/17/04 at 11:50 a.m. for Resident #14, revealed a person on a bicycle came to the facility to tell us the resident had walked to her street. Facility staff person drove to pick up resident. The resident had been out front with his wife and she left thinking the resident would go back into the facility. 13. An incident report dated 5/16/04 at 9:45 a.m. revealed Resident #15, was returned to the facility by the police after being found riding an electric wheel chair on the street after the police had received a phone call regarding the resident's safety. The "steps taken to prevent recurrence," states that the resident was told never to leave facility by herself and she agreed. 15. These observations were cited as a Class I deficiency as the failures of the facility present the possibility of placing all residents in imminent danger with a strong probability of physical harm or death. This constitutes a violation of Section 400.428(1), Florida Statutes (2004) for which a fine of five thousand dollars ($5000.00) is authorized pursuant to Section 400.419(1)(a), Florida Statutes (2004). COUNT UI THE FACILITY FAILED TO MAINTAIN A SAFE ENVIRONMENT FREE OF INSECTS THAT ARE HARMFUL TO THE RESIDENTS AND THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION OF DEMENTIA RESIDENTS, in violation of ¢ Rule 58A-5.023(1)(a), Florida Administrative Code (2004) 21 CLASS I DEFICIENCY 16. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 17, Rule 58A-5.023(1)(a), Florida Administrative Code (2004) provides: The ALF shall be located, designed, equipped, and maintained to promote a residential, non- medical environment, and provide for the safe care and supervision of all residents. 18. The survey conducted on or about May 5, 2005 showed: Based on observations, interviews and record reviews, the facility failed to maintain a safe environment free of insects that are harmful to the residents, and failed to provide adequate supervision of dementia residents to keep them out of harms way and within the facility. This is evidenced by 1 (Resident #1) of 15 sampled residents, a resident who wandered outside unnoticed and sustained multiple ant bites requiring hospitalization. One (Resident #5) of 15 sampled residents, who was a known "risk for flight," was able to elope (flee) from facility on two occasions necessitating his/her return to the facility by law enforcement. The facilities lack of awareness as to the whereabouts of the residents at all times places the residents at risk to imminent danger with a very substantial probability that serious physical harm or death could result. The lack of treatment to the environment to keep free of insects can and has been harmful to the residents. The findings include: 1) A review on 5/5/05, of an Initial Adverse Incident 1 Day Report revealed that on 4/30/05, Resident #1 was found outside, sitting on the ground where she sustained numerous ant bites. The report stated that the adverse incident does represent a potential risk to other residents, it further stated, "It is possible for anyone to suffer ant bites.” Therefore, the facility is contacting the extermination company to see if there is any new product on the market that can be used for ant control. As of 5/5/05, the ground had not been treated for ants. Additional information contained in the report is as follows: "resident found outside by nurse aide_____sitting on an ant pile. Resident brought in and immediately showered. Clothes changed. Buttocks and upper thighs reddened. Pt in no resp. distress. Pt's chart checked - allergic to PCN. Alcohol and moisture barrier was applied. Dtr notified at 2PM (incident took place about 7AM) - no distress noted. Info gave to PM nurse. Doctor's office notified at 22 2:30PM. Service will have doctor call back. 2 call placed to Dr's office at 4PM. No return calls. Daughter gave Benadryl - 25mg PO at 5PM." 5/1/05 - 10:00 a.m. - “Resident found sitting in ant bed on 4/30/05 has multiple ant bites all over buttocks, Peri area, and lower abdomen. Daughter is escorting her to __(Hospital) in Pt. Charlotte at this time. ER notified as well as Dr. (on call for ) Answering service also to fax info to Dr. 's office." 10:15 a.m. - "resident was given Ativan 0.5mg PO before leaving at 10AM for increased anxiety - ER notified when called.” 4:45 p.m. - "received call from daughter " " at this time- resident admitted to _(hospital). Review of the hospital record obtained on 5/5/05 revealed the following: 5/1/05 - 11:13 a.m, - Arrived in Emergency Room with multiple ant bites to legs and trunk. "Emergency Department Course and Treatment" - in part - "Obviously, the reason this patient will be admitted at this point is due the her history of Alzheimer's dementia, the multiple ant bites that she had sustained, the risk for secondary infection, and the uncertainty of the adequacy of care at the facility that she came from. Dr. is in agreement with this." "Emergency Room Nursing Record" revealed: Chief Complaint: "was found outside sitting on an ant hill. Bit by red ants on chest, vaginal area, and buttocks.” “Additional Findings:" Peri area, thighs, covered with ant bites too many to count. 11:42 Adult Prot Services notified @ 1-800-962-2873 (name of person taking call) took report. Telephone interview with the resident's daughter on 5/5/05 at about 12:45 p.m., revealed that this was the second time this resident had been bitten by ants in this facility and required treatment. She stated she was not sure of the date but thought it was some time in J anuary. Review of the clinical record for Resident #1 found a physician's order dated 11/29/04, for the treatment of ant bites. Further review of the nurse's notes and other facility documentation failed to find any record of this event. : On 5/5/05 at about 4:15 p.m., a walking tour of the facility grounds, in the fenced in area, revealed a random sample of 29 different ant hills/areas of hills. The 29 areas/hills were currently active with very small red ants observed. 23 2) Resident #5 was admitted to the facility on 4/25/05, with an admission diagnosis of Alzheimer's and dementia. Listed on the 1823 (Health Assessment For Assisted Living Facilities) under Special Precautions - "Escape Precautions." The resident was admitted from a behavioral center. 4/26/05 7:55 p.m. - "resident found in patio area in front of secure doors. Walked into kitchen. Brought back to secure area. Resident is flight risk. Staff continued to monitor resident so that (s)he does not follow visitors out the door." 5/1/05 5:25 p.m. - "Staff have been searching building for approx 30 minutes. Last seen by staff right after eating supper at approx 4:50PM - PGPD (Punta Gorda Police Department) notified and given description of resident. Owner of facility notified and he notified family." 5/1/05 8:45 p.m. - "resident returned to facility by PGPD. Resident ambulatory and no abrasions noted. Sneakers, socks, and pant legs wet. Resident remains confused. No distress noted. Spouse notified of his return and appointment tomorrow with Dr. at 11:45 AM Dr's office notified that he had returned.” 5/2/05 8:25 p.m. - "Resident observed Jumping fence and running west. 911 called. Responded stat. Resident found and retumed to facility at 8:40PM. Administrator notified. Spouse called. Stated that resident was on Librium when he was at hospital and did sleep most of time. No distress or injury noted." 3) On 5/5/05 at about 11:40 a.m., an observation was made of the closed unit currently housing 18 dementia residents. This area has 4 exit doors. The main door coming from the front of the facility, which is locked, an exit door to the outside fenced area from the end of two hallways and a central exit to another building as well as to the outside fenced area. These doors are equipped with alarm equipment. When the three unlocked doors were opened during observation, no alarm was heard. During an interview with a staff member on this unit at this time, it was stated that the doors are alarmed and they are on timers. This unit has alarms active from 5:00 p.m. until 7:00 a.m. She was asked why the alarms were not active during the day and she stated that she did not know. She was asked how she knew when a resident was outside, she said they just know because they are not in the common area. She further stated that they have a policy for hydration for residents when they are outside. She stated that they check on them and offer fluids every 8 to 10 minutes. Further interview revealed that she knows when the residents are outside because when she hears the alarms, she checks her watch and 8 to 10 minutes later, she will go and check on the resident and offer them fluids. Again, she was asked about what happens when the alarms are off and she stated she just knows when her residents are outside. Observation of the exit doors in building two, which according to the staff houses the higher acuity residents numbering 16 at present, found the same alarm system and none of the three exit doors were active at 11:45 am. The residents on this unit are known to be roamers and go in and 24 out of the building all day long. The residents have free access to the yard, which encompasses about one acre. Interview with the Administrator at about 11:50 a.m., revealed that the alarms are turned off during the day because they are (the sound) an irritant to residents, staff and families. He further stated that family members had approached him on numerous occasions, because the alarms going off all day Jong bothered the residents. The back unit (building two) has the door alarms active 7:00 p.m. to 7:00 a.m. only. 19. These observations were cited as a Class I deficiency as the failures of the facility present the possibility of placing all residents in imminent danger with a strong probability of physical harm or death. This constitutes a violation of Rule 58A-5 -023(1)((a), Florida Administrative Code (2004) for which a fine of five thousand dollars ($5000.00) is authorized pursuant to Section 400.419(1)(a), Florida Statutes (2004). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: 1) Enter factual and legal findings as set forth in the allegations of Counts I-III. 2) Assess a seven thousand five hundred dollar ($7500.00) fine for Count I, five thousand dollar fine ($5000.00) for Count I, and five thousand dollar fine ($5000.00). 3) Assess a survey fee in the amount of five hundred dollars ($500.00). 4) Enter any other relief the Court deems just and appropriate. Respectfully submitted on this AG day of May, 2005. Oba pi a Jay Fowler, Senior Attorney Florida Bar No. 339067 Agency for Health Care Administration 25 2295 Victoria Street, Room 346C Fort Myers, FL 33901 Phone: (239) 338-3203 Fax: (239) 338-2372 NOTICE The Respondent, Punta Gorda Elderly Care Center, Inc. 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 Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Dr., Bldg. 3, MSC 3, Tallahassee, Florida, 32308; Attention: Agency Clerk. THE RESPONDENT IS FURTHER NOTIFIED, IF THE REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. CERTIFICATE OF SERVICE I HEREBY. CERTIFY that the original Administrative Complaint, Explanation of Rights form, and Election of Rights forms have been mailed by certified mail, return receipt requested (certified receipt no. 7004 1160 0002 9081 1105) to: Mickey G. Melton, Administrator, Punta Gorda Elderly Care Center, 2295 Shreve Street, Punta Gorda FL 33950 on this 19 day of May, 2005. 6] pie Fowler, Senior Attorney 26

Docket for Case No: 05-002184