Certified Mail Receipt (7004 1160 0003 3739 8927) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR - HEALTH CARE ADMINISTRATION, Ole-Y Ilo Petitioner, AHCA NOS: 2006006431 v. 200600643: —Fitiaion of Administrative Hearings LAKEWOOD NURSING CENTER, INC., : d/b/a LAKEWOOD NURSING CENTER, Respondent. COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (““AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Lakewood Nursing Center, Inc. d/b/a Lakewood Nursing Center (hereinafter “Lakewood Nursing Center”), pursuant to Section 120.569, and 120.57, Fla. Stat., (2005), and alleges: NATURE OF THE ACTION __1. This is an action to impose one (1) administrative fine in an amount of Five Thousand Dollars ($5,000.00), against Lakewood Nursing Center for one (1) class II deficiency, pursuant to Sections 400,23(8)(b), 400.102(1)(a), Fla. Stat. (2005), and Rule 59A-4, Fla. Admin. Code. The Agency also intends to impose a conditional rating effective June 20, 2006, through July 02, 2006, pursuant to Section 400.23(7), Fla. Stat. (2005), case no. 2006006431. JURISDICTION AND VENUE. 2. This Agency has jurisdiction pursuant to 400, Part Il and Section 120.569 and 120.57, Fla. Stat., (2005). 3. Venue lies in Putnam County, Crescent City, Florida, pursuant to Section 120.57, Fla. Stat., (2005); and Chapter 59A-4, Fla. Admin. Code (2005), and Rule 28.106.207, Fla. Admin. Code. (2005). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statues and rules governing nursing home facilities pursuant to Chapter 400, Part II, Fla. Stat., (2005), and Chapter 59A-4, Fla. Admin. Code (2005). 5. Lakewood Nursing Center is a non-profit corporation, whose 92-bed nursing home facility is located at 100 North Lake Street, Crescent City, Florida. Lakewood Nursing Center is licensed as a nursing home facility license #SNF12810961; certificate number 13749, effective July 03, 2006, through June 30, 2007. Lakewood Nursing Center was at all times material hereto, a licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT I LAKEWOOD NURSING CENTER FAILED TO PROVIDE CARE AND SERVICES TO ENSURE RESIDENT’S HEALTH AND SAFETY BY FAILING TO NOTIFY THE PHYSICIAN OF A RESIDENT’S PAIN AFTER SUSTAINING A FALL, PROVIDING APPROPRIATE RESPONSE TO A RESIDENT’S COMPLAINTS OF PAIN AND A REQUEST FOR A TRANSFER TO A HOSPITAL AND PROVIDING SERVICES FOR TRANSFER IN ACCORDANCE WITH THE RESIDENT’S PLAN OF CARE FOR 1 OF 3 SAMPLED RESIDENTS (#3). THESE FAILURES RESULTED IN THE RESIDENT SUSTAINING A FALL, A DELAY IN TRANSFER TO A HIGHER LEVEL OF CARE FOR MORE THAN 13 HOURS AND THE RESIDENT SUFFERING A FRACTURE OF THE NECK RESULTING IN PARALYSIS. N STATE TAG N216- ACTION BY AGENCY AGAINST LICENSEE; GROUNDS Section 400.23(8)(b), Fla. Stat. (2005) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Section 400.102(1)(a), Fla. Stat. (2005) ACTION BY AGENCY AGAINST LICENSEE; GROUNDS 6. AHCA te-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about June 21, 2006, AHCA conducted a complaint investigation at the Respondent's facility. AHCA cited the Respondent based on the findings below, to wit: a.) On or about June 21, 2006, Lakewood Nursing Center failed to provide care and services to ensure resident’s health and safety be failing to notify the physician of a resident’s pain after sustaining a fall, providing appropriate response to a resident's complaints of pain and a request for a transfer to a hospital and providing services for _ transfer in accordance with the resident’s plan of care for 1 of 3 sampled residents (#3). These failures resulted in the resident sustaining a fall, a delay in transfer to a higher level of care for more than 13 hours and the resident suffering a fracture of the neck resulting in paralysis. The findings are: Review of resident #3 record revealed he/she had been admitted to the facility on November 11, 2004. The resident's diagnosis was: Degenerative Joint Disease, . Osteoporosis, Dementia, Diabetes, Depression, Peripheral Vascular Disease and Hypokalemia. Review of the Minimum Data Set (MDS) annual dated 12/26/05 revealed the resident was coded as a 1 short term memory problem with modified independence (some difficulty in new situations); for transfers was coded 2/2 (limited assistance, received physical help in guided maneuvering of limbs or non weight bearing assistance 3 or more times in 7 days; the resident was coded as a 3 in balance(not able to attempt test without physical help). Review of the Rap Summary for falls identified the resident had a history of falls and behaviors at times that increase the risk of falls. Review of the care plan revealed on 3/10/06 an lo approach was added instructing 2 person assist with gait belt. Review of the Fall Log Monthly Review for June 9, 2006, revealed resident #3 had fallen at 7 PM, in the resident's room, during transfer, then was transferred to an acute care facility. Review of the 1 Day report, 6/12/06, indicated the nursing assistant was assisting the resident to bed with a gait belt, "when the resident pushed weight against her, causing both of them to fall against the mattress then sliding to the floor." Nursing documentation dated 6/9/06, at 10 PM, revealed that the resident fell at 7 PM, while being assisted to bed. Documentation indicates the resident leaned forward, the aide lost her balance and the resident fell on top of her, hitting the cushion first and then his/her left arm on the bed rail of the other resident's bed. Further documentation indicated the family had been notified and the physician on call was notified, giving orders for Tylenol 325 mg, two tablets every 6 hours as needed for pain. Nursing documentation dated 6/9/06, at 11 PM, revealed the resident was "yelling and screaming (he/she) wanted to go to the hospital, is yelling that (race) threw me on the floor." the nurse documented that the resident had made racial remarks and the house supervisor was called to assess and speak with the resident. Nurse's note for 6/10/06, at 2 AM, revealed the resident was lying in bed, yelling, he/she was going to get a lawyer and was cold. The aide repositioned the resident, ensuring the resident was not incontinent and covered with a blanket. The house supervisor assessed the "problem".The resident told her that he/she wanted to complain about the staff letting him/her fall. The nurse documented again about the resident's racial remarks and that the resident stated he/she will get the staff fired. On 6/10/06, at 4 AM, nurse's documentation indicated the resident was still upset, the aide did the AM care and the resident requested to get out of bed in the wheel chair. The resident complained of pain and was medicated with Tylenol as ordered. On 6/10/06, at 4:30 AM, documentation indicates the resident was up in wheelchair, sleeping with no signs/symptoms of pain or discomfort. On 6/10/06, at 8:10 AM, nursing documentation revealed skilled nursing assessment of resident #3, complained of "pain in cervical area, (the resident) states (he/she) cannot move arms." The nurse further indicates the resident is unable to grasp or raise his/her arms. When the arms are raised passively, the resident is unable to keep the arms in the raised position. The physician was notified at this time (over 13 hours after the fall), and the resident was then transferred to a hospital for evaluation. Review of Emergency Room (ER) nurses notes dated 6/10/06, at 10:05 AM, indicated "during transfer last night the resident fell, struck head on the railing." The resident complained of neck pain and inability to move upper extremities, bilaterally. The documentation indicates the resident complained of pain posterior Cspine 6-7 and was unable to further assess due to dementia. The resident was unable to move upper extremities, per nursing documentation. The ER physician saw the resident at 10:32 AM, on 06/10/06. Documentation indicated the resident had no sensation or movement to the arms, and decreased sensation to the legs. The ER physician ordered a CT scan of the cervical spine, as well as, the brain and did not identify any fractures of the cervical spine. Additionally, the resident was given Solu-Medrol drip (steroids) for 8 hours while awaiting tertiary care. The resident was transferred to neurosurgeons services at another hospital for further evaluation and care. Review of the receiving hospitals Emergency Department Outpatient Consultation revealed the patient stated he/she could not move arms or legs after falling on 6/9/06 and hit “his/her neck. On examination, the resident had no feeling in the arms, trunk, back, legs or urogenital triangle. The resident could not move arms or legs. It was noted that the resident had a high chance of respiratory failure due to the paralysis below the C4 level. Review of the Death Summary from the 2™ receiving hospital revealed the resident had developed acute quadriplegia (paralysis) at approximately C4 (cervical area of the spinal column, neck area) after the fall at the nursing home. The physician further indicated the CT and MRI (xray images, enhanced) did reveal evidence of likely fracture subluxation causing a spinal cord injury. It was noted the resident had a DNR (Do Not Resuscitate) and the severity of his/her condition was discussed, he/she declined any further intervention and was put on comfort type care. The patient’s respiratory status declined over the following few days and eventually expired on 6/16/06. On 6/20/06, at 4 PM, interview staff #1, revealed that on 6/9/06, at 7 PM, she was transferring resident #3, from the wheelchair to the bed. She indicated that "somehow the resident twisted upper body to the left," she lost her balance, and they both fell towards the other resident's bed. The aide stated she did not really know what the resident hit, but did indicate she was using a gait belt. She went after the nurses and it was during shift change and the nurse that was going off duty did the assessment. The resident was put to bed after the assessment. The aide revealed that a half an hour later she went back to check on the resident and the resident demonstrated that he/she could move his/her head. She stated during the interview that she was not aware that the resident's care plan required a two person assist for transfers. The aide was vague when questioned as to the resident's complaints of pain. She did indicate that the resident's bed was in a low position not on the floor. On 6/21/06, at 12:40 PM, interview with staff #6, revealed that she had worked on 6/9/06, 7 AM to 7 PM. She was getting ready to go off shift when an aide reported that during transfer resident #3 and the aide had fallen on the floor. Staff #6 indicated that she and the oncoming nurse had responded, but she did the assessment. She stated that the resident was complaining of arms hurting and that the oncoming nurse asked her if she wanted to send the resident out to the hospital, she then asked the oncoming nurse if she wanted to send the resident out, at which she (the oncomming nurse) replied no. She (staff #6) admitted to not checking the resident's neck when she assessed because the resident was lifting his/her shoulders up and moving the head. Staff #6 indicated that the resident had been feeding himself with encouragement using hands and arms prior to this incident. She stated she was not aware that the care plan required a two person assist with transfers for this resident, stating that she had transferred the resident herself with assistance in the past. Staff #6 indicated that she felt they (the faciltiy) had taken away the LPN's right to make a judgement and send the resident's out to a hospital on their own because the facility had a policy that an Registered Nurse (RN) has to do an assessment first before a resident can be sent out. On 6/21/06, at 10:45 AM, interview with staff 3 revealed that she worked on 6/9/06, at 7 PM to 6/10/06, 7 AM. She indicated that during report from the previous nurse, that an aide reported that she had fallen with a resident (#3) on the floor while attempting to transfer the resident from the chair to the bed. Staff #3 revealed that staff #6, conducted the assessment and she wanted to send the resident out to the hospital, but staff #6 said no, that the resident was okay. She said before she knew it the aide and nurse had picked the resident up and put him/her in bed. The staff person stated "I would have sent the resident out." Staff #3 indicated that the RN on duty assessed the resident several times during the night, but she didn't want to send the resident out. When the resident yelled out wanting to go to the hospital, the RN would go in and talk, offer reassurance and the resident would calm down for awhile. Staff #3 revealed "they took our rights away to make judgement calls and send out residents to the hospital. We have to call an RN to make that decision." The staff member #3 indicated that she did call the MD that was on call and got an order for Tylenol for the resident's pain. The tylenol was given at 10 PM , on 6/9/06 and at 4 AM on 06/10/06. On 6/21/06, at 12 noon, interview with the RN, Assistant Director of Nursing (ADON), revealed that she works all kinds of hours and on 6/9/06, she was at the building from about 3 PM until 8 PM and had not been informed of resident #3 falling. She was not aware the resident fell until 3:30 AM, on 6/10/06, when an aide had the resident in a wheelchair out by the nurse's station. The ADON asked why the resident was out of bed and the staff stated he/she want to get out of bed and watch TV. The resident then asked the LPN for something for pain and at that time the ADON discovered the resident had fallen, the evening before. She did not evaluate the resident then as the resident had fallen asleep in the wheelchair in front of the TV. Later that morning, the LPN, that started working at 7 AM, asked the ADON to evaluate resident #3, that he/she could not feel arms or shoulders being touched. She indicated the resident could move his/her head, when she lightly touched the resident's “upper neck", he/she said it hurt. Being she did not know the resident well, she discussed findings with the day Licensed Parctical Nurse (LPN) and it was decided to send the resident out to the hospital. On 6/21/06, at 10 AM, interview with staff member #2 revealed that she worked on 6/10/06, 7 AM to 7 PM and was resident #3's nurse. She indicated the aides had taken the resident down to the main dining room for breakfast, but brought him/her back to the floor saying that the resident felt nauseated and could not feed him/herself. When the staff member assessed resident #3, she discovered the resident's arms were flacid, he/she could not move arms or hands. When she touched his/her neck lightly the resident complained of pain. The physcian was called and he ordered for the resident to be sent to the hospital for evaluation. The staff member revealed that she had worked the weekend before and the resident was feeding him/herself and had improved. She indicated when a resident falls a full body assessment is suppose to be done, checking range of motion, pain, pupils and look thoroughly for any signs of injury. On 6/21/06, at 12:25 PM, interview with staff member #5 revealed she worked on 6/10/06, from 7 AM to 3:30 PM. When the staff member was asked if she had gotten the resident out of bed that morning she replied “no, (he/she) was already in the wheelchair, when we got (the resident) to the dining room, (he/she) stated could not eat, couldn't lift (his/her) arms." The resident was brought back upstairs and the next thing she knew the resident was being transferred out to the hospital. She stated she was not aware the resident was suppose to have two people assist with transfer per the care plan. On 6/21/06, at 1:30 PM, interview with the occupational therapist (OT #8) that had provided some therapy in the past with the resident revealed that when the resident first was admitted to the facility he/she was very angry and difficult to work with. The resident had tremors and trouble with coordination. She then indicated that they had gotten the resident special spoons to eat with and he/she started feeding him/herself. The resident's whole attitude changed per the OT. She revealed that it had been a long time since the resident was receiving therapy, but she indicated that restorative nursing had been working with him/her for awhile and review of the restorative notes revealed the resident was to have two person assist when being transferred. The OT revealed that the staff have ongoing training. with transfers and lifting every month at orientation . On 6/21/06, at 1:20 PM, interview with the on call physician revealed that he was on call on 6/9/06 and does remember being notified of the resident #3 falling. He said it was reported to him that the resident had no head injury, loss of conciousness, therefore, no indication of neuro checks. The physician stated "I have to go by what the nurses tell me, otherwise 1 would be sending every fall out to the hospital." He admitted to not knowing the resident, but that he was on call for the attending physician. On 6/21/06, at 8:30 AM, interview with the Director of Nursing (DON) revealed she did investigate this incident and is still investigating it. She indicated that she did not find out about the incident until Monday morning, 6/12/06. The staff have been instructed to call her with any incident and they did not do it for this. She’ said "they have called me for everything else, | just don't know why they did not call me Friday or Saturday. They told me they did not feel it was an incident that 1 needed to know about." 8. The regulatory provisions of the Fla. Stat. (2005) that is pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (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 1 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. * * * 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. * Ok 400.23 Rules; evaluation and deficiencies; and licensure status- (7) The agency shall, at least every 15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a licensure status to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations, and inspections. The agency shall assign a licensure status of standard or conditional to each nursing home. a ed 9. The violation alleged herein constitutes an uncorrected class II deficiency, and warrants a fine of $5,000. WHEREFORE, AHCA demands the following relief: 1. Enter factual and findings as set forth in the allegations of this administrative complaint. 2. Impose a fine in the amount of $5,000. 3. A conditional rating effective June 20, 2006, through July 02, 2006. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2005). Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Michael O. Mathis, Senior Attorney. RESPONDENT IS FURTHER NOTIFED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL REASULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. afb Respectfully submitted this oe “day of September 2006. Michael O. Mathis, Esquire Fla. Bar. No. 0325570 Counsel of Petitioner, Agency for Health Care Administration Bldg. 3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5873 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail on ast “day of Qo brhen, 2006 to William Mickillop, Administrator, Lakewood Nursing Center, 100 North Lake Street, Crescent City, Florida 32112. Wabndny dud Michael O. Mathis, Esquire DER: COMPLETE THIS SECTION ompleta items 4, 2, and 3, Also complete sm 4 If Restricted Dellvery is desired. int your name and address on the reverse > that we can return the card to you. ttach this card to the back of the mallpiece, r on the front if space permits. (eee DI Agent 1 Addresses An 1 D. Is delivery address different from ttem 4 IF YES, enter dalivery address below: 3. ServicsType Crtified Mall (1 Express Mall O Registered 1 Return Receipt for Merchandise Clinsured Malt, 01 6.0.0. TTT 4, Restricted Delivery? (Extra Fee) J Yes Article Number 7oo4 11460 O004 3739 ade? {Transfer from service label) ; For 3811, February 2004 = Bomestlc Return Receipt 402895-02-M+15: 739 84er Postage | # wunavel La Qaaanth Wes Postmark Return Reciep! Fee Hora (Endarsement Required) o 37 Aeslticted Dellvery Fae {Endarsemant Required} ‘otal Postage & Fees 7004 ALb0 0003 4

Docket for Case No: 06-004169