STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, ; AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Ob _ { DD» 7 . . oo . . AHCA NO: 2006001706(fine) 2006001707(CL) Vs. PEACE RIVER HMA NURSING CENTER, INC., d/b/a PEACE RIVER NURSING AND REHABILITATION CENTER, Respondent. ; / ADMINISTRATIVE COMPLAINT RAE ERATIVE COMPLAINT ' COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against Peace River HMA Nursing Center, Inc., d/b/a Peace River Nursing and Rehabilitation Center (“Respondent”), pursuant to Section 120.569, and 120.57, Florida Statutes (2005), and alleges: NATURE OF THE ACTION 1... Thisis an action to assign a conditional license to Respondent, pursuant.to Section 400.23(7)(b), Florida Statutes (2005), to assess an administrative fine of fifty thousand dollars ($50, 000.00) pursuant to Sections 400, 23(8)(a) and (b), Florida Statutes (2005), and to assess a six month survey cycle fee of six thousand dollars ($6000.00) pursuant to Section 400. 19(3), Florida Statutes (2005). A copy of the original conditional licenses (includes renewal license) are attached as Exhibits “A” and “B” to the administrative complaint and are incorporated herein by reference. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2005). 3. AHCA has jurisdiction pursuant to Chapter 400, Part Il, Florida Statutes (2005). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2005). | PARTIES . 5. AHCA is the regulatory agency tesponsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part I, Florida Statutes (2005), and Chapter 59A-4, Florida Administrative Code (2005). | . 6. Peace River HMA Nursing Center, Inc. aba Peace River Nursing and Rehabilitation Center is a corporation with a physical and principal address of 2370 Harbor _Bivd., Port Charlotte, FL 33952. . 7. Peace River Nursing and Rehabilitation Center is a 104 bed skilled nursing facility and is licensed by AHCA as a skilled nursing facility having been issued license number ‘SNF10560961. 8. Respondent is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part II, Florida Statutes (2005) and Chapter 59A-4, Florida Administrative Code (2005). COUNT I THE FACILITY FAILED TO IMPLEMENT ESTABLISHED POLICY AND - PROCEDURES TO PROTECT FEMALE RESIDENTS FROM UNWANTED SEXUAL ADVANCES; THE FACILITY FAILED TO ENSURE ADEQUATE CARE PLANNING WAS INSTITUTED TO PROTECT BOTH THE FEMALE VICTIMS AND MALE wu PERPETRATORS; THE FACILITY FAILED TO ENSURE ALL STAFF. WAS KNOWLEDGEABLE OF WHAT IS REPORTABLE AS UNWANTED SEXUAL ; - ADVANCES AND FAILED TO PROVIDE THE CARE AND SERVICES TO PROTECT ; THE RESIDENTS; THE FACILITY’S QUALITY ASSURANCE TEAM FAILED TO MEET.ON A REQUIRED BASIS TO IDENTIFY TRENDS OF POTENTIAL HARM AND/ OR NEGLECT; THE MEDICAL DIRECTOR FAILED TO ATTEND QUALITY: ASSURANCE AND RISK MANAGEMENT MEETINGS ON A REQUIRED BASIS; THE FACILITY DID NOT CONSISTENTLY IDENTIFY THE VICTIMS, FAILED TO PHYSICALLY AND EMOTIONALLY ASSESS THE VICTIMS, AND DID NOT IMPLEMENT EFFECTIVE MEASURES TO PROTECT THE FEMALE RESIDENTS ON THE ALZHEIMER UNIT FROM ACTUAL AND POTENTIAL HARM, in violation of Section 400.102(1)(a), Florida Statutes (2005) PATTERNED CLASS I DEFICIENCY 9. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. Section 400.102(1)(a), Florida Statutes (2005) provides: 400.102 Action by agency against licensee; grounds.-- (1) Any of the following conditions shall be grounds for action by the agency against a licensee: (a) An intentional or negligent act materially affecting the health or safety of residents of the facility; : “11. Respondent was in violation of the above provision. During a complaint investigation survey conducted on or about January 26, 2005, the following was observed: Based on clinical record review, review of facility's investigation of incidents and accidents, grievance log, interview with the facility's Administrator, Director of Nursing (DON), Risk Manager, Abuse Liaison/Staff Development coordinator, Long Term Care Unit Manager, Social Worker, and review of the facility's policy and procedures to prevent neglect, the facility failed to implement established policy and procedures to protect 3 (Resident #23, #24 and #41) , identified female residents who had written documentation of unwanted sexual advances and 26 documented cases of unidentified female residents who were subjected to unwanted sexual advances and numerous incidents of potential harm for unidentified female residents. The facility failed to ensure adequate care planning was instituted to protect both the female victims and male perpetrators. . The facility failed to ensure all staff was knowledgeable of what is reportable as unwanted sexual advances. and failed to provide the care and services to protect. . The facility's Quality Assurance Team failed to meet on a required basis to identify trends of potential harm and or neglect. The Medical Director failed to attend Quality Assurance and Risk Management meetings ona required basis. The facility had not consistently identified the victims, failed to physically and emotionally assess the victims, and had not implemented effective measures to protect the female residents on the Alzheimer unit from actual and potential harm. The findings include: 1. After review of the facility's accident and incident log, the survey team requested the investigation into two accounts of sexual inappropriate behavior towards two female residents (Resident #23 and #24). Review of the investigation into the incident involving Resident #24 revealed the following: "6/26/05 - The resident found with male resident in bed with her. Dress was pulled up and brief intact. Resident with '0' apparent injury. Male was redirected. A stop sign was placed on the [door] of (resident's) room." Other than redirecting Resident #22, the facility did not implement any actions to prevent further occurrences of potential sexual molestation to females on the unit, Further clinical record review of Resident #22's chart revealed the following: ; 6/25/05 4:30 PM - "(Resident #22) has been found in room -- in bed with female resident whose room it is X.3 this shift. Remove each time. Last time he was noted to be holding her down in’ bed on top of her and rubbing her body with his stating ‘[ sorry’. Separated and (resident) told to not to go into room anymore. Will continue to monitor for any further problems." 6/26/05 12 noon- "(Resident) has made 3 attempts to get in room -- (same room as before). Redirect fre (frequently) by staff. At 7:17.AM made in {into) room. Noted to be kissing female resident inroom. Removed by staff. Cont (continue) redirect." 2. Review of the investigation into the incident involving Resident #23 revealed the following: - 7/14/05 - “Residents family reported to charge nurse that the resident told them a --- male (Resident #21) came into her room and had his hand down her blouse, Resident is alert with some confusion, able to relate, event. No Physical injury noted. Offending resident with history of sexually inappropriate behavior. Psych consult ordered: Will continue to monitor." 3. Further review of the incident accident log and review of subsequent investigations revealed the following regarding Resident #21:. 5/4/05 - "Resident cognitively impaired with history of sexual inappropriate behavior. ‘Currently ; on medication to decrease this behavior. Dr. --- notified. Psych consult ordered. Resident supervised when out of room." : 7/13/05 - "Resident was observed by charge nurse to have hand down resident's blouse holding breast. Resident was redirected to room and Dr. --- and Dr. ---- notified.” There is no identification of the female victim. ‘ 7/19/05 - statement only - "Resident observed." 4, Resident's #21 clinical record was reviewed. The following was noted: The resident has been in the facility since 10/9/02 with diagnosis including but not limited to dementia, bipolar disorder and depression. : 3/4/05 nurses notes 1:45 p.m. "Noted to have L (left) hand down female Resident blouse . squeezing her breast. Resident separated and will monitot for any further behavior problems." There was no identification of the female victim, , . 7/13/05 nurses note 10:00 a.m. "Noted to have L; (left) hand down female holding R (right) breast in hand and kissing her mouth." Female victim not identified. Corresponds with Incident report of this date. resident's blouse ' 7/13/05 nurses notes 11:45 a.m. "Staff reports that (resident #21) sexual behavior is getting worse. Noted to be putting hand down females pants all of the time." The number and identity of the female victims are not acknowledged. 7/14/05 wurses note 2:00 p.m. "Continues with sexual behavior toward female Residents X 3, female breasts." ° ; : Female victims not identified ' 7/15/05 fax to physician. “Noted to have hand down female resident blouse holding R breast in hand and kissing her mouth." : , Female victim not identified. 7/19/05 nurses note 3:15 p.m. "After I arrived 2 CNA's reported to me that Res. (resident) was caught feeling 2 female residents in their private areas below the waist." Female victims not identified. A psychiatric consult was ordered. 8/3/05 Spiritual Assessment Sheet note. "This gentleman was attending the musical on Francis Lane. One of the lady residents-was sitting on the arm of his wheelchair and he was touching her inappropriately. I reported same to staff." : 8/13/05 nurses note 3 - 11 shift. "CNA notified me of inappropriate behavior, resident putting hands down female resident's shirt." . Female victim not identified. . 8/14/05 nurses notes 8:00 p.m. "In day room CNA witnessed resident ' female slacks, Removed resident to opposite side room." Female victim not identified. putting hands down 8/15/05 nurses note 10:00 p.m. “Resident attempted to put hand inside of a female resident's undetwear. CNA told resident not to act this way and the male resident replied, 'T can do whatever I want .' 1 to 1 with male resident with some effect. Resident attempted to put his hand inside of the female resident underware (sic) in the Francis Lane Hall while he was going to Francis Lane DR (dining room) for supper." , The female victim is not identified 8/24/05 nurses note 2:30 a.m. "Called to room -- by CNA. Noted in bed -- (male resident #21) and female Resident lying in bed. (Resident #21) had his hand down her pants. When saw staff he pulled his hand out. Female taken from room," : Female victim not identified. : a 9/3/05 murses notes 2:00 p.m. "(Resident #21) pushed a female resident irito room. First inappropriate behavior noted. Cautioned not to touch the females and not to move'them in their w/cs (wheelchairs)." : 9/6/05 nurses notes 10:00 a.m, "Reported to me that (resident #21) inappropriately touched a female while sitting next to her in Rosary in Chapel Yesterday. ..." ‘ 9/15/05 nurses note 2:30 p.m. ."“CNA reported pt (patient) (resident #41- female resident) on fir (floor) at bedside of (Resident #21). CNA teported (Resident #21) hand noted up shirt of (Resident #41). No harm/injury noted. ..." . No incident report recorded. 9/15/05 nurses note 7:00 p.m. "Reinforced to Res. (Resident) of improper touching. Res. verbally states he understands. ..." 9/19/05 Weekly Summary note: "Needs frequent supervision as goes into other resident's rooms, esp (especially) female residents." . 9/30/05 nurses note 4:00 a.m. "Up frequently during noc walking into other residents ' rooms and was directed back to own room." " 10/4/05 ‘nurses notes 12:00 am. "Resident up in hallway, confused. Redirected back to his bed then returned un-noticed and entered a female resident's room attempting to lay down in such resident's bed in room -- who managed to vernally (sic) chase him away."" Female victim not identified. ; , .10/17/05 Weekly summary report. "Continues to wander. Will try to go into female residents’ rooms by self." ; 10/24/05 nurses note 7:00 p.m. "Report received of Resident approaching female Residents, he © Was reminded not to.touch. ...." Female victims not identified. 10/24/05 weekly summary. "Continues to wander into female room: s, has to be reminded they: are not here for him and his special needs.” 10/25/05 nurses note 10:00 p.m. "Noted several times to-have hands on female residents, remind that he was not to touch them. ..." 1:1 CNA monitoring. 10/26/05 nurses note 9:45 a.m. "(Resident #21) was in Francis dayroom when staff observe him with his hand down shirt of female Resident blouse, also had other hand down her pants. . Residents separated. (Resident #21) reminded that he was not to treat female residents that way - and sent to his room. ..." 10/27/05 nurses note 2:00 p.m. "Sexual behavior has gotten wor female in is immediate surrounding, supervisor notified," : Female victims not identified. se. Was noted to touching every 10/27/05 nurses note 3:30 p.m. "Resident (cont) continues to be inappropriate with behavior X 10, has been 1:1 with nurse." . , 10/27/05 nurses note 9:30 p.m. "Resident has been quiet and calm 6:00 P until out of alarm or turned off per self pt slipped down hall to a lady's room and was trying to fondle her." Placed on 1:1. with CNA. ; Female victim not identified. 10/28/05 nurses note 2:00 p.m. (Resident #21 residents, hds also been seen X 2 with hand d will also stand in doorway of his room tr when they pass by." Female victims not identified. . ) has been observed X 4 attempting to grab female own female residents blouses. ..-(Resident #21) ying to get female residents to come in, ... grabs at them 10/28/05 nurses note 3:40 PM. "Resident cont to grab, fondle et rub women sexually." 1:1 with staff. Haidol given. Female victims not identified. 10/28/05 nurses note 8:40 PM "Resident cont to be restless et using inappropriate sexual _ advances to ladies." Repeat Haldol given. 10/29/05 nurses notes 11:30 AM. getting two female residents into When sent to his room will come Haldol given. Nurse Manager made aware, "Constantly trying to get to female residents has been seen his room. When in dayroom, will grab at female residents. out and when staff busy, will try to get to females in hallways." 10/29/05.nurses note, not timed. "During waking hours resident will be provided 1: supervision by staff." ; ; 10/29/05 nurses note 3:00 PM. "Found in dayroom with hand down female resident blouse." Ativan given. Female victim not identified. 10/29/05 nurses note 9:00 PM. "Sitter out of room momentarily. I observed from desk. Resident came out of room attempted to go into female resident’s room next to his, but was stopped before he could get through the door." . Ativan given. : : 10/30/05 nurses note 7:30 PM. "Reported by 6:30 AM CNA that (Resident #21) was seen petting new female resident while she was in wheelchair touching breast and trying to kiss her. Separated and he was sent to room, Also I observe when I was on duty at 7 AM he was trying to £0 into room --, redirected." . Female victim not identified. 11/1/05 nurses noted 9:40 PM. shift, rerouted to room." Female victim not identified. "Qesident) attempted to fondle one person at begriming (sic) The last note indicating problems with behavior is dated 12/01/05 at 11:00 PM and treads, "Resident has made no sexual advances or inappropriate sexual behavior in past three days." There are no prior notes indicating what behavior may have been observed from 11/23/05 until 12/1/05, , , Review of the MDS (Minimum Data Set) dated 10/21/05 the resident has cognition of "3", Severely impaired - never/rarely made decisions. , Area E.4 Behavioral symptoms a. Wandering, c. Socially inappiopriate/ disruptive behavioral symptoms, (made disruptive sounds, noisiness, screaming, self abusive acts, sexual behavior or disrobing in public, smeared/threw food/feces. hoarding, rummaged through others belongings).and e. Resident scored as 1/1. Behavior of this type occurred 1 to 3 days in last 7 days. ‘ , The most recent MDS is a quarterly review dated 1/18/06 and indicates Area B, 4 d. Socially inappropriate/disruptive behavioral symptoms, remains the same. This indicated these behaviors have oceurted 1 to 3 days in the last 7 days. Review of the nurse 's notes does not reflect what behaviors have taken place. Review of Resident #21 care plan reveals the following. ; ‘ 7/26/05 and updated 10/13/05, "Problem - Behavioral symptoms. Physically Abusive: (others were hit, shoved, scratched, and sexually abused. Goal - Resident will demonstrate improved behavior as evi sexually inappropriate behavior through next review date." There is a note indicating this goal was rewritten on 1/24/06, during survey. denced by no more than 3 episodes of Care Plan dated 1/24/06 (during the survey)- Behavioral symptoms related to diagnosis of psychosis, dementia, agitation, anxiety, Organic Brain syndrome and CVA. This evidenced by: Wandering with no rational purpose seemingly oblivious to needs or safety. Verbally abusive behavior: (others were threatened, screamed at, cursed at), Physically abusive: (others were hit, shoved, scratched, sexually abused. Socially inappropriate/disruptive behavior: (made disruptive noises, noisiness, screaming, self- abusive acts, sexual behavior of disrobing in pubic, smeared/threw food/feces, hoarding, . Tummaged through others belongings. : - Resists Care: (resident taking medications/injections, ADL assistance or eating), Goal: Resident will demonstrate improved behavior as evidenced by no more than 3 episodes of sexually inappropriate behavior through NRD (next review date). Interventioris are medication based and monitoring for signs and symptoms of change in behavior. 5. The facility has a policy entitled - Behavior Management and Aggression Control -. The policy reads in part: "Purpose: To educate the nursing staff in order that they will become effective in working with a resident manifesting aggressive behavior. ; Procedure: 1. Ifaresident ina nursing home demonstrates aggressive behavior and a potential for violence.exits staff are to: a.) Assist the resident to a quiet area of the facility, a place that is free from all stimuli, and away from other residents." j.) Provide ‘for the safety of all other facility residents. 1.) Notify Social Services for therapeutic intervention, " There is no documentation of staff protecting any of the female victims. There is no documentation that family members or ‘puardians of the female victims were notified after each incident. ‘ . ; : 6. Review of the facility's policy and procedures for the Prevention of Abuse/Neglect reads: "Neglect: the failure or omission on the part of the caregiver of the person or disabled adult to provide the care and services necessary to maintain the physical and menial health of an aged person or disabled adult including but not limited to, food, clothing, medicine, shelter, - supervision and medical services, that a prudent person would deem essential for the well-being of an aged person or disabled adult.. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonabl y be expected to result in serious physical or mental harm or a substantial risk of death." . Abuse representative: "The highest ranking nursing official currently in the building.” Reporting: A.) Reporting is mandatory. Florida law requires that every citizen who knows or has cause to suspect that a resident is abuses, neglected or exploited can immediately ....report such suspicion to the Florida Abuse Hotline. Reporting the incident to the employee's supervisor is sufficient, provided the supervisor takes the appropriate Steps..." B.) The facility will ensure that all alleged violations involving known or suspected abuse (physical, sexual or emotional/psychological), neglect or exploitation will be reported ' immediately to the employee's supervisor, facility specific abuse representatives, Director of Nursing and Administrator. ..."- Facility's Policy and procedures related to preparation of an "Event Report" reads, "The Event Report should be completed when an unusual or abnormal patient care, ..." "An Event is a potentially harmful event or occurrence which is not an intended result of care and treatment being rendered, and which could result in potential loss to’Patient," “Events which require immediate notification of Risk Management and/or the Administrator on call are: ... Physical crime against a patient; such as assault, battery, rape, sexual molestation." ".... A call must be placed to the Director of Risk Management. to include death, Fracture, Allegation of Sexual Misconduct." ; Training: "All employees will receive orientation and annual education regarding identifying and reporting abuse in accordance with federal and state law. ...A. Appropriate interventions to deal with aggressive and/or catastrophic reactions of Residents.’ ...D. What constitutes abuse, neglect and misappropriation of Resident property." ’ Prevention: ...D. Situations in which abuse, neglect, and/or misappropriation of Resident property are more likely to occur will be identified and included in all educational efforts. Such areas as: 1. Physical environment such as secluded area. 3. Residents with needs and behaviors which may lead to conflict or neglect such as a Resident with: a) a history of aggressive behavior. b.) behaviors such as entering other resident's room. ..." "4) A Resident showing signs of the above listed needs will be monitored addressed and their care plan will be up dated accordingly." : Resident #21 is ambulatory and attends meals and activities in the main dining room and chapel. Investigation:"A. upon receiving a report of suspected abuse, neglect or exploitation, the charge nurse and/ or supervisor will immediately examine the Resident. The findings of such "examinations will be recorded in the medical record. B. The Administrator, Director of Nursing, and the facility specific Abuse Representative will be contacted immediately. There is no documentation indicating the staff understood or provided appropriate care and services to prevent the ongoing unwanted sexual advances of Residents #21 and #22 towards the female residents. C. Upon Teceiving information concerning a report of potential abuse, neglect or exploitation, Social Services will monitor the Resident's feelings concerning the incident and the Resident's reaction to his or her involvement in the investigation.” Protection: "A.) The facility will take steps necessary to ensure that the Safety is maintained during an active abuse investigation of abuse, neglect or exploitation investigation with any state agency. B.) The facility will discuss the investigation status with the resident. The resident will have frequent welfare checks by Social Services Department to assure psychological needs are _ being met throughout the investigation. These will’be documented in the Resident's chart." There is no documentation on the female Victims ' charts (#23, #24 and #41) which indicates Social Services saw these residents after the sexual molestation occurred, There is no documentation on Resident #21 Tecord to indicate, between the time period of 4/19/05 and 9/21/05 and up to the present date that Social Service has-been involved with the care planning and assessment of Resident #21. There is no documentation on Resident #23 chart to indicate the Social Worker was involved with the care planning and assessment of this Resident. : 7, Inan interview on 1/25/06 at 3:00 p.m. the Risk Manager stated that no practice issues regarding patient safety in the skilled nursing facility (SNF) have been identified by the SNF Risk Management/Quality Improvement Committee requiring; investigation, policy or procedure changes, and staff education. The Risk Manager stated the only recent issue to go through the Quality Assurance process concerned transferring patients from the hospital to the SNF with the patient's medications. The Risk Manager stated that he does not receive the resident grievance Teports. He stated that the Administrator gives him an oral summary of the grievance reports. The Risk Management or Quality Assurance policies and procedures were unavailable during the survey. In an interview on 1/25/06 at 4:00 p.m. the Administrator stated that he does not have the Policies and Procedures (P&Ps) for Risk Management or Quality Assurance. The. administrator stated that he has’some P&Ps in his computer but not all of the P&Ps. He looked through the files in his computer for the Risk Management and Quality Assurance P&Ps but was unable to locate any. He stated all of the P&Ps used by the previous owners of the facility were kept on the computer hard drive. The administrator stated when the previous owners left in : February 2005 they took the computer hard drive with them. The administrator stated that the ‘previous owners left a computer memory disk with 1500 pages of P&Ps for the new owners; however, administration has not organized and printed the policies from the computer disk. Some P & Ps were provided to the survey team prior to exit. However, there is no indication the governing body has approved these policy and procedures for Quality Assurance and Risk Management. There is no effective date and no date of acceptance. ; 8. An interview was held on 1/26/06 at 11:20 am. with members of the Quality Improvement/Risk Management Committee including: the Administrator, Social Services Director, Risk Manager, Director of Nursing, Long Term Care Unit Manager and the Staff Development Director present. Adverse incident investigation and Teporting was discussed. No documentation was found to show that a sufficient investigation was undertaken to determine the validity of the allegations for a variety of issues including protection from abuse. The committee ‘Inembers acknowledged that there has been a system failure. The DON stated that the system is not working. : , In an interview on 1/26/06 at 9:30 p.m. the Administrator stated he did not consider the behavior of the male resident toward female residents to be abuse.. The Administrator stated that the male resident received psychiatric treatment. The Administrator did state that the female residents who were mistreated did not receive any services. There was no documentation that the Quality Inprovement/Risk Management Committee met during the period from 3/17/05 through 10/18/05. The facility has minutes for committee meetings held on 3/16/05, 10/19/05, 11/16/05, 12/28/05 and 1/18/06. Review of the Quality Improvement Comunittee minutes for 3/1 6/05, .10/ 19/05, 11/16/05, 12/28/05 and 1/18/06 revealed that the committee did not discuss protection of female residents from unwanted touching and sexual advances. The records revealed the Medical Director attended only 2 of the 5 meetings.for which there are minutes: the 3/16/05 and the 11/16/05 meetings. ' 9. Failure to prevent harm to female residents after repeated incidents of unwanted sexual advances, failure to follow policy and procedures to identify and prevent neglect by proper supervision of residents, failure to adequately utilize facility administrative resources and failure to report neglect to State officials has represented a system failure in this facility resulting in an immediate jeopardy situation.; and ongoing failure to recognize, identify and implement care and services to protect frail residents constitutes immediate jeopardy. 12. Section 400.23(8)(a), Florida Statutes (2005) provides: (8) The agency shall adopt rules to provide that, when ‘the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned. deficiency is a deficienc y where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which thé problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of deficiencies as follows: (a) A class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care ina facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for 12 correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency, The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class I deficiencies during the last anual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. . : : 13. As this was a patterned class I deficiency, a fine in the amount of twelve thousand five hundred dollars ($12,500.00) is appropriate, 14. The deficiency also supports conditional licensure status from the survey date of January 26, 2006 as defined in Section 400.23(7)(b), Florida Statutes (2005), which reads as follows: ’ A conditional licensure status means that a facility, due to the presence of one or more class I or class I deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class I, class IL, or class II deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. COUNT THE FACILITY FAILED TO MAINTAIN A QUALITY ASSESSMENT AND ASSURANCE COMMITTEE THAT MET ON A QUARTERLY BASIS AND IDENTIFIED ISSUES AND DEVELOPED PLANS OF CORRECTION FOR DEFICIENCIES WHICH NEGATIVELY AFFECTED THE QUALITY OF CARE AND SERVICES PROVIDED TO A NUMBER OF UNIDENTIFIED FEMALE RESIDENTS, in violation of. Rule 59A-4,123(1), Florida Administration Code (2005) WIDESPREAD CLASS Il DEFICIENCY 15. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein, 16. Rule 59A-4.123(1), Florida Administrative Code (2005) provides: 59A-4.123 Risk Management and Quality Assurance. 13 (1) The facility shall maintain a risk mana gement and quality assurance committee as required in Section 400.147, F.S. : ; 17. This facility failed to meet this rule, asa survey conducted on or about January 26, 2006 showed: Based on record review and staff interview, the facility failed to maintain a quality assessment and assurance committee that meets on a quarterly basis and identifies issues and develops plans of correction for deficiencies which negatively affected the quality of care and services provided to a number of unidentified female residents. Female residents were not protected from touching and other unwanted physical encounters from two male residents occurring over an 11 month period. , ‘ ; The findings include: 1. There was no documentation that thé from 3/17/05 through 10/18/05. The fac quarter and fourth quarter. : Quality Improvement Committee met during the period ility has minutes for only two quarters in 2005; the first 2. A review of nursing notes for Resident #21 revealed that the resident touched female residents inappropriately on at least 14 occasions over an 11 month period. 3. In an interview on 1/24/06 at 3:00 p.m. the Risk Manager stated that no practice issues regarding patient safety in the skilled nursing facility (SNF) have been identified by the SNF Risk Management/Quality Assurance Committee requiring: investigation, policy or procedure changes, and staff education. The Risk Manager stated the only recent issue to go through the Quality Assurance process. concerned transferring patients from the hospital to the SNF with the patient 's medications. : 4. Review of the Quality Improvement Committee minutes for 3/1 6/05, 10/19/05, 11/16/05, 12/28/05 and 1/18/06 revealed that the committee did not discuss protection of femalé residents from unwanted touching and sexual advances by male residents. 5. An interview was held on 1/26/06 at 11:20 a.m. with members of the Quality Improvement/Risk Management Committee including: the Administrator, Social Services Director, Risk Manager, Director of Nursing (DON), Long Term Care Unit Manager and the Staff Development Director present. Adverse incident investigation and reporting was discussed. No documentation was found to show that a sufficient investigation was undertaken - to determine the validity of the allegations for a variety of issues including protection from abuse. The committee members acknowledged there has been a system failure. The DON stated that the system is not working. ; . 18. Section 400.23 (8)(b), Florida Statutes (2005) provides: 14 (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency ’ is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of deficiencies as follows: ° * , (0) A class II deficiency is a deficiency that the agency determines has compromised the _ resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or.class II deficiencies during the last annual inspection or any inspection or complaint investigation since the Jast annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. : : 19. As this was a widespread class II deficiency, a fine in the amount of seven thousand five hundred dollars ($7,5 00.00) is appropriate. 20. The deficiency also supports conditional licensure status from the survey date of January 26, 2006 as defined in Section 400.23(7)(b), Florida Statutes (2005), which reads as follows: ° A conditional licensure status means that a facility, due to the presence of one or more class J or class I deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class I, class TI, -or class TI deficiencies at the time of the follow-up survey, a standard licensure status may be assigned, COUNT I THE FACILITY FAILED TO IMPLEMENT ESTABLISHED POLICY AND ; PROCEDURES TO PROTECT THREE IDENTIFIED FEMALE RESIDENTS AND TWENTY-SIX UNIDENTIFIED FEMALE RESIDENTS WHO HAD WRITTEN DOCUMENTATION OF UNWANTED SEXUAL ADVANCES; THE FACILITY 15 FAILED TO INVESTIGATE INJURIES OF UNKNOWN ORIGIN, AND FAILED TO , INVESTIGATE POTENTIAL ABUSE; FACILITY STAFF WHO HAD KNOWLEDGE OF THE ABOVE RESIDENTS? INCIDENTS FAILED AS MANDATORY REPORTERS TO NOTIFY THE STATE AGENCY OF NEGLECT AND POSSIBLE ABUSE AS OUTLINED IN SECTION 415.1034, FLORIDA STATUTES, - in violation of Section 415.1034, Florida Statutes (2005) WIDESPREAD CLASS I. DEFICIENCY 21. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. | 22. Section 415.1034, Florida Statutes (2005) provides: ‘415.1034 Mandatory reporting of abuse, mandatory reports of death.-- negiect, or exploitation of vulnerable adults; 1) MANDATORY REPORTING.,-- (a) Any person, including, but not limited to, any: 1. Physician, osteopathic physician, medical examiner, emergency medical technician, or hospital personnel en, care, or treatment of vulnerable adults; chiropractic physician, nurse, paramedic gaged in the admission, examination, 2 2. Health professional or mental health professional other than one listed in subparagraph 1.; 3. Practitioner who relies-solely on spiritual means for healing: 4. Nursing home staff: assisted livin g facility staff; adult day care center staff: adult family-care home staff: social worker; or other Pp rofessional adult care, residential, or institutional staff; 5. State, county, or municipal criminal justice employee or law enforcement officer; 6. An employee of the Department of Business and Professional Regulation conducting inspections of public lodging establishments under s. 509.032; 7. Florida advocacy council member or long-term cate ombudsman council tember; or 8. Bank, savings and loan, or credit union officer, trustee, or employee, who knows, or has reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the central abuse hotline. . .(b) To the extent-possible, a report made pursuant to paragraph (a) must contain, but need not be limited to, the following information: . 1. Name, age, race, sex, physical description, and location of each victim alleged to have been abused, neglected, or exploited. , 2. Names, addresses, and telephone numbers of the victim's family members, _3. Name, address, and telephone number of each alleged perpetrator. 4. Name, address, and telephone number of the care giver of the victim, if different from the alleged perpetrator. 5. Name, address, and telephone number of the person reporting the alleged abuse, neglect, or exploitation. 6. Description of the physical or psychological injuries sustained. 7. Actions taken by the reporter, if any, such as notification of the criminal justice agency. 8. Any other information available to the reporting person which may establish the cause of abuse, neglect, or exploitation that occurred or is Occurring. 23. . The statute was violated by the facility as indicated by the survey conducted on or about January 26, 2006: Based on clinical record review, review of facility's investigation of incidents and accidents, grievance log, interview with the facility's Administrator, Director of Nursing (DON), Risk Manager, Abuse Liaison/Staff Development coordinator, Long Term Care Unit Manager, Social Worker, and review of the facility's policy and procedures to prevent neglect, the facility failed to implement established policy and procedures to protect 3 (Resident #23, #24 and #41) identified female residents who had written documentation of unwanted Sexual advances , 26 documented cases of unidentified female residents who were subjected to unwanted sexual advances and numerous incidents of potential harm for unidentified female residents. The facility failed to investigate injuries of unknown origin to Residents #2, #8, #25, #26, #27 * and #28, . The facility failed to investigate potential abuse to Resident #33. All facility staff who had knowledge of the above residents' incidents failed as mandatory reporters to notify the state agency of neglect and possible abuse as outlined in chapter 415.1034 ’ of the Florida Statutes. The findings include: 1. After review of the facility's incident and accident lo g, and evaluation of the residents grievances, the survey team asked the facility for the investigations of incidents affecting Residents #2, #8, #25, #26, #27, #28 and #33. The following information was obtained. Resident #2 had an injury noted to his head on 5/21/05. The investigation read, "Resident noted with AM care to have lump on side of head. Origin unknown. '0' change in mental status." There was no interview with the resident or family. There were no direct care interviews. There was no indication the resident’s clinical record was reviewed. : Resident #8 had a reported incident of finger pain on 9/4/05. The facility investigation read: "Resident with confision,, unable to relate event. -Nurse noted resident with finger pain on 9/4/05..'0' edema or bruising noted. 9/7/05 AM bruising and edema R (right) little finger noted. X-ray done. (positive for fracture) Resident is noted to be resistive to care at times. Tabs monitor used in bed and Broda chair. X-ray notes degenerative changes at wrist. Resident with history of fractures." : The resident resides on the closed Alzheimer unit. There was no indications interviews were conducted with the direct care staff. There was no indication the resident ambulates on her own nor is there indication the resident has a history of falls. Resident #25 had an injury reported bya CNA on 11/15/05. The investigation read, "Resident with confusion, unable to relate event, ambulates ad lib, combative and Tesistive to c bruise/edema noted on left ting finger, cause unanswered," There was no interview with the residents family. There were no direct care interviews. There was no indication the resident’s clinical record was reviewed. are at times. Resident #26 had a bruise noted to her shoulder on 6/14/05. The investigation read, "Resident with cognitive loss unable to relate event. Bruise of unknown origin on back of right shoulder, Dr. -- and family notified." ; . There were no direct care interviews. There was no in reviewed. dication the resident's clinical record was Resident #27 had a bruise to the shin on 5/4/05. The investigation read, impaired. Unable to communicate how bruise occurred. Bruise on left 1 edema, skin intact, '0' s/s of pain.” There was no interview with residents family. There were no direct care interviews. There was no indication the resident’s clinical record was reviewed. "Resident cognitively ower shin red. ‘0! Resident #28 had a bruise to the left arm on 3/23/05.:The investigation read, "Spoke with resident who is unable to recall origin of bruise. Bruise is dark purple - approximately soft ball sized. Site is non tender w/o edema. Full rom (range of motion) LUE (left upper extremity)." 18: There was no interview with the resident’s family. There were no direct care interviews. There ‘was no indication the resident’s clinical record was reviewed. - : Review of the grievance records indicates a grievance was filed by Resident #33 on 7/6/05. The grievance read, "Resident complained that a male CNA was too Tough with her when receiving personal care, (res. has new sore wrist which is bruised)." ; The investigation included an interview with the resident and the male CNA, It concludes the CNA did not recall any incident where the resident may have struck her wrist, Interview with the Quality assurance team on 1/26/05 at 11:20 am., which included the nurse who did this investigation and the Risk Manager, revealed the Risk Manager did not receive this grievance and no investigation into possible abuse was started, : 2. After farther review of the facility's accid investigation into two accounts of sexual in (Resident #23 and #24). ent and incident lo g, the survey team requested the appropriate behavior towards two female residents Review of the investigation irito the incident involving Resident #24 revealed the following: "6/26/05 - The resident found with male resident in bed with her. Dress was pulled up and brief intact. Resident with '0' apparent injury. Male was redirected. A stop sign was placed on the [door] of (resident's) room.” ; Other than redirecting Resident #22, the facility did not implement any actions to prevent further occurrences of potential sexual molestation to females on the unit. Clinical record review of Resident #22 chart revealed the following: 6/25/05 4:30 p.m. - "(Resident #22) has been found in room -- in bed with female resident whose room it is X 3 this shift. Remove each time. Last time he was noted to be holding her down in bed on top of her and rubbing her body with his Stating 'Isorry', Separated and (resident) told to not to go into room anymore. ...Will continue to monitor for any further problems." 6/26/05 12 noon- "(Resident) has made 3 attempts to get in room - Redirect fre (frequently) by staff. At 7:17 AM made in (into) room resident in room. Removed by staff. Cont (continue) redirect." - (same.room as before). - Noted to be kissing female 2. Review of the investigation into the incident involving Resident #23 revealed the following: 7/14/05 - "Residents family reported to charge nurse that the resident told them a --- male (Resident #21) carne into her room and had his hand down her blouse. Resident is alert with | sical injury noted. Offending resident with history of sexually inappropriate behavior. Psych consult ordered. Will continue to monitor." Further review of the incident accident lo following regarding Resident #21: 5/4/05 - “Resident cognitively impaired with history on medication to decrease this behavior. Dr. --- noti supervised when out of room." g and review of subsequent investigations revealed the of sexual inappropriate behavior. Currently fied. Psych consult ordered. Resident 19 7/13/05 - "Resident was observed by charge nurse to have hand down resident’ breast. Resident was redirected to room and Dr. --- and Dr. ---- notified." There was no identification of the female victim. s blouse holding 7/19/05 - statement only - "Resident observed." Resident's #21 clinical record was reviewed. The following was noted: The resident has been in the facility since 10/9/02: with diagnosis including but not limited to dementia, bipolar disorder and depression. : 5/4/05 nurses notes 1:45 p.m. "Noted to have L (left) hand down female Resident blouse squeezing her breast. Resident separated and will monitor for any further behavior problems." There was no identification of the female victim. 7/13/05 nurses note 10:00 am. "Noted to have L (left) hand down holding R (right) breast in hand and kissing her mouth." Female victim not identified. Corresponds with Incident report of this date, female resident's blouse 7/13/05 nurses notes 11:45 a.m. "Staff reports that (Resident #21) sexual behavior is getting worse. Noted to be putting hand down females’ pants all of the time." The number and identity of the female victims were not identified. female breasts." Femiale victims not identified 7/14/05 nurses note 2:00 p.m. "Continues with sexual behavior toward female Residents X 3, 7/15/05 fax to physician. "Noted:to have hand down female resident blouse holding R breast in hand and kissing her mouth." Female victim not identified, 7/19/05 nurses note 3:15 p.m. "After I arrived 2 CNA's reported to me that Res. (resident) was caught feeling 2 female residents in their private areas below the waist." Female victims not identified. A psychiatric consult. was ordered, : 8/3/05 Spiritual Assessment Sheet noted: "This gentleman was attending the musical on Francis Lane. One of the lady residents was sitting on the arm of his wheelchair and he was touching her inappropriately. I reported same to staff.” 8/13/05 nurses note 3 - 11 shift. "CNA notified me hands down female resident 's shirt." Female victim not identified. of inappropriate behavior, resident putting 8/14/05 nurses notes 8:00 p.m. "In day room CNA witnessed resident putting hands down female slacks. ... Removed resident to opposite side room." 20 "Female victim not identified. 8/15/05 nurses note 10:00 p.m. "Resident attempted to ‘put hand inside of a female resident's underware (sic). CNA told resident not to act this way aud the male resident replied, 'I can do whatever I want' 1 to 1 with male resident with some effect. Resident attempted to put his hand inside of the female resident underwear in the Francis Lane Hall while he was going to Francis | Lane DR (dining room) for supper." ” The female victim was not identified 8/24/05 nurses note 2:30 a.m. "Called to room -- by CNA. Noted in bed -- (male resident #21) and female Resident lying in bed. (Resident #21) had his hand down her pants. When saw staff - he pulled his hand out. Female taken from room." . Female victim not identified. _ 9/3/05 nurses notes 2:00 p.m. "(Resident #21) pushed a female resident into room. First inappropriate behavior noted. Cautioned not to touch the females and not to move them in their wics (wheelchairs)." 9/6/05 nurses notes 10:00 a.m. "Reported to me that (resident #21) inappropriately touched a female while sitting next to her in Rosary in ‘Chapel Yesterday. ..."_ 9/15/05 nurses note 2:30 p.m. "CNA reported pt (patient) (resident #41- female resident) on fir (floor) at bedside of (Resident #21). CNA reported (Resident #21) hand noted up shirt of (Resident #41). No harm/injury noted. ..." ; No incident report recorded, 9/15/05 nurses note 7:00 p.m. "...Reinforced to Res. (Resident) of improper touching. Res. verbally states he understands. ..." . 9/19/05 Weekly Summary note. "Needs frequent supervision as goes into other resident's rooms, esp (especially) female residents." 9/30/05 nurses note 4:00 a.m. " ip frequently during noc walking into other residents’ room and was directed back to’ own room." : 10/4/05 nurses notes 12:00 a.m. "Resident up in hallway, confused. Redirected back to his bed then returned un-noticed and entered a female resident's room attempting to lay down in such resident's bed in room -- who managed to vernally (sic) chase him away." ; Female victim not identified. 10/17/05 Weekly summary report. "Continues to wander. Will try to go into female rooms resident by self." : mo , : 10/24/05 nurses note 7:00 p.m. was reminded not to touch: ....” "Report received of Resident approaching female Residents, he Female victims not identified. 21 10/24/05 weekly summary. "Continues to wander into female rooms, has to be reminded they are not here for him and his special needs." 10/25/05 nurses note 10:00 p.m. "Noted several times to have hands on female residents, remind that he was not to touch them. ..." 1:1 CNA monitoring. 10/26/05 nurses note 9:45 a.m. "(Resident #21) was in Francis dayroom when staff observed him with his hand down shirt of female Resident blouse, also had other hand down her pants, Residents separated. (Resident #21) reminded that he was not to treat female residents that way - and sent to his room. ..." ; ~ 10/27/05 nurses note 2:00 p.m. "Sexual behavior has gotten worse. Was noted to touching every female in his immediate surrounding, supervisor notified.” Female victims not identified. . 10/27/05 nurses note 3:30 p.m. "Resident (cont) continues to be inappropriate with behavior X 10, has been 1:1 with nurse," 10/27/05 nurses note 9:30 PM. "Resident has been quiet and calm 6:00 P until, out of alarm or tured off per self pt slipped down hall to a lady's room and was trying to fondle her." Placed on 1:1 with CNA. Female victim not identified. - 10/28/05 nurses note 2:00 p.m. (Resident #21) has been observed X 4 attempting to grab female residents, has also been seen X 2 with hand down female residents’ blouses. ...(Resident #21) will also stand in doorway of his room trying to get female residents to come in, ... grabs at them when they pass by." . Female victims not identified. 10/28/05 nurses note 3:40 p.m. "Resident cont to grab, fondle et rub women sexually." 1:1 with staff. Haldol given. ; Female victims not identified. 10/28/05 nurses note 8:40 p.m. "Resident cont to be restless et using inappropriate sexual advances to ladies." Repeat Haldol given. : 10/29/05 nurses notes 11:30 a.m. “Constantly trying to get to female residents has been seen getting two female residents into his room. When in dayroom, will grab at female residents. When sent to his room will come out and when staff busy, will try to get to females in hallways." Haldol given. ; Nurse Manager made aware. 11/29/05 nurses note, not timed. "During waking hours resident will be provided 1:1 supervision by staff." 11/29/05 nurses note 3:00 Ativan given. Female victim not identified, p.m. "Found in dayroom with hand down female resident blouse." 10/29/05 nurses note 9:00 p.m. "Sitter out ofroom momentarily. I observed from desk. Resident came out of room attempted to go into female residents room next to his, but was | stopped before he could get through the door." . Ativan given. 10/30/05 nurses note 7:30 p.m. "Reported by 6:30 AM CNA that (Resident #21) was seen. petting new female resident while she was in wheelchair touching breast and trying to kiss her. . Separated and he was sent to room, Also I observe when I was on duty at 7 AM he was trying to go.into room --, redirected." : . Female victim not identified, 11/1/05 nurses noted 9:40 p.m. shift, rerouted to room." Female victim not identified, "(Resident) attempted to fondle one person at begriming (sic) The last note indicating problems with behavior is dated 12/01/05 at 11:00 p.m. and read: "Resident has made no sexual advances or inappropriate sexual behavior in past three days." There were no prior notes indicating what behavior may have been observed from 11/23/05 until 12/1/05, . . ‘The MDS (Minimum Data Set) dated 10/21/05 stated that the reside Severely impaired - never/rarely made decisions. Area E.4 Behavioral symptoms a. Wandering, c. Socially inappropriate/disruptive behavioral symptoms, (made disruptive sounds, noisiness, screaming, self abusive acts, sexual behavior or disrobing in public, smeared/threw food/feces, hoarding, rummaged through others belongings).and e. Resident scored as 1/1. Behavior of this type occurred 1 to 3 days in last 7 days. - : nit has cognition of "3", The most recent MDS was a quarterly review dated mt 8/06 and indicates Area E. 4 d. Socially inappropriate/disruptive behavioral symptoms, remains the same. This indicated.these behaviors have occurred 1 to 3 days in the last 7 days. The nurse's notes did not reflect what behaviors have taken place. Review of Resident #21 care plan revealed the following: 7/26/05 and updated 10/13/05, "Problem - Behavioral symptoms. Physically Abusive: (others were hit, shoved, scratched, and sexually abused: Goal - Resident will demonstrate improved behavior as evidenced by no more than 3 episodes of sexually inappropriate behavior through next review date.” There was a note indicating this goal was rewritten on 1/24/06, during survey. Care Plan dated 1/24/06 - Behavioral symptoms related to diagnosis of psychosis, dementia, agitation, anxiety, Organic Brain syndrome and CVA.. This was evidenced by: 23 Wandering with no rational purpose seemingly oblivious to needs or safety. . Verbally abusive behavior: (others were threatened, screamed at, cursed at). Physically abusive: (others were hit, shoved; scratched, sexually abused. Socially inappropriate/disruptive behavior: (made disruptive noises, noisiness, screaming, self- abusive acts, sexual behavior of disrobing in pubic, smeared/threw food/feces, hoarding, ‘ Tummaged through others belongings. ; ; Resists Care: (resident taking medications/injections, ADL assistance or eating). Goal: Resident will demonstrate improved behavior as evidenced by no more than 3 episodes of sexually inappropriate behavior through NRD (next review date). Interventions were medication based and monito: ring for signs and symptoms of change in behavior. The facility has a policy entitled - Behavior Management and Aggression Control -. The policy reads in part: "Purpose: To educate the nursing staff in order that they will become effective in ’ working with a resident manifesting aggressive behavior. sO Procedure: 1. Ifa resident ina nursing home demonstrates a: for violence exits staff are to: a.) Assist the resident to a quiet area of the facility, a place that is free from all stimuli, and away from other residents. .." j.) Provide for the safety of all other facility residents. L.) Notify Social Services for therapeutic intervention." ggressive behavior and a potential There was no documentation of staff protecting any of the female victims. There was no documentation that family members or guardians of the female victims were notified after each incident. , The facility's policy and procedures for the Prevention of Abuse/Neglect read: "Neglect: the failure or omission on the part of the caregiver of the person or disabled adult to provide the care and services necessary to maintain the physical and mental health of an aged person or disabled adult including but not limited to, food, clothing, medicine, shelter, supervision and medical services, that a prudent person would deem essential for the well-being of an aged person or disabled adult.. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or mental harm or a substantial risk of death. Abuse representative: ."The highest ranking nursing official currently in the building." Reporting: A.) Reporting is mandatory. Florida law requires that every citizen who knows or has cause to suspect that a resident is abused, neglected or exploited can immediately ...report | such suspicion to the Florida Abuse Hotline. Reporting the incident to the employee's supervisor is sufficient, provided the supervisor takes the appropriate steps... : B.)’ The facility will ensure that all alleged violations involving known or suspected abuse (physical, sexual or emotional/psychological), neglect or exploitation will be’ reported immediately to the employee ' S supervisor, facility specific abuse representatives, Director of Nursing and Administrator. ..." : The facility's Policy and procedures related to preparation of an “Event Report" read, " The Event Report should be completed when an unusual or abnormal patient care,... An Event is a potentially harmful event or occurrence which is not an intended result of care and treatment being rendered, and which could result in potential loss to Patient, " "Events which require immediate notification of Risk Management and/or the Administrator on call are: ... Physical crime against a patient, ....such as assault, battery, rape, sexual molestation." ".... A call must be placed to the Director of Risk Management. to include death, Fracture, ...Allegation of Sexual Misconduct." "Training: All employees will receivé orientation and annual education regarding identifying -and reporting abuse in accordance with federal and state law. ...A. Appropriate interventions to deal with aggressive and/or catastrophic reactions of Residents. ...D. What constitutes abuse, neglect and misappropriation of Resident property." . "Prevention: ...D. Situations in which abuse, neglect, and/or misappropriation of Resident © property are more likely to occur will be identified and included in all educational efforts. Such areas as: 1. Physical environment such as secluded area. 3. Residents with needs and behaviors which may lead to conflict or neglect such as a Resident with: a) a history of aggressive behavior. b.) behaviors such as entering other resident's room. ..." "4) A Resident showing signs of the above listed needs will be monitored addressed and their care plan will be up dated accordingly." Resident #21-is ambulatory and attends meals and activities in the main dining room and chapel. Investigation: "A. upon receiving a report of suspected abuse, neglect or exploitation, the charge nurse and/ or supervisor will immediately examine the Resident, The findings of such examinations will be recorded in the medical record. B. The Administrator, Director of Nursing, and the facility specific Abuse Representative will be contacted immediately." There was no documentation indicating the staff appreciated the sexual behavior of Residents #21aand #22 as repeated neglect towards the female residents. "C. Upon receiving information concerning a report of potential abuse, neglect or exploitation, Social Services will monitor the Resident's feelings concerning the incident and the Resident's reaction to his or her involvement in the investigation." Protection: "A.) The facility will take steps necessary to ensure that the Safety is maintained during an active abuse investigation of abuse, neglect or exploitation investigation with any state agency. ; B.) The facility will discuss the investigation status with the resident. The resident will have frequent welfare checks by Social Services Department to assure psychological needs are being met throughout the investigation. These will be documented in the Resident's chart." 25° There was no documentation on the female victims’ charts (Resident #23, #24 and #41) which indicates Social Services saw these residents after the sexual molestation occurred. There was no documentatiori on Resident #21’s record to indicate, between the time period of 4/19/05 and 9/21/05 and up to the present date that Social Service has been involved with the care planning and assessment of Resident #21. . There-was no documentation on Resident #23’s chart to indicate the Social Worker was involved . with the care planning and assessment of this Resident, In an interview on 1/25/06 at 3:00 p.m. the Risk Manager stated that no practice issues regarding patient safety in the skilled nursing facility (SNF) have been identified by the SNF Risk Management/Quality Improveinent Committee requiring; investigation, policy or procedure changes, and staff education. The Risk Manager stated the only recent issue to go through the Quality Assurance process concerned transferring patients from the hospital to the SNF with the patient's medications. The Risk Manager stated that he does not receive the resident grievance reports, He stated that the Administrator gives him an oral summary of the grievance reports. Interview with the Risk Manager on.1/26/06 at 11:20 a.m. revealed he did not receive the grievance for Resident #33 and was not aware of the bruising to the resident’s wrist. The Risk Management or Quality Assurance policies and procedures were not provided to the surveyor. In an interview on 1/25/06 at 4:00 p.m. the Administrator stated that he does not have the Policies and Procedures (P&Ps) for Risk Management or Quality Assurance. The ; administrator stated that he has some P&Ps in his computer but not all of the P&Ps. Helooked . through the files in his computer for the Risk Management and Quality Assurance P&Ps but was unable to locate any. He stated all of the P&Ps used by the previous owners of the facility were kept on the computer hard drive. The administrator stated when the previous owners left in February 2005 they took the computer hard drive with them. The administrator stated that the previous owners left a compuier memory disk with 1500 pages of P&Ps for the new owners; however, administration has not organized and printed the policies from the computer disk. Some P & Ps were provided to the survey team prior to exit. However, there was no indication ' the governing body has approved these policy and procedures for Quality Assurance and Risk _ Management. There was no effective date and no date of acceptance. An interview was held on 1/26/06 at 11:20 a.m. with members of the Quality Improvement/Risk Management Committee including: the Administrator, Social Services Director, Risk Manager, Director of Nursing, Long Term Care Unit Manager and the Staff Development Director present. Adverse incident investigation and reporting was discussed. No documentation was found to show that'a sufficient investigation was undertaken to determine the validity of the allegations for a variety of issues including protection from abuse. The committee members acknowledged that there has been a system failure. The DON stated that the system 1s not working. In an interview on 1/26/06 at 9:30 p.m., the Administrator stated he did not consider the behavior of the male resident toward female residents to be abuse. The Administrator stated that the male 26 resident received psychiatric treatment. The Administrator.stated that the female residents who were mistreated did not receive any services. : “There was no documentation that the Quality Improvement/Risk Management Committee met during the period from 3/17/05 through 10/18/05. The facility has minutes for committee meetings held on 3/16/05, 10/19/05, 11/16/05, 12/28/05 and 1/18/06. Review of the Quality Improvement Committee minutes for 3/ 16/05, 10/19/05, 11/16/05, , 12/28/05 and 1/18/06 revealed that the committee did not discuss protection of female residents from unwanted touching and sexual advances. The records revealed the Medical Director attended only 2 of the 5 meetings for which there were minutes: the 3/16/05 and the 11/16/05 meetings. ; Failure to prevent harm to female residents after repeated incidents of unwanted sexual advances, failure to fully investigate injuries of unknown origin, failure to include the Risk Manager in resident grievance evaluations, failure to follow policy and procedures to identify and prevent neglect, failure to adequately utilize facility administrative resources and failure to report neglect to State officials has represented a system failure in this facility resulting in substandard care. 24. Section 400.23(8)(b), Florida Statutes (2005) provides: (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the - deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or avery’ . limited number of staff, or.a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by - repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which _ the problems causing the deficiency are pervasive in the facility or represent systemic failure that _ has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of deficiencies as follows: (b) A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and ° psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. : 27 25. As this was a widespread class II deficiency, a fine in the amount of seven thousand five hundred dollars ($7,500.00) is appropriate. 26. The deficiency also supports conditional licensure status from the survey date of January 26, 2006 as defined in Section 400.23(7)(b), Florida Statutes (2005), which teads as follows: A conditional licensure status means that a facility, due to the presence of one or more class [ or class II deficiencies, or class Il deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class I, class Il, or class II deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. ‘COUNT IV THE FACILITY ADMINISTRATION FAILED TO ESTABLISH A QUALITY ASSURANCE PROGRAM THAT EFFECTVELY REVIEWS RESIDENT GRIEVANCES . AND RESPONDS QUICKLY TO DEFICIENCIES, in violation of Section 400.147(1), Florida Statutes (2005) . WIDESPREAD CLASS II DEFICIENCY 27. AHCA te-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. . ; 28. Section 400.147(1), Florida Statutes (2005) reads: 400.147 Internal risk management-and quality assurance program.-- (1) Every facility shall, as part of its administrative functions, establish an internal tisk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: 28 (a) A designated person to serve as risk manager, who is responsible.for implementation and oversight of the facility's risk management and quality assurance program as required by this section. : : ; (b): A tisk managemént and quality assurance committee consisting of the facility risk manager, the administrator, the director of nursing, the medical director, and at least three other members of the facility staff. The risk management and quality assurance committee shall meet at least ° monthly. (c) Policies and procedures to implement the internal risk management and quality assurance program, which must include the investigation and analysis of the frequency and causes of general categories and specific types of adverse incidents to tesidents. (d) The development and implementation of an incident reporting system based upon the . affirmative duty of all health care providers and all agents and employees. of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. (e) The development of appropriate measures to minimize the risk of adverse incidents to residents, including, but not limited to, education and training in risk management and tisk prevention for all nonphysician personnel, as follows: 1. Such education and training of all nonphysician personnel must be part of their initial orientation; and ; ; 2. At least 1 hour of such education and training must be provided annually for all nonphysician personnel of the licensed facility working in clinical areas and providing resident care, (f) The analysis of resident grievances that relate to resident care and the quality of clinical services. ‘ 29. This statute was violated as evidenced by the survey of January 26, 2006.. That. showed: Based on record reviews and staff interviews the facility administration failed to establish a quality assurance program that effectively reviews resident grievances and respond quickly to deficiencies. The findings include: #22 revealed that 14 or more female residents were touched in a sexual manner by a male resident. The encounters perpetrated by Resident #21 occurred repeatedly over the past 11 months. Records revealed that Resident #22 had three encounters in one day. There were 1. Review of adverse incident reports, grievance reports and nursing notes for Residents #21 and 29 grievance reports that lacked documentation of sufficient investigation to determine if an adverse incident report should have béen initiated. : : 2. Tn an interview on 1/24/06 at 3:00 p.m. the Risk Manager stated that no practice issues regarding patient safety in the skilled nursing facility (SNF) have been identified by the SNF Risk Management/Quality Improvement Committee requiring; investigation, policy or procedure changes, and staff education. The Risk Manager stated the only recent issue to go through the Quality Assurarice process concerned transferring patients from the hospital to the SNF with the patient's medications. The Risk Manager stated that he does not receive the resident grievance reports. He stated that the Administrator gives him an oral summary of the grievance reports. 3. In an interview on 1/24/06 at 4:00 p.m. the Administrator stated he does not have the Policies and Procedures (P&Ps) for Risk Management or Quality Assurance. - 4. Review of the Quality Improvement Committee minutes for 3/ 16/05, 10/19/05, 11/16/05, 12/28/05 and 1/18/06 revealed that the committee did not discuss protection of female residents from unwantéd touching and sexual advances, 5. An interview was held on 1/26/06 at.11:20 a.m. with members of the Quality Improvement/Risk Management Committee including: the Administrator, Social Services Director, Risk Manager, Director of Nursing, Long Term Care Unit Manager and the Staff. Development Director present. Adverse incident investigation and reporting was discussed. No documentation was found to show-that a sufficient investigation of grievance reports was undertaken to determine the validity of the allegations for a verity of issues including protection from abuse. The committee members acknowledged that there has been a system failure. The DON stated that the system is not working. : 30. Section 400.23(8)(b), Florida Statutes (2005) provides: (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the. scope of the of locations. A pattemed deficiency is a deficienc ’ residents are affected, or more than a very limited number of staff are involved, or the situation has occurréd in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency Shall indicate the classification-on the face of the notice of deficiencies as follows: (b) A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and - psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for 30 an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one _ or more-class I or class II deficiencies during the last annual inspection or any inspection or -complaint investigation since the last annual inspection. A fie shall be levied notwithstanding the correction of the deficiency. . 31. As this was a widespread class II deficiency, a fine in the amount of seven thousand five hundred dollars ($7,500.00) is appropriate. 32. The deficiency also supports conditional licensure status from the survey date of J anuary 26, 2006 as defined in Section 400.23(7)(b), Florida Statutes (2005), which reads as follows: . A-conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class II deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class I, class I, or class II deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. COUNT V THE FACILITY ADMINISTRATION FAILED TO ENSURE ALL STAFF WERE KNOWLEDGEABLE OF WHAT IS REPORTABLE AS A NEGLECT OR POSSSIBLE ABUSE SITUATION AND THEREFORE DID NOT INITIATE AN ADVERSE INCIDENT INVESTIGATION FOR NEGLECT OR POSSIBLE SEXUAL ABUSE ON TWENTY-SIX UNIDENTIFIED FEMALES WHO HAD UNWANTED SEXUAL ; ADVANCES, ° - in violation of Section 400.147(1)(d), Florida Statutes (2005) WIDESPREAD CLASS I! DEFICIENCY 33. AHCA re-alleges and incorporates by reference patagraphs one (1) through eight (8) above as if fully set forth herein. 34. Section 400.147(1)(d), Florida Statutes (2005) reads: 400.147 Internal risk management and quality assurance program.-- 31 (1) Every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: (d) The development and implementation of an incident reporting system based upon the ~ affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. : 35. This statute was violated as evidenced by the survey of January 26, 2006. That showed: ‘Based on clinical record review, review of facility's investigation of incidents and accidents, grievance log, interview with the facility's Administrator, Director of Nursing (DON), Risk Manager, Abuse Liaison/Staff Development coordinator, Long Term Care Unit Manager, Social Worker, and review of the facility's policy and procedures regardin g submission of adverse incidents to the facility Risk Manager the facility failed to ensure all staff was knowledgeable of what is reportable as a neglect or possible abuse situation and therefore did not initiate an adverse incident investigation, : Residents #23, #24 and #41 had documentation of unwanted sexual advances and adverse ° incidents were not initiated to rule out neglect and or abuse. The facility did no initiate an adverse incident investigation on 26 unidentified females, who had unwanted sexual advances, for neglect by the facility or‘possible sexual abuse. Failure to initiate adverse incident investigations into possible abuse ot neglect has harmed residents and has the potential to effect all residents in this facility. The findings include: 1. After review of the facility's accident and incident log, the survey team requested the investigation into two accounts of sexual inappropriate behavior towards two female residents (Resident #23 and #24), : Review of the investigation into the incident involvin: g Resident #24 revealed the following: "6/26/05 - The resident found with male resident in bed with her. Dress was pulled up and brief intact. Resident with '0' apparent injury. Male was redirected, A stop sign was placed on the [door] of (resident's) room." Other than redirecting Resident #22, the facility did not implement any actions to prevent further: occurrences of potential sexual molestation to females on the-unit, ; 32 This was not submitted by the Risk Manager as a I day Adverse Incident Reort. Clinical record review of Resident #22 chart revealed the following: ; 6/25/05 4:30 p.m. "(Resident #22) has been found in room -- in bed with female resident whose room it is X 3 this shift. Remove each time. Last time he was noted to be holding her down in bed on top of her and rubbing her body with his stating ‘I sorry’. Separated and (resident) told to not to go into room anymore. ...Will continue to monitor for any further problems." 6/26/05 12 noon - "(Resident) has made 3 attempts to get in room —- (same room as before). Redirect fre (frequently) by staff. At 7:17 AM made in (into) room. Noted to be kissing female ‘resident inroom. Removed by staff. Cont (continue) redirect." . : 2. Review of the investigation into the incident involving Resident #23 revealed the following: 7/14/05 - “Residents family reported to charge nurse that the resident told them a --- male (Resident #21) came into her room and had his hand down her blouse. Resident is alert with some confusion, able to relate, event. No Physical injury noted. Offending resident with histo of sexually inappropriate behavior. Psych consult ordered, Will continue to monitor." | This was not submitted by the Risk Manager as a 1. day Adverse Incident Reort. Ty Further review of the incident accident log and review of subsequent investigations revealed the following regarding Resident #21: ; 5/4/05 - "Resident cognitively impaired with history of sexual inappropriate behavior. Currently on medication to decrease this behavior. Dr. --- notified. Psych consult ordered. Resident supervised when out of room." 7/13/05 - "Resident was observed by charge nurse to have hand down resident's blouse holding» breast. Resident was redirected to room and Dr. --- and Dr. ---- notified." ; : There was no identification of the female victim, : 7/19/05 - statement only - "Resident observed." . Resident's #21 clinical record was reviewed. The following was noted: . The resident has been in the facility since 10/9/02 with diagnosis including but not limited to ; dementia, bipolar disorder and depression. 5/4/05 nurses notes 1:45 p,m. "Noted to have L (left) hand down female Resident blouse squeezing her breast. Resident separated and will monitor for any further behavior problems." There was no identification of the female victim. 7/13/05 nurses note 10:00 a.m. "Noted to have'L (left) hand down female resident's blouse holding R (tight) breast in hand and kissing her mouth," Female victim not identified. Corresponds with Incident report of this date. 7/13/05 nurses notes 11:45 a.m. "Staff reports that (Resident #21) sexual behavior is getting worse. Noted to be putting hand down females pants all of the time." 33 These number and identity of the female victims were not identified. 7/14/05 nurses note 2:00 p.m. "Continues with sexual behavior toward female Residents X 3, female breasts." Female victims not identified. 7/15/05 fax to physician. "Noted to have hand down female resident blouse holding R breast in hand and kissing her mouth." Female victim not identified. 7/19/05 nurses note 3:15 p.m. "After I arrived 2 CNA's reported to me that Res. (resident) was caught feeling 2 female residents in their private areas below the waist." Female victims not identified. A psychiatric consult was ordered. 8/3/05 Spiritual Assessment Sheet note. "This gentleman was attending the musical on Francis Lane. One of the lady residents was sitting on the arm of his wheelchair and he was touching her inappropriately. I reported same to staff." 8/13/05 nurses note 3 - 11 shift, "CNA notified me of inappropriate behavior, resident putting hands down female resident's shirt." - Female victim not identified. 8/ 14/085 nurses notes 8:00 p.m. "In day room CNA witnessed resident patting hands down female slacks. ... Removed resident to opposite side room." Female victim not identified. 8/15/05 nurses note 10:00 p.m. "Resident attempted to put hand inside of a female resident's underware (sic). CNA told resident not to act this way and the male resident replied, 'I can do whatever I want’ 1 to 1 with male resident with some effect. Resident attempted to put his hand inside of the female resident underware (sic) in the Francis Lane Hall while he was going to Francis Lane DR (dining room) for supper." The female victim was not identified 8/24/05 nurses note 2:30 a.m. "Called to room -- by CNA. Noted in bed -- (male resident #21) and female Resident lying in bed. (Resident #21) had his hand down her pants. When saw staff he pulled his hand out. Female taken from room." Female victim not identified. 9/3/05 nurses notes 2:00 p.m. "(Resident #2 1) pushed a female resident into room. First inappropriate behavior noted. Cautioned not to touch the females and not to move them in their wi/cs (wheelchairs)." 9/6/05 nurses notes 10:00 a.m. "Reported to me that (resident #21) inappropriately touched a _ female while sitting next to her in Rosary in Chapel Yesterday. ..." 34 9/15/05 nurses note 2:30 p.m. “CNA reported pt (patient) (resident #41- female resident) on flr (floor) at bedside of (Resident #21). CNA reported (Resident #21) hand noted up shirt of (Resident #41). No harm/injury noted. ..." ; No incident report recorded. 9/15/05 nurses note 7:00 p.m. "...Reinforced to-Res. (Resident) of improper touching. Res. verbally states he understands. ..." : 9/19/05 Weekly Summary note. "Needs frequent supervision as goes into other resident's rooms, esp (especially) female residents." 9/30/05 nurses note 4:00'a.m. "Up frequently during noc walking into other residents ' room and was directed back to own room." 10/4/05 nurses notes 12:00 AM. "Resident up in hallway, confused. Redirected back to his bed then returned un-noticed and entered a female resident's room attempting resident's bed in room -- who managed to vernally (sic) chase him away." Female victim not identified. : to lay down in such 10/17/05 Weekly summary report. “Continues to wander. Will try to go into female rooms resident by self.” ; 7 : 10/24/05 nurses note 7:00 p.m. “Report received of Resident approaching female Residents, he was reminded not to touch. ...." : Female victims not identified. 10/24/05 weekly summary. "Continues to wander into female rooms, has to-be reminded they _ are not here for him and his special needs." 10/25/05 nurses note 10:00 p.m. "Noted several times to have hands on female residents, remind that he was not to touch them. ..." 1:1 CNA monitoring. 10/26/05 nurses note 9:45 am. "(Resident #21) was in Francis dayroom when staff observe him with his hand down shirt of female Resident blouse, also had other hand down her pants. Residents separated. (Resident #21) reminded that he was not to treat female reside nis that way and sent to his room. ...” 10/27/05 nurses note 2:00 p.m. "Sexual behavior has gotten worse. Was noted female in [h]is immediate surrounding, supervisor notified." Female victims not identified. to touching every 10/27/05 nurses note 3:30 p.m. "Resident (cont) continues to be inappropriate with behavior X 10, has been 1:1 with nurse." 10/27/05 nurses note 9:30 p.m. "Resident has been quiet and calm 6:00 P until out of alarm or turned off per self pt slipped down hall to a lady's room and was trying to fondle her." - Placed on 1:1 with CNA. Female victim not identified. _ 10/28/05 nurses note 2:00 p.m. "(Resident #21) has been observed X 4 attempting to grab female residents, has also been seen X 2 with hand down female residents blouses. ...(Resident #21) will also stand in doorway of his room trying to get female residents to come in, ... grabs at them when they pass by." Female victims not identified, 10/28/05 nurses note 3:40 p.m. "Resident cont to grab, fondle et rnb women sexually." 1:1 with staff. Haldol given. ; Female victims not identified, 10/28/05 nurses note 8:40 p.m. "Resident cont to be restless et using inappropriate sexual advances to ladies." Repeat Haldol given. 10/29/05 nurses notes 11:30 a.m. getting two female residents into When sent to his room will come Haldol given, Nurse Manager made aware. “Constantly trying to get to female residents has been seen his room. When in dayroom, will grab at female residents. out and when staff busy, will try to get to females in hallways." 11/29/05 nurses note, not timed. "During waking hours resident will be provided 1:1 supervision by staff." . 11/29/05 nurses note 3:00 p.m. Ativan given. Female victim not identified, “Found in dayroom with hand down female resident blouse." 10/29/05 nurses note 9:00 PM. "Sitter out of Toom momentarily. I observed from desk, Resident came out of room attempted to go into female residents room next to his, but was . stopped before he could get through the door." Ativan given.. 10/30/05 nurses note 7:30 p.m. "Reported by 6:30 AM CNA that (Resident #21) was seen petting new female resident while she was in wheelchair touching breast and trying to kiss her, Separated and he was sent to room, Also I observe when I was on duty at 7 AM he was trying to go into room --, redirected." Female victim not identified, 11/1/05 nurses noted 9:40 p.m. "(Resident) attempted to fondle one person at begriming (sic) shift, rerouted to room." ° . . : Female victim not identified. The last note indicating problems with behavior is dated 12/01/05 at 11:00 p.m. and read: “Resident has made no sexual advances or inappropriate sexual behavior in past three days." 36 There were no prior notes indicating what behavior may have been observed from 11/23/05 until 12/1/05, The MDS (Minimum Data Set) dated 10/21/05 stated that the resident has cognition of "3 ", Severely impaired - never/rarely made decisions. . . Area E.4 Behavioral symptoms a. Wandering, c. Socially inappropriate/disruptive behavioral symptoms, (made disruptive sounds, noisiness, screaming, self abusive acts, sexual behavior or disrobing in public, smeared/threw food/feces, hoarding, rummaged through others : belongings).and ¢. Resident scored as 1/1. Behavior of this type occurred 1 to 3 days in last 7 days. , : The most recent MDS was a quarterly review dated 1/18/06 and indicates Area E.4 d. Socially inappropriate/disruptive behavioral symptoms, remains the same. This indicated these behaviors have occurred 1 to 3 days in the last 7 days. . The nurse's notes did not reflect what behaviors have taken place. Review of Resident #21 care plan revealed the following: 7/26/05 and updated 10/13/05, "Problem - Behavioral symptoms. Physically Abusive: (others were hit, shoved, scratched, and sexually abused. , Goal - Resident will demonstrate improved behavior as evidenced by no more than 3 episodes of sexually inappropriate behavior through next review date." : : There was a.note indicating this goal was rewritten on 1/24/06, during survey. Care Plan dated 1/24/06 - Behavioral.symptoms related to diagnosis of psychosis, dementia, agitation, anxiety, Organic: Brain syndrome and CVA, This evidenced by: Wandering with no rational purpose seemingly oblivious to needs or safety. Verbally abusive behavior: (others were threatened, screamed at, cursed at), Physically abusive: (others were hit, shoved, scratched, sexually abused, Socially inappropriate/disruptive behavior: (made disruptive noises, Noisiness, screaming, self- abusive acts, sexual behavior of disrobing in pubic, smeared/threw food/feces, hoarding, Tummaged through others belongings. Resists Care: (resident taking medications/injections, ADL assistance or eating). ' Goal: Resident will demonstrate improved behavior as evidenced by no more than 3 episodes of sexually inappropriate behavior through NRD (next review date). Interventions were medication based and monitoring for signs and symptoms of change in behavior. : ’ The facility has a policy entitled - Behavior Management and Aggression Control -’ reads in part: "Purpose: To educate the nursing staff in order that they will become working with a resident manifesting aggressive behavior. Procedure: 1. Ifa resident in a nursing home demonstrates aggressive behavior and a potential for violence exits staff are to: a.) Assist the resident to a quiet area of the facility, a place that is free from all stimuli, and away from other residents, ..". j.) Provide for the safety of all other facility residents. L.) Notify Social Services for therapeutic intervention. There was no documentation of staff protecting any of the female victims. . The policy effective in 37 There was no documentation that family members or guardians of the female victims were notified after each incident. ‘ : The facility's policy and procedures for the Prevention of Abuse/Neglect reads: "Neglect: the failure or omission on the part of the caregiver of the person or disabled adult to provide the care and services necessary to maintain the physical and mental health of an aged person or disabled adult including but not limited to, food, clothing, medicine, shelter, supervision and medical services, that a prudent person would deem essential for the well-being of an aged person or disabled adult. Negiect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or mental harm or a substantial risk of death.” : Abuse representative: ''The highest ranking nursing official curently in the building." Reporting: -A.) Reporting is mandatory. Florida law requires that every citizen who knows or has cause to suspect that a resident is abuses, neglected or exploited can immediately ....report such suspicion to the Florida Abuse Hotline. Reporting the incident to the employee's supervisor is sufficient, provided the supervisor takes the appropriate steps..." B.) The facility will ensure that all alle ged violations involving known or suspected abuse (physical, sexual or emotional/psychological), neglect or exploitation will be reported immediately to the employee 's supervisor, facility specific abuse representatives, Director of - Nursing and Administrator. ..." Facility's Policy and procedures related to preparation of an Event Report read: " The Event Report should be completed when an unusual or abnormal patient care, ..." “An Event is a potentially harmful event or occurrence which is not an intended result of care and treatment being rendered, and which could result in potential loss to Patient, " "Events which require immediate notification of Risk Management and/or the Administrator on call are: ... Physical crime against a patient, ....such as assault, battery, rape, sexual molestation.” ".... A call must be placed to the Director of Risk Management. to include death, Fracture, ...Allegation of Sexual Misconduct." : Investigation: "A. upon receiving a report of suspected abuse, neglect or exploitation, the charge nurse and/ or supervisor will immediately examine the Resident. The findings of such examinations will be recorded in the medical record. B. The Administrator, Director of Nursing, and the facility specific Abuse Representative will be contacted immediately. : The facility policy and procedure regarding adverse incidents read: "Any one of the following is automatically defined as an "adverse incident" and must be Teported on the One-Day Adverse | Incident Report to the Agency for Health Care Administration within one business day after the tisk manager or designee is made aware if he occurrence of the incidents: : Abuse, neglect, or exploitation as defined in 415 102, F.S., Vulnerable Adult." 38 There was no documentation indicating the staff appreciated the sexual behavior of Residents #21aand #22 as repeated neglect towards the female residents. In an interview on 1/25/06 at 3:00 p.m. the Risk Manager stated that no practice issues regarding patient safety in the skilled nursing facility (SNF) have been identified by the SNF Risk Management/Quality Improvement Committee requiring; investigation, policy or procedure changes, and staff education. The Risk Manager stated the only recent issue to go through the Quality Assurance process concemed transferring patients from the hospital to the SNF with the patient's medications. The Risk Manager stated that he does not receive the resident grievance reports. He stated that the Administrator gives him an oral surmmary of the grievance reports. An interview. was held on 1/26/06 at 11:20 am. with members of the Quality Improvement/Risk Management Committee including: the Administrator, Social Services Director, Risk Manager, Director of Nursing, Long Term Care Unit Manager and the Staff Development Director present. Adverse incident investigation and reporting was discussed. No documentation was found to show that a sufficient investigation was undertaken to determine the validity of the allegations for a variety of issues including protection from abuse, No adverse incident investigations had been initiated for the above residents. The committee members acknowledged that there has been a system failure, The DON stated that the system is not working, ‘ Tn an interview on 1/26/06 at 9:30 p.m. the Administrator stated he did not consider the behavior of thé male resident toward female residents to be abuse, The Administrator stated that the male. resident received psychiatric treatment: The Administrator stated that the female residents who were mistreated did not receive any services. 36. Section 400.23(8)(b), Florida Statutes (2005) provides: (8) The agency shall adopt rules to provide that; when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very . limited number of staff, or a'situation that occurred only occasionally or in a very limited number of locations, A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation . has occurred in several locations, or the same resident ot residents have been affected by tepeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of thie notice of deficiencies as follows: (b) A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental; and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 fora widespread deficiency. 39 The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class T or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. ae 37. As this was a widespread class 0 deficiency, a fine in the amount of seven thousand five hundred dollars ($7,500.00) is appropriate. 38. The deficiency also supports conditional licensure status from the survey date of January 26, 2006 as defined in Section 400.23(7)(b), Florida Statutes (2005), which reads as follows: A conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class III deficiencies not corrected within the time established by the ‘agency, is‘not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the. agency. Ifthe facility has no class I, class Il, or class I deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. ‘ COUNT VI THE FACILITY ADMINISTRATION FAILED TO. EFFECTIVELY OVERSEE THE RISK MANAGEMENT AND QUALITY ASSURANCE PROGRAM, in violation of Section 400.147(2), Florida Statutes (2005) WIDESPREAD CLASS II DEFICIENCY 39, ) AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 40. Section 400.147(2), Florida Statutes (2005) reads: ‘400.147 Internal risk management and quality assurance program.— (2) The internal risk management and quality assurance pro gram is the responsibility of the facility administrator. : 40 ‘Al. This statute was not met as indicated by the following from the survey conducted on or about January 26, 2006: Based on staff interview and record review, the facility administration failed to effectively oversée the risk management and quality assurance program. The findings include: . ‘lL. Review of adverse incident reports, grievance reports and nursing notes for Residents #21 and #22 revealed that 14 or more female residents were touched in a sexual manner by a male resident. The encounters perpetrated by resident #21 occurred repeatedly over-the past 11 months. Records reveal that Resident #22 had three encounters in one day. There were grievance reports that lacked documentation of sufficient investigation to determine if an adverse incident report should have been initiated. 2. Tn an interview oni/24/06 at 3:00 p.m. the Risk Manager stated that no practice issues regarding patient safety in the skilled nursing facility (SNF) have been identified by the SNF Risk Management/Quality Improvement Committee requiring; investigation, policy or procedure changes, and staff education. The Risk Manager stated the only recent issue to go through the Quality Assurance process concerned transferring patients from the hospital to the SNF with the patient's medications. * 3. In an interview on 1/24/06 at 4:00 p.m. the Administrator stated he does not have the Policies and Procedures (P&Ps) for Risk Management or Quality Assurance. 4. An interview was held on 1/26/06 at 11:20 a.m. with members of the Quality Improvement/Risk Management Committee including: the Administrator, Social Services Director, Risk Manager, Director of Nursing, Long Term Care Unit Manager and the Staff Development Director present. Adverse incident investigation and reporting was.discussed. No documentation was found to show that a sufficient investigation was undertaken to determine the validity of the allegations for a verity of issues including protection from abuse. The committee members acknowledged that there has been a system failure. The DON stated that the system is not working. 42. Section 400.23(8)(b), Florida Statutes (2005) provides: (8) The agency shall adopt rules to provide that, when the criteria established under subsection (2) are not met, such deficiencies shall be classified according to the nature and the scope of the deficiency. The scope shall be cited as isolated, patterned, or widespread. An isolated deficiency is a deficiency affecting one or a very limited number of residents, or involving one or a very limited number of staff, or a situation that occurred only occasionally or in a very limited number of locations. A patterned deficiency is a deficiency where more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by 41 repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. A widespread deficiency is a deficiency in which the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. The agency shall indicate the classification on the face of the notice of deficiencies as follows: (b) A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 43. As this was a widespread class Ti deficiency, a fine in the amount of seven thousand five hundred dollars ($7,500.00) is appropriate. 44. The deficiency also supports conditional licensure status from the survey date of January 26, 2006 as defined in Section 400.23 (7)(b), Florida Statutes (2005), which reads as follows: A conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class II deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the agency. If the facility has no class I, class Ii, or class IZ deficiencies at the time of the follow-up survey, a standard licensure status may be assigned. SURVEY FEE 45. Pursuant to Section 400.19(3), Florida Statutes (2005), Peace River Nursing and Rehabilitation Center qualifies for a 6-month survey cycle fee of $6,000.00 as at least otie class I or two or more class I deficiencies have been cited. That statute reads: 400.19 Right of entry and inspection.— (3) The agency shall every 15 months conduct at least one unannounced inspection to determine compliance by the licenseé with statutes, and with rules promulgated under the provisions of those statutes, governing minimum standards of construction, quality and adequacy of care, and 42 tights of residents. The survey shall be conducted every 6 months for the next 2-year period if the facility has been cited for a class I deficiency, has been cited for two or more class II , deficiencies arising from separate surveys or investigations within a 60-day period, or has had three or more substantiated complaints within a 6-month period, each resulting in at least one class I or class II deficiency. In addition to any other fees or fines in this part, the agency shall assess a fine for each facility that is subject to the 6-month survey cycle. The fine for the 2-year period shall be $6,000, one-half to be paid at the completion of each survey. The agency may adjust this fine by the change in the Consumer Price Index, based on the 12 months immediately preceding the increase, to cover the cost of the additional surveys. The agency shall verify through subsequent inspection that any deficiency identified during the annual inspection is corrected. However, the agency may verify the correction of a class II or class TV deficiency unrelated to resident rights or resident care without reinspecting the facility if adequate written documentation has been received from the facility, which provides assurance that the deficiency has been corrected. The giving or causing to be given of advance notice of such unannounced inspections by an employee of the agency to any unauthorized person shall constitute cause for suspension of not fewer than 5 working days according to the provisions of chapter 110. CLAIM FOR RELIEF WHEREFORE, the Agency resp ectfully requests the following relief: 1) Make factual and legal findings in favor of AHCA on Count I-VI; 2) Uphold the issuance of the conditional license with an effective date of. January 26, 2006; . 3) Assess an administrative fine against Respondent in the total amount of fifty-six thousand dollars ($56,000.00) pursuant to Section 400.23(8)(a) and (b), Florida Statutes (2005), and Section 400.19(3), Florida Statutes (2005). oo. 4) Enter whatever other relief the court finds to be just and appropriate. DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes (2005), Peace River Nursing and Rehabilitation Center shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility NOTICE Respondent hereby 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 43 out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the attention of: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922- 5873: RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted on this | day of March, 2006. , Bar. No..339067 Counsel for Petitioner Agency for Health Care Administration 2295 Victoria Ave. Room 346C Fort Myers, FL 33901-3884 (239) 338-3203 (office) (239) 338-2699 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that an original Administrative Complaint and Exhibit “A” has been sent by U.S. Certified Mail Return Receipt Requested (return receipt # 7004 25100007 6070 9725) to Steve Cope, Administrator, 2370 Harbor Blvd., Port Charlotte, FL, 33952 and a copy by U.S. Certified Mail Return Receipt Requested (return receipt # 7004 2510 0007 6070 9732) to CT Corporation System, Registered Agent, 1200 S. Pine Island Road, Plantation, FL 33324 this — ey of March, 2006. (04 FOWLER, ESQUIRE 44

Docket for Case No: 06-001259