nee, STATE OF FLORIDA 4 Z oS AGENCY FOR HEALTH CARE ADMINISTRATION 4p, ~ ; , Ve &O Ae, “a tsa. 0, STATE OF FLORIDA, AGENCY FOR Capi Rg Ge HEALTH CARE ADMINISTRATION, Mel Petitioner, D (, uqsy Vv. AHCA Case Nos. 2006007276 : 2006007277 EMERALD SHORES HEALTH CARE ASSOCIATES, LLC, Respondent. | / | ADMINISTRATIVE COMPLAINT COMES NOW that Agency for Health Care Administration (hereinafter “AHCA” or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Emerald Shores Health Care Associates (“Respondent”) pursuant to Chapter 400, Part II, Florida Statutes (2006), Sections 120.569 and 120.57, Florida Statutes (2006) . NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $20,000 and a survey fee in the amount of $6,000.00 pursuant to Sections 400.022 (1) (1), 400.19, 400.19 (3), and 400.23(3), Florida Statutes (2005) and Rule 59A-4.107 (5), Florida Administrative Code, for one widespread(1) class I deficiency and two isolated (2) class II deficiencies (AHCA No. 2006007276). Additionally, this is an action to impose a conditional licensure rating from April 7, 2006 through May 19, 2006, pursuant to Section 400.23 (7) (b), Florida Statutes (2005) (AHCA No. 2006007277). JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2006), and Chapter 28-106, Florida Administrative Code. 3. Venue lies in Bay County, pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes (2005), and Chapter 59A-4, Florida Administrative Code. 5. Respondent is a skilled nursing facility located at 626 N. Tyndall Parkway, Callaway, Florida 32404. Respondent was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. License No. SNF1292096. COUNT I _ FACILITY FAILED TO MEET MINIMUM STAFFING REQUIREMENTS SECTION 400.23(3) , FLORIDA STATUTES (2005) WIDESPREAD CLASS I DEFICIENCY 6. AHCA re-alleges and incorporates (1) through (5) as fully set forth herein. The facts are as follows: 7. An annual survey was conducted at the facility between April 3, 2006 and April 7, 2006. at approximately 5:30 p.m. on April 5, 2006, Registered Nurse (RN) (#18) was observed assisting with dining. RN #18 had previously been observed administering medications on the 200 hall of the North unit prior to dining. Review of the Medication Administration Record (MAR) for RN _ #18’s assigned medication cart on 4/5/06 at 6:10 p.m., revealed many 5:00 p.m. medications not initialed by the RN as given. 8. Interview with RN #18 at 6:35 p.m. on April 5, 2006, revealed RN #18 had been pulled from administering 5:00 p.m. medications to complete dining duties. RN #18 stated “a nurse is pulled each evening from the North unit for dining duties because it has two nurses for 50 residents.” The facility has 3 medication carts, each staffed by a nurse with approximately 26 residents on each cart. RN #18 stated they were originally scheduled off and were called in to take the place of the nurse who would normally be assigned to this medication cart. RN #18 stated they were less than half finished administering 5:00 p.m. medications. 9. Review of the facility’s pharmacy policy on-Medication Administration revealed that medications are to be administered within one hour before and one hour after the scheduled time. Medications are administered according to the established medication administration schedule for the facility. The facility’s medication administration times are once daily (QD)at 9:00 a.m., 1:00 p.m., or 5:00 p.m., twice daily (BID)at 9:00 a.m. and 5:00 p.m., three times daily (TID)at 9:00 a.m., 1:00 p.m., and 5:00 p.m., and four times daily (QID)at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. Antibiotics should be given per physician order. Coumadin is given at 5:00 p.m. Medications to be given on an empty stomach (Foxamax, Protonix, ‘ Glucophage, and Glucovance) . 10. RN #18 was observed at approximately 6:40 p.m. on April 5, 2006, administering Xanax (anti-anxiety medication), which was ordered to be given routinely at 9:00 p.m. Resident #22 then asked the nurse for his/her sleeping pill. RN #18 told resident #22 that he/she had already received it, indicating the Xanax. Resident #22 had orders for Restoril for insomnia as needed. Restoril was not given. RN #18 ‘stated they always gave the Xanax early because the resident goes to bed early and the resident will go to sleep for the night. RN #18 stated they had called the physician for a time change, but an order had not been received. Resident #22’s diagnosis is Alzheimer’s, Anxiety, Hypertension, and Lumbago. 11. RN #18 was observed at approximately 6:45 p.m. on April 5, 2006, preparing medications that had been ordered to have been given at 5:00 p.m., for administration to resident #23. Resident #23 was to be given Razadyne 8 mg and a House Shake. RN #18 stated resident #23 also has orders for Albuterol Inhaler, but was unable to locate the medication in the cart. RN #18 also stated that they would have to check on that medication later. Resident #23 was not in his/her room, and RN #18 was unsure where the resident was located at the time. RN #18 wasted the dose of Razadyne and gave the House Shake to Resident #9. 12. Resident #23 was observed ambulating to the medication cart around 6:50 p.m. on April 5, 2006. RN #18 was observed at approximately 7:00 p.m., administering to Resident #23 the Razadyne 8 mg, which was ordered to have been administered at 5:00 p.m. RN #18 did not administer the House Shake or the Albuterol inhaler as ordered. 13. Resident #23 was diagnosed with Chronic Obstructive Airway Disease (Albuterol inhaler is a bronchodilator used to treat this disease), Anxiety, Depressive Disorder, Cough, Allergic Rhinitis, Insomnia, Nausea with vomiting, and Alzheimer’s Disease. 14. RN #18 was observed at approximately 6:58 p.m. on April 5, 2006, administering Senna-S (Laxative/bowel stimulant), and a Health Shake (Nutritional Supplement) to resident #9. The physician ordered these items to be administered at 5:00 p.m. RN #18 also administered Xanax 0.25 mg at 6:58 p.m., which was ordered to be given as needed for anxiety. Resident #9 was observed at this time sitting in his/her wheelchair at the nurses’ station and appeared calm. Resident #9 was laughing and talking to staff. Resident #9 was observed propelling self in his/her wheelchair up and down the hall of the North Unit while the nurse was administering medications. RN #18 stated they usually gave the Xanax at night to “slow him down.” RN #18 did not indicate any other reason for administering the Xanax. 15. Resident #9 is cognitively impaired and has been diagnosed with constipation, esophageal reflux, depressive disorder, anxiety, insomnia, and Alzheimer’s Disease. 16. RN #18 was observed at 7:05 p.m. on April 5, 2006, administering Senna-S and a Health Shake to Resident #11. These were ordered to be administered at 5:00 p.m. 17. RN #18 stopped administering medications at 7:05 p.m. because it was the end of his shift. RN #18 was observed at 7:20 p.m. on April 5, 2006 completing a narcotic medication count and reporting with the on-coming RN #19. RN #18 then left the floor. Review of the Medication Administration Records (MARS) on the North Unit cart for RN #18 on April 5, 2006 at 7:30 p.m. revealed the 4:00 p.m., 5:00 p.m., and 6:00 p.m. medications had not been administered for 9 residents (#5, #7, #23, #25, #26, #27, #28, #29, and #30). 18. Resident #5 did not receive Cosopt Bye Drops used to treat glaucoma. Review of the MAR revealed a 4:00 p.m. medication, Marinol 2.5 mg, was not initialed by the nurse as given. Interview with RN #18 at 7:55 p.m. on April 5, 2006, confirmed that the resident was not given the Cosopt Eye Drops. RN #18 stated that they did give the Marinol, but did not initial the MAR indicating the medication was given. Review of the medical record revealed a nurses’ note acknowledging the resident did not receive the Cosopt Eye Drops, and the physician was notified on April 6, 2006 at 1:20 a.m. with orders to administer the medications “now.” 19. On April 5, 2006, Resident #7 did not receive his/her 5:00 p.m. Gose of Reminyl 4 mg (Anti-Alzheimer medication), Colace 100 mg (Laxative/Stool Softner), or Duoneb 2.5-0.5 mg/3 ml nebulizer treatment (combination of Albuterol sulfate 3 mg and Ipratroprium bromide 0.5 mg). Also, Resident #7 did not receive his/her 6:00 p.m. dose of Xanax 0.25 mg. Review with RN #19 of the Narcotic Controlled Drug Record and narcotic count confirmed that Xanax was not administered for Resident #7. Resident #7 has been diagnosed with Dementia, Constipation, Anxiety, Chronic Airway Obstruction Disease, Congestive Heart Failure, and Parkinson’s. 20. On April 5, 2006, Resident #25 did not receive his/her 5:00 p.m. dose of Comtan 200 mg (Anti-Parkinson’s medication used to decrease signs and symptoms), Razadyne 8 mg, Colace 100 mg (Laxative), Sinemet 25-100 mg (Anti-Parkinson’ s medication used to relieve tremors and rigidity in Parkinson’s syndrome). The Davis Drug Guide for Nurses states “Comtan and Sinemet should be taken as directed. The Comaton if suddenly stopped can result in a withdrawal reaction, which includes elevated temperature, muscular rigidity, altered consciousness, elevated CPK.” Resident #25 was diagnosed with Parkinson’s, Depressive Disorder, Insomnia, Constipation, Heartburn, Diverticulosis, Anemia, and Spinal Stenosis. 21. On April 5, 2006, Resident #26 did not receive his/her 5:00 p.m. dose of Aspirin 81 mg (used to decrease incidence of transient ischemic attacks and Cerebral Vascular Incident (Stroke), Colace 100 mg (Laxative), Seroquel 50 mg (Anti- psychotic medication), Neurontin (Anti-convulsant/analesgic, used to treat pain/decreased seizures), Norvasc 10 mg (anti- hypertensive medication used to decrease blood pressure) , and Coreg 25 mg (anti-hypertensive medication use to decrease heart rate and blood pressure). Resident #26 was diagnosed with CVA/Stroke, Hemiplegia, Coronary Atherosclorosis, Cardiac Dysrhythmias, History of MI/Heart Attack with a Defibrillator, Depressive Disorder, Constipation, Diabetes, Hypertension, Abnormality of Gait, and Muscular Disuse Atrophy. 22. Review of the medical record revealed a nurses’ note dated April 6, 2006 at 1:30 a.m., which confirmed that the above medications were not given to Resident #26. Physician was notified at 1:30 a.m., and ordered a STAT (immediate) dose of the medications to be given, which included Aspirin, Seroquel, Neurontin, Norvasc, Coreg, and Colace. 23. According to Davis Drug Guide for Nurses,. the abrupt withdrawal of Coreg can precipitate “life-threatening arrhythmias, hypertension, or myocardial ischemia (heart attack) .” 24. On April 5, 2006, Resident #27 did not receive his/her 5:00 p.m. dose of Sinemet 25-100 mg, or Seroquel 37.5 mg, Methadone 5 mg (pain medication). In addition, Resident #27 was not given his/her. 6:00 p.m. dose of Xanax 0.5 mg or Lortab 5 mg/500 mg (pain medication). Review with RN #19 of facility Narcotic Controlled Drug Record and count of narcotics on April 5, 2006 at 9:15 p.m. confirmed that Xanax, Methadone, and Lortab were not given to Resident #27, ag ordered. Review of the medical record for Resident #27 on April 6, 2006 at 12:45 a.m. also confirmed the above medications were not administered and the physician was contacted. 25. According to the Davis Drug Guide for Nurses, “Methadone should be given at regularly administered times to be effective in controlling chronic severe pain and should not be discontinued abruptly, in order to prevent withdrawal symptoms.” 26. Review of Resident #27's medical record revealed the Methadone was increased from 2.5 mg to 5 mg on 3/30/06 due to resident experiencing increased levels of pain. The Lortab 5 mg/500 mg was changed on 3/30/06, from as: needed to every 6 hours, because the resident was experiencing increased level of pain. Resident #27 was diagnosed with Anxiety, Senile Dementia, Alzheimer’s Disease, Osteoporosis, Muscoskeletal Symptom Limb, and Compound Fracture of Spine. 27. Resident #27 was observed on April 5, 2006 at 7:55 p.m., sitting ina wheelchair with a brace from his/her hips to their neck. When the surveyor asked Resident #27 if he/she had pain, the resident did not verbally respond, but pointed to their left hip. 28. On April 5, 2006, Resident #28 did not receive his/her 5:00 p.m. dose of Reminyl 4 mg (Anti-Alzheimer medication) or 6:00 p.m. dose of Xanax 0.25 mg. According to the pavis Drug Guide for Nurses, Reminyl should be given as ordered twice a day for therapeutic effects of decreased signs and symptoms of Dementia. Resident #28 diagnoses include: Alzheimer's Disease, Senile Depressive, Anxiety, Depressive Disorder, Endocrine 10 Disorder, and Osteoporosis. Review of the medical record for resident #28 did not reveal the physician: was notified that resident #28 did not receive the above medications. 29. Review of the Narcotic Controlled Drug’ Record and narcotic count with RN #19 on April 5, 2006 at 9:15 p.m., confirmed the Xanax was not administered to Resident #28 at 6:00 p-m., as ordered. 30. On April 5, 2006, Resident #29 did not receive his/her 5:00 p.m. dose of Symmetrel 100 mg (Anti-Parkinson’s medication), Wellbutrin SR 150 mg (for depression), Metamucil powder 1 packet (laxative), Bactrim 800 mg (Anti-infective) , or 6:00 p.m. dose of Ampicillin 500 mg (Anti-infective). Review of the.medical record revealed a nurse’s note on April 6, 2006 at 1:20 a.m., confirming that Resident #29 was not given the medications listed above, as ordered. The physician and medical director were paged with return calls on April 6, 2006 at 6:00 a.m. The physician ordered to give the meds at the regularly scheduled time, since they were due this a.m. Resident #29 had orders to begin intravenous antibiotics, Ceftazadine 2 grams, when the Ampicillin and Bactrim were completed for a Urinary Tract Infection. 31. Resident #29 was diagnosed with a Urinary Tract Infection, Urostomy, Depressive Disorder, Multiple Sclerosis, 11 Debility, Quadriplegia, Osteoporosis, and Stomach Function “Disease. 32. According to Davis Drug Guide for Nurses, Symmetrel should be tapered gradually; abrupt withdrawal may precipitate a parkinsonian crisis. Wellbutrin should be administered in doses in equally spaced time increments throughout the day to minimize the risk of the adverse drug reaction of seizures. Bactrim and Ampicillin should be taken as ordered to maintain therapeutic blood levels of the medication to treat the infection. 33. Review of the medical record revealed a nurse note on 4/6/06 at 1:20 A.M. confirming resdient #29's medications as listed above were not given at 5:00 P.M. and 6:00 P.M. The phyician and medical director were paged with return calls on 4/6/06 at 6:00 A.M. Physician ordered to give meds at regularly scheduled time, since they were due this A.M. Resident #29 had orders to begin intravenous antibiotics Ceftazadine 2 grams when the Ampicillin and Bactrim were completed for a Urinary Tract Infection. 34. Resident #30 did not receive on 4/5/06 at 4:00 P.M.- ~ Reglan 5 mg before meals (Class: Antiemetic; Action: Management of esophageal reflux) - Accolate 20 mg before meals (Class: Bronchodilator; Action: Decreased frequency and severity of bronchoconstriction) 12 According to the Davis Drug Guide for Nurses, Accolate should be given on an empty stomach at evenly spaced intervals. Resident #30 received dinner at approximately 5:45 P.M. Resident #30 has diagnoses of Esophageal Reflux and End-Stage Lung Cancer which requires the use of bronchodilators to manage the respiratory condition. 35. On April 5, 2006, Resident #30 did not receive his/her 5:00 p.m. dose of Lopressor 25 mg (Anti-hypertensive medication), Potassium Chloride 20 MEQ (Electrolyte supplement) , Coumadin 5 mg (Anti-coagulant used to prevent Thromboembolic events, which include venous thrombosis, pulmonary embolism, atrial fibrillation with embolization, decreased risk of death, and decrease risk of MI/Heart attack), Serevent discus 50 meq 1 puff (Bronchodilation of lungs) or Combivent 2 puffs (Bronchodilator). Also, Resident #30 did not receive his/her 6:00 p.m. dose of Morphine Sulfate 20 mg/ml (pain medication) or Xanax 0.5 mg. Review of the Narcotic Controlled Drug Record and a count of the facility’s narcotics with RN #19 on April 5, 2006 at’ 9:15 p.m., confirmed the Morphine Sulfate and Xanax were not administered to Resident #30, as ordered. 36. According to the Davis Drug Guide for Nurses, Lopressor should be given at the same time each day and not missed; abrupt withdrawal can result in precipitation of life- threatening arrhythmias, hypertension, or myocardial ischemia 13 (heart attack). Potassium Chloride, if not taken as ordered, can result in hypokalemia (low blood levels of Potassium), which can result in symptoms of weakness, fatigue, U wave on ECG, heart arrhythmias, polyuria, and polydipsia. Coumadin is a blood thinner and should be taken as ordered to prevent further commlicatior- of bleod clot formation. Morphine should be given ac ate als before the pain becomes severe. Xanax should be taken as directed, as abrupt withdrawal can result in sweating, v miting, muscle cramps, tremors, and convulsions.” wo * resident #30's medical record revealed resident was a 68 year-old Hospice resident. Resident was re- admitted to the facility on 3/11/06. Resident #30’s Minimum Data Set (MDS) rated the resident’s cognitive skills as a “0” /Independent -decisions consistent/reasonable. MDS lists pain as “1”/Pain less than daily and “3”/times when pain is horrible or excruciating. MDS lists pain sites as back, hip, and joint pain. MDS lists “End-stage disease, 6 or fewer months to live.” Resident has a diagnoses of End-State Lung Cancer, Fracture of Femur, cellulitus of leg, Obstructive Chronic Bronchitis with acute exacerbation, Cardiac. Dysrythmia, Sleep Apnea, Osteoporosis, and Esophageal Reflux. Resident has a history of Acute Respiratory Failure. 38. Interview with resident #30 on April 5, 2006 at 7:49 p-m. revealed resident had not received afternoon medications. 14 Resident stated that they were aware the facility was ina change of shift and did not want to bother the nurses. Resident had a clock in his/her room. Resident stated that he/she was experiencing pain in the pelvis and neck areas. Resident was asked by surveyor to rate pain on a scale of 1 to 10, with 1 representing minor pain and 10 the worst pain you have ever experienced. Resident #30 stated he/she was currently experiencing pain at a rating of 6. 39. Interview with resident #30 on April 6, 2006 at 11:30 a.m. revealed that medications are occasionally received late. Resident stated that by the time Morphine was given to the resident at 9:00 p.m. last night his/her pain level was at a 7, on scale of 1 to 10. Resident #30 is a Licensed Practical Nurse. 40. Review of the medical record revealed an entry of April 6, 2006 at 1:20 a.m., for resident #30, which confirmed the resident did not receive her 4:00 p.m., 5:00 p.m., or 6:00 p.m. medications. The facility attempted to notify the primary physician at 1:20 a.m. There was not a return call, so the Medical Director was paged at 2:00 a.m. The Medical Director did not return the call until 6:10 a.m., and orders were received to administer Coumadin 5 mg now and to obtain a Protime level to assess blood levels of the Anticoagulant Coumadin. 15 41. During an interview with the RN supervisor on April 6, 2006 at 3:15 p.m, the supervisor stated that the facility had attempted to obtain the blood but was unsuccessful and would attempt again tomorrow morning. 42. Record review on April 5, 2006 at 7:30 p.m. revealed that resident #45 did not receive his/her 4:30 p.m. accucheck/finger stick blood sugar with sliding scale insulin. RN #19 was questioned and contacted RN #18, who was still in the building, eating dinner. RN #18 stated that they had checked the blood sugar, but did not write the results down. RN #18 stated that Resident #45 did not require sliding scale insulin based on the results of the blood sugar. 43. On April 5, 2006 at 7:30 p.m. RN #19 stated that they did not begin to administer 9:00 p.m. medications until 8:00 p.m. During an interview with RN #19 on April 5, 2006 at 8:05 p.m., as they began to administer medications, RN #19 stated that if the MAR was not initialed by the nurse, they assumed the medication had been given. Furthermore, RN #19 stated that they would not give any 5:00 p.m. medications, which were not initialed. 44. During an interview with the Director of Nurses (DON) on April 6, 2006 at 4:00 p.m. the DON stated that all resident MAR’s had been reviewed and the primary physician and the Medical Director were notified of the medications not given by 16 RN #18 on April 5, 2006. DON stated that the residents who did not receive 5:00 p.m. medications were monitored all night for any change in condition. Review of this information revealed the physian was not notified of the missed medications for residents #7, #23, #25, and #28. 45. Review of this information revealed residents #5, #26, #27, #28, #29, and #30 were monitored during the night by a Social Worker, who is not a Licensed Nurse with specialized knowledge and skills capable of adequately assessing a change in medical condition. ) 46. During observation on April 5, 2006 at 5:50 p.m. on the North Unit, a call light for room 209B began ringing. Certified Nursing Assistants (CNA’s) were observed feeding residents. RN #18 was in the main dining room assisting with medications. The RN unit manager and the Social Worker were sitting at the nurses’ station. Room 209B’s call light was not answered until 6:05 p.m. duration of 15 minutes. 47. During observation on April 5, 2006 at 7:05 p.m. on the North Unit, a call light for room 204B began ringing. The call light was not answered until 7:11 p.m. duration of 6 minutes. 48. During observation on April 5, 2006 at 7:16 p.m. on the North Unit, a call light for room 100A began ringing. The call light was not answered until 7:21 p.m. duration of 5 17 Minutes. At this time, nurses were observed to be involved with change of shift. CNA’s were not observed on the halls. There were various residents in the halls. At 7:45 p.m., resident #46 from ‘room 804A was observed in the hallway in a wheelchair attempting to open the door to room 501A. There was not any staff observed in the, hallway. 49. During observation of the South Unit on April 4, 2006 at 8:00 a.m., LPN #16 began administering 9:00 a.m. medications at 8:00 a.m. LPN #16 was observed for approximately 15 minutes, and the surveyor went on to perform other tasks. Observation on April 4, 2006 at 10:35 a.m. revealed that LPN #16 was continuing to administer 9:00 a.m. medications to residents. 50. LPN #16 was observed beginning at 10:40 a.m. on April 4, 2006 administering Potassium Chloride 10%, 7.5 ml (used in conjunction with Lasix.to prevent potassium depletion), Lasix 20 ml (used to remove excess fluid), Proscar 5 mg (used to manage Benign Prostatic Hyperplasia), Celebrex 200 mg (used to decrease pain and inflammation caused by arthritis), and Metformin HCL 500 mg (used to maintain blood sugar) to resident #17, which were ordered to be administered at 9:00 a.m. 51. Resident #17 was diagnosed with Chronic Airway Obstruction, Osteoarthritis, Diabetes, Malignant Neoplasm Prostate, Muscle Disuse Atropy, and difficulty walking. 18 52. LPN #16 was observed on April 4, 2006 at 10:50 a.m. administering Lorezapam 0.5 mg (Anxiety medication), Lasix 20 mg, Altace 5 mg (blood pressure medication), Sucralfate 1 mg (ulcer medication), Digitek 0.125 mg (medication used to increase cardiac output and slow the heart rate), and Prednisolone 1% eye drops (used to manage inflammatory eye conditions), to patient # 18, which were ordered to be administered at 9:00 a.m. 53. LPN # 16 finished administering 9:00 a.m. medications for the South Unit at 11:05 a.m. on April 4, 2006. During an interview with LPN #16 at 11:10 a.m., the LPN stated that this is the largest medication administration of the day. The LPN further stated that he/she was the only nurse for 27 residents and had to stop during administration of medications to care for residents. 54, LPN #15 was observed administering medications on the 400 hall of the North Unit at 10:50 a.m. on April 4, 2006. During an interview at 11:00 a.m. with LPN #15, the LPN stated that they had just completed 9:00 a.m. administration of medications. The LPN further stated that they do not rush | administration of medications, and it takes a while.to complete administration of medications. LPN #15 had 27 residents to whom medications had to be administered. 19 55. During observation at 4:15 on April 5, 2006, LPN #17 was observed beginning administration of medications for the 4:00 p.m. and 5:00 p.m. medications. During an interview at 6:15 p.m. with LPN #17, the LPN stated that they were completing administration of 5:00 p.m. and 6:00 p.m. medications. 56. LPN #17 was observed at 6:20 p.m. administering to Resident #19, a multivitamin, an Asprin 81 mg (used to decrease incidence of Stroke), Senna-S (Laxative/bowel stimulant), and Persantine 50 mg (Coronary Vasodilator), which were ordered to be administered at 5:00 p.m. 57. An interview conducted with Resident #19’s spouse on April 7, 2006 at 10:40 a.m., revealed that Resident #19 had a new diagnosis of Alzheimer’s and had 3 strokes. Resident # 19 was observed to be wheelchair bound. 58. On April 5, 2006 at 6:20 p.m:, while LPN #17 was administering medications, Resident #19 stated that he/she needed a diaper change and some assistance. Resident #19 was observed to be in bed with the head of bed elevated approximately 45 degrees, and was slumped in the bed. LPN #17 stated to the resident that he/she would have to wait. LPN #17 was observed continuously for 20 minutes and did not assist Resident #19 or notify other staff to assist the resident. Two Certified Nursing Assistants were observed at this time, in resident rooms, feeding the residents. 20 59. LPN #17 was observed at 6:25 p.m. on April 5, 2006, administering Thiamine 100 mg (vitamin), Multivitamin, Folic Acid 1 mg (vitamin), FeSo04 325mg (Iron supplement), and Colace 100 mg, to Resident #20, which were supposed to have been administered to the resident at 5:00 p.m. LPN #17 was also observed at 6:30 administering to Resident #17 Glucotrol 5g (blood sugar medication), Glucophage 500 mg (blood sugar medication), and a Multivitamin with Iron. All of the above medications were to have been administered to the residents at 5:00 p.m. LPN #17 stated resident #17 did not receive his medications earlier because resident had already gone to the dining room when the nurse went to the resident's room. Resident #17 is wheelchair bound and staff must take resident to the dining room. Resident #17 completed dinner and returned to their room. LPN #17 waited to administer the resident #17's medications until after the completion of all other residents administration of medications. 60. The Davis Drug Guide for Nurses states that Glucotrol should be taken 30 minutes before a meal and do not administer after last meal of the day. The Davis Drug Guide for Nurses also states that Glucotrol and Glucophage should be given at the same time each day. 21 61. Resident # 20 was diagnosed with Alzheimer’s Disease, Iron Deficiency Anemia, Septicemia, Hypopotassemia (Hypokalemia), Renal and Ureteral Disease, and Constipation. 62. Resident # 17 was diagnosed with Alzheimer’s, Chronic Obstructive Airway Disease, Osteoarthritis, Diabetes, Malignant Neoplasm Prostate, Muscle Disuse Atrophy, and’ difficulty walking. 63. On April 5, 2006 at 6:30 p.m., LPN #17 initiated an Albuterol Nebulizer treatment for Resident #17 which was prescribed for 6:00 p.m. LPN #17 left Resident #17 with the medication immediately after setting up the nebulizer and applying the mask. LPN #17 stated that he/she would check back with the resident. Albuterol Nebulizer treatment is a bronchodilator used for the control of the resident’s Chronic Obstructive Airway Disease. 64. Review of facility policy titled, “Medication Administration: Nebulizer reveals, “the nurse is to stay with the resident during the completion of the treatment (approximately 10 minutes) and encourage the resident to cough and expectorate during and after the treatment. The nurse is to also evaluate the resident’s respiratory status after the completion of the treatment, to include: breath sounds, cough effort, sputum production, heart rate, and respiratory rate.” 22 65. Review of the medical record revealed that listed on the back of the Medication Administration Record of April 4, 2006, was a notation that Resident #17 refused to keep the nebulizer mask on his/her face. LPN #17 did not take the time to complete administration of this medication to ensure that it was delivered as ordered by the physician. Record review for Resident #17 revealed he/she was not assessed or care-planned by the facility to self-administer medications. 66. LPN #17 completed administering 5:00 p.m. medications for the South Unit at 6:35 p.m. on April 5, 2006. During an interview at 6:35 p.m. with the LPN, he/she stated that it usually takes 1 % hours to complete administering medications. LPN #17 began administering medications at 4:15 p.m. and Finished at 6:35 p.m., for a total of two hours and twenty minutes. LPN #17 stated he/she had to stop and administer an injection to an agitated resident, which increased medication pass time. LPN #17 was the only nurse on duty for 27 residents. LPN #17 also stated that this is the normal staffing pattern for this unit. 67. On April 5, 2006 from 6:15 p.m. to 6:40 p.m., while LPN #17 was administering medications, the call lights were observed to be ringing for rooms 601 and 808. They rang for approximately 5 to 10 minutes without staff intervention. At approximately 6:30 p.m. a resident was heard continuously 23 yelling “help” down the South hall. The only staff present in the hall was the LPN, who continued to administer medications and did not respond to the resident. 68. Observation of Resident #19 at 6:39 p.m. revealed that the resident was continuously hollering “help me”. Resident #19 stated, “my back is killing me, I need a nurse to put the bed down and I can’t find my call light.” The call light was noted ‘to be behind the head of the bed and was not accessible to the resident. The surveyor pushed the call light, which did not work. .The CNA entered the room at 6:40 p.m. and was questioned by the surveyor as to why the call light was not functioning. The CAN confirmed that the call light was not functioning. Resident #19’s spouse was interviewed on April 7, 2006 at 10:40 a.m., and stated that ninety percent of the time resident #19’s call light is behind the head of the bed out of the resident’s reach. He/she visits daily to feed his/her spouse lunch. At 10:44 a.m. on April 7,.2006, the surveyor pushed the call light, and it was still not functioning. Interview with CNA #28 on April 7, 2006 at 10:44 confirmed that the call light was not working, that CNA #28 was aware of this, and that CNA #28 had not reported it to anyone because CNA #28 checked on the resident frequently. 69. A 10:46 a.m. interview with LPN #16, who was the charge nurse on the South Unit on April 7, 2006, revealed that 24 LPN #16 was unaware of any call lights not working. Interview on April 7, 2006 at 10:50 a.m. with the maintenance director revealed that the maintenance director was on the way to fix Resident #19’s call light because it had just been reported by Resident #19’s spouse. 70. Resident #19 is the resident who had asked LPN #17 for assistance, who was slumped in the bed at 6:20 p.m., and who asked to have his/her diaper changed. Resident #19’s needs were neglected from 6:20 p.m. until the CNA arrived at 6:40 p.m. 71. On April 5, 2006, Resident #21’s call light was observed on for approximately 5 minutes. LPN #17 stated at 6:30 p.m. “I will turn off his call light and help him, later”. LPN #17 was in the middle of administering medications. LPN #17 was observed entering the room of Resident #21. Resident #21 stated ‘I need someone to turn on my television.” Resident #21 is a paraplegic. LPN #17 stated “I will need to come back”. Resident #21 was insistent, and LPN #17 turned on the television. 72. Observation of LPN #21 during administration of medications on the South Unit on April 6, 2006, beginning at 6:25 a.m. with LPN #21 revealed that at 6:32 a.m., LPN #21 administered Cardopa and Levadopa 25mg/100 (Anti-Parkinson’s medications used to relieve tremors), and Comtan 200 mg (Anti- Parkinson’s medication used to decrease signs and symptoms) to 25 Resident #34. The above medications were ordered to be administered at 5:00 a.m. 73. Resident #34 was diagnosed with Chronic Airway Obstructive Disease, Osteoporosis, Diabetes, Schizophrenia, Anxiety, Atrial Fibrillation, and muscle weakness. 74. On April 6, 2006 at 6:40 a.m., LPN #21 was approached by the LPN/education coordinator and asked if assistance was needed to complete the 6:00 a.m. administration of medications. LPN #21 stated yes and LPN #20 began administration of medications on the other hall of the South Unit. 75. LPN #21 continued administration of 6:00 a.m. medications past 7:00 a.m. LPN #21 was observed on April 6, 2006 at 7:07 a.m. administering to Resident #19, Xanax 0.25 and Lortab 5 mg/500 mg (to be given routinely every 6 hours), medications that were ordered to be administered at 6:00 a.m. 76. During observation on April 6, 2006 at 7:15 a.m., LPN #21 was observed administering to Resident #20, Prevacid 30 mg (Anti-Ulcer medication), which was ordered to be. administered at 6:00 a.m. Resident #20 was diagnosed with Reflux Esophagitis, Alzheimer’s Disease, Anxiety, Depressive Disorder, Iron Deficiency Anemia, and Constipation. 77. ‘DPN #21 completed administering 6:00 a.m. medications on the South Unit at 7:15 a.m. 26 78. DLPN.#20 was observed at 7:00 a.m. on April 6, 2006, administering 6:00 a.m. medications beginning at 6:40 a.m. on the South Unit. He/She was observed at 7:15 a.m. administering Haloperidol 5 mg (Anti-psychotic medication) to Resident #31. Resident #31 has Haloperidol (Haldol) ordered every 8 hours. LPN #20 was unable to locate the medication and documented it as not given. LPN #20 stated that he/she had still not received the medication from the pharmacy. LPN #20 located the medication in another drawer and administered the medication. 79. Review of Resident #31's MAR at 7:15 a.m. on April 6, 2006 revealed that Resident #31 was a new admission. Resident #31's Haldol was begun on April 4, 2006. The facility had not administered the Haldol since admission. Resident #31 missed at least 5 doses of Haldol. LPN #20 stated that waiting 3 days for the delivery of a medication is acceptable. 80. During observation of Resident #31 on April 5, 2006 at 1:00 p.m., he/she appeared to be extremely agitated, attempting to rise unsteadily out of the wheelchair. The RN unit manager brought Resident #31 to the nurses’ station and left the resident. Another wheelchair bound resident told Resident #31 to sit down. Resident #31’s wheelchair was not locked and as the resident stood, the chair would slide. Resident #31 had bruising to his/her face froma fall, which occurred prior to admission to the facility. The treatment nurse was observed 27 coming over and assisting Resident #31 with sitting back down in his/her wheelchair, then left to attend to another resident. Resident #31 rose again and was holding onto a table, which contained Easter decorations. The table was on wheels and was not locked. The table began to slide with the resident. A CNA and the treatment: nurse came to the resident, and he/she was removed from the area. Resident #31 was observed continuously for approximately 20 minutes with ongoing agitated behavior. 81. Resident #31 was observed on April 5, 2006 at 2:00 p.m. with the treatment nurse/LPN and a CNA, who were providing one on one care, because of his/her agitation, attempts to leave his/her wheelchair, and the potential for him/her to fall. 82. Haldol was administered to Resident #31 on April 6, 2006 at 7:15 a.m., and then every 8 hours, as ordered by the physician. On April 7, 2006 at 10:30 a.m. the Resident was observed calmly sitting at the nurses’ station. a3. LPN #20 was observed on April 6, 2006 at 7:20 a.m. administering Lortab 7.5 mg, which was ordered to be administered at 6:00 a.m. to Resident #2. ' 84. LPN #20 completed administering 6:00 a.m. medications at 7:20 a.m. on April 6, 2006. 85. During observation of the 200 hall of the North Unit on April 6, 2006 at 6:50 a.m. the Administrator approached RN #19 and asked if assistance was needed with completion of 28 administration of medications. RN #19 responded, yes, and the MDS Coordinator (LPN) was assigned to assist with administration of medications. The MDS Coordinator (LPN) was observed administering medications. . 86. Observation of administration of medications for the 200 hall of the North Unit with RN #19 at 7:05 a.m. revealed RN #19 was administering 6:00 a.m. medications. RN #19 was observed initiating an Atrovent nebulizer treatment to resident #30 at 7:20 a.m. RN #19 left Resident #30 with the treatment in progress, which is in violation of facility policy. Resident #30 had not been assessed or care-planned for self- administration of medications. 87. The 6:00 a.m. administration of medications for the 200 hall of the North Unit was finished at 7:20 a.m. on April 6, 2006. 88. On April 6, 2006 at 7:00 a.m. LPN #15 approached the surveyor and asked when the surveyors wanted administration of medications completed. The surveyor asked LPN #15 what the policy was and the LPN stated “I guess we will have to find it.” LPN #15 continued to ask questions of the surveyor (when the surveyor wanted her to complete medication pass). The LPN/education coordinator #20 was present and stated to LPN #15 that the Standard of Practice for nursing administration of 29 medications is 1 hour before or 1 hour after the prescribed time. 89. On April 6, 2006 at 10:47 a.m. LPN #15 was observed administering 9:00 a.m. medications. At 11:05 a.m. LPN #15 administered Senna 8, Plavix 75 mg, Altace 2.5 mg, Cozaar 25 mg, Culturella, and Xopenex nebulizer to Resident #32. Resident #32 was diagnosed with a Urinary Tract Infection, Hypertension, Senile Dementia, and Trans Cerebral Ischemia. 90. LPN #15 was observed initiating the nebulizer treatment for Resident #32, which involves preparing the medication and applying the mask on the resident. LPN #15 then left the room. LPN #15 stated “I just turn it on and come back later.” This is in violation of the facility policy for proper nebulizer administration. Resident #32 was not assessed or care planned, by the facility for ability to self-administer the nebulizer treatment. Resident #32 was to receive Diazepam (Valium), which is a sedative/anti-anxiety medication. The medication was ordered to be given twice a day. The medication cart did not have the Diazepam. The medication had to be ordered from a local pharmacy and the 9:00 a.m. dose was not administered as ordered by the physician. 91. Interview on April 6, 2006 at 3145 p.m. with LPN #15 confirmed that Resident #32 did not receive his/her 9:00 a.m. dose of Valium. UPN #15 stated that the local pharmacy 30 delivered the medication at an unknown time. LPN #15 contacted the physician at 3:55 p.m. and informed him/her of the missed 9:00 a.m. dose of Valium. The physician said to hold that dose and give the next dose due at 9:00 p.m. During an interview with the RN supervisor at 3:45 p.m. on April 6, 2006, he/she stated that the local pharmacy delivered the Valium at 1:00 p.m. 92. LPN #15 was observed on April 6, 2006 at 11:20 a.m. administering Lasix 20 mg, Zoloft 100 mg, Fosamax 35 mg, Namenda 10 mg, Coreg 3.125 mg, Vitamin E 1000 units, Prednisone 5 mq, Digitek 0.125 mg, and K-DUR 20 MEQ to Resident #33. LPN #15 also administered to Resident #33 a Health Shake, which was ordered to be administered at 9:00 a.m. 93. During an interview with LPN #15 on April 6, 2006 at 11:20 a.m., upon completion of administration of medications, LPN #15 stated “it always takes this long”, referring to administration of medications. LPN #15 further stated “must converse” with residents. When the surveyor asked if LPN #15 was going to begin administration of 12:00 p.m. medications, the LPN stated he/she had “flexibility” and would go to lunch now. LPN #15 stated it was difficult to complete all tasks during shift and he/she was often unable to complete documentation and would stay late or it “doesn’t get done.” 94. On April 6, 2006 at 3:20 p.m., LPN #15 was observed in- Resident #2’s room. The LPN stated they were administering 31 Lortab 7.5/500 mg, which was ordered to be administered every 8 hours. LPN #15 stated, the medication was ordered for 2:00 pem. but was not given. The LPN realized the error during a narcotic count with the oncoming nurse. 95. During observation of the North Unit on April 6, 2006 at 6:00 p.m., LPN #17 was administering 5:00 p.m. medications. LPN #17 stated that they still had to give medications to residents #28, #27, #41, and #40. LPN #17 was observed to continue administering medications. Review of the MAR’s confirmed that 5:00 p.m. medications were not initialed by the LPN as given for residents #28, #27, #41, and #40. LPN #15 administered the medications and completed administration of - 5:00 p.m. medications at 6:25 p.m. 96. During an interview conducted on April 6, 2006 at 6:00 p.m., with LPN #22, the LPN stated they had one more resident (#39) to whom to administer 5:00 p.m. medications. Review of the MAR revealed Resident #39 was to receive Periactin 4 mg, an appetite stimulant, before meals. The MAR was not initialed to indicate that this medication was administered. During an interview with LEN #22, the LPN confirmed that the resident had not received the 4:00 p.m. Periactin or 5:00 p.m. Dilantin (anti-convulsant for seizures), or a house shake. LPN #22 stated the resident was not in his/her room when LPN #22 originally went to administer medications. LPN #22 was unsure 32 where the resident was and stated he/she was probably smoking. LPN #22 further stated that the resident then went to dinner and was waiting for him/her to return. As of 6:15 p.m., Resident #39 had not received his/her 4:00 p.m. or 5:00 p.m. medications. 97. Upon the surveyors’ arrival to the facility on April 3, 2006 at 8:10 p.m., two CNA’s requested a confidential interview. The CNA’s stated that they were concerned with the care the residents were receiving. They further stated that the facility is consistently understaffed, which results in an inability to provide needed care and services to the residents. The CNA’s also stated that many resident falls occurred due to lack of supervision. 98. During an interview conducted on April 7, 2006 at 1:30 p-m. with the Risk Manager it was revealed that the facility has a high incidence of falls. The license capacity of the facility is 77. During the month of March 2006, the residents experienced 22 falls. During the quarter of January through March 2006, there were 51 resident falls. A trend was identified by the Risk Manager of an increase in falls on the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts, which have less staffing. The Risk Manager stated the increased falls for March 2006 was attributed to a higher acuity of care needs required of residents.’ 33 99. On April 3, 2006 at 8:35 p.m., Resident #9 was observed in a wheelchair in the main hallway in front of the dining room. This hallway is the furthest from both nurse stations and does not contain any resident rooms. The hallway is not visible from the nurse stations. The resident was self- propelling in the wheelchair and attempting to open closed doors. ‘The resident was observed opening the dining room door. Another resident (#23) wandered into the area and was watching the surveyor and Resident #9. There was no staff present in the area. Resident #9 had a chair alarm, which went of when the resident readjusted a sheet which was thrown over his/her shoulders. Resident #9 was attempting to continue into the dining. room when the chair alarm went off. A CNA responded after approximately 3 minutes and took both residents to the North Unit. A check of the other doors on the hallway revealed an unlocked clean linen door. The door had a similar latch to the, dining room latch, which Resident #9 was observed opening. The clean linen door opened into the laundry room. The laundry room door opened into a storage room with an unlocked door to the parking lot. The parking lot is on a busy highway. The door was opened and an alarm sounded. It took approximately 10 minutes before staff responded to the alarm. The alarm sounds at the nurses’ station. 34 100. During an interview with the Maintenance Director on April 3, 2006 at 9:05 p.m., he/she stated the hallway’s clean linen door and the outside door should be locked at all times. He/she then stated the doors are locked “because things they can get into.” The laundry room contained Virex (ready to disinfect cleaner on a desk at wheel chair level). Per the material safety data sheet (MSDS) the Virex is a danger to health, is corrosive, can cause eye and skin burns, and is “harmful or fatal if swallowed.” The laundry room contained 3 bottles of ‘glass and multi-surface cleaner available at wheelchair level. Per the MSDS, the glass and multi-surface cleaner is hazardous and flammable. The laundry room also had an open 5 gallon bucket of chlorinated bleach stored on the floor. Per the MSDS on chlorinated bleach, it can cause severe irritation or burns to skin, tearing, irritation, or chemical burns to eyes, and even blindness. It is harmful if swallowed and can cause chemical burns to the mouth, throat, and stomach, and can irritate the mouth, throat, or lungs if inhaled. The soiled linen room also contained a bottle of rust stain remover, which per the MSDS is an acute health hazard and causes severe irritation to the respiratory tract, skin, eyes, and mucous membranes. If the rust stain remover is ingested it can be “fatal.” The soiled linen storage room contained one small container of baseboard stripper and a gallon of floor stripper. 35 Per the MSDS, the baseboard stripper can be corrosive if it comes into contact with a person’s eyes and may cause permanent damage, including blindness; it can be corrosive upon contact with the skin and may cause permanent damage; it may cause irritation and corrosive effects to the nose, throat, and respiratory tract if inhaled and May cause burns to the mouth, throat, or stomach if ingested. It is noted that “individuals with chronic respiratory disorders such as asthma, chronic bronchitis, emphysema may be more susceptible to irritating effects.” The soiled linen room also contained an unlabeled spray bottle of a white colored liquid, a container of Fabuloso cleaner, a bottle of Dandruff shampoo, a container of Tuff Stuff cleaner, and a container of concentrated Grout Safe, all of the above-listed items did not have an MSDS sheet. 101. The storage room contained a 1 gallon container of Lime-A-Way, which was at wheelchair level. The MSDS on Lime-A- Way indicates that if exposed to eyes, it can cause chemical burns and may cause blindness; if exposed to skin it can cause chemical burns; if swallowed it is harmful and can cause chemical burns of the mouth, throat, and stomach; if inhaled it can cause burning, sneezing, coughing, and difficulty breathing; and “people with asthma or other lung problems may be more affected.” The storage room also contained 2 gallons of Kool- Klene, which according to the MSDS can Cause irritation to eyes 36 and skin; if swallowed may cause stomach distress, including nausea or vomiting; and if inhaled may cause dizziness or irritation. The storage room contained 3 containers of Butyl Free low-odor UHS floor stripper 3.78 liters. Per the MSDS, the floor stripper can be corrosive if it comes into contact with a person’s eyes and may cause permanent damage, including blindness; it can be corrosive with skin contact and may cause permanent damage; it may cause irritation and corrosive effects to the nose, throat, and respiratory tract if inhaled, and it may cause burns to the mouth, throat, or stomach if ingested. It is noted that “individuals with chronic respiratory disorders such as asthma, chronic bronchitis, emphysema may be more susceptible to irritating effects. “The storage room contained baseboard stripper, 2 containers of UHS cleaner maintainer, 2 containers of Floor Science, and 9 - 32 ounce bottles of toilet bowl cleaner antibacterial/antimicrobial. Per the MSDS information the toilet bowl cleaner, it can be an eye and skin irritant. 102. During observation on April 5, 2006 at 3:50 p.m., Resident #9 was observed in the hallway in front of the dining room self-propelling in his wheelchair to the 800 hall to the South Unit and proceeding down the 500 hall to the North Unit without supervision. At 4:30 p.m., Resident #9 was observed self-propelling in his wheelchair to the South Unit nurses’ 37 station. At 5:40 p.m., Resident #9 was observed self-propelling in his wheelchair to the end of the 400 hall to the exit door. A delivery person opened the door, the alarm sounded, and the staff removed Resident #9 from the door and back to the nurses’ station on the North Unit. At 8:13 p.m., Resident #9 was observed in his wheelchair wandering up the halls without staff monitoring him. The Resident is care-planned for close monitoring related to wandering and elopement behaviors. 103. On April 6, 2006 at 11:30 a.m., a family member of Resident #4 requested an interview. The family member stated that he/she comes to the facility almost daily, andthe facility is always dirty; Resident #4's bathroom is often dirty, the facility is understaffed; the consistent understaffing has led to Resident #4 making his/her own bed; nurses bring medications into the room and leave before Resident #4 has taken the medications; the family constantly has to go over medications with staff due to frequency of new nurses, and Resident #4 sometimes receives too much or too little medication. The family member of Resident #4 stated that he/she has asked staff to supervise the resident when the resident takes showers because he/she is afraid the resident will fall. ‘The resident ig over 90 years old but is still alert. and ambulatory. ‘The facility has failed to provide the supervision as requested. The resident requires encouragement to come out of his/her room, 38 but the staff does not provide this encouragement. The Resident is very sociable and likes to go to the dining room for dinner, but on two separate occasions the residents were not allowed to do so. One time was due to painting. The resident’s family questioned the Dietary Manager and was told it was due to a lack of staffing. The Dietary manager was seen distributing ice to residents. The dietary manager stated they were distributing the ice due to a shortage of staff. 104. During an interview conducted on April 6, 2006 at 11:45 a.m., Resident #4 stated that facility staffing is a problem, “always” a new staff member and no continuity in staffing. Resident #4 went into his/her bedroom one day, and there was another female resident in the bedroom. Resident #4 did not know the female resident’s name and notified staff to have her removed from the bedroom. 105. During observation of the South Unit on April 4, 2006 at 12:45 p.m., the CNA’s were observed passing out meal trays. “At 12:50 p.m. the call light for room 808B was ringing. The CNA’s continued passing out the trays, and the nurse continued administering medications. The call light was not answered until 1:00 p.m. (10 minutes). 106. During observation of the South Hall on April 4, 2006 at 6:45 a.m., Resident #48 was observed to be calling out for help. The door was open, and the resident could be heard out in 39 the hall. The resident was saying “please help me.” There was no staff visible in the hallways. At 6:47 a.m. the reSident was asked if he/she was able to push the call light, which was in reach. The resident attempted to push but was unable to do so. The resident indicated that he/she needed “pee pot.” The resident was observed to continue calling out for help. At 6:50 a.m. the resident was yelling “I need to get up.” The DON was observed walking by the room as the resident was yelling and not assisting. At 6:55 a.m. a CNA went into the room. The CNA appeared to be change of shift staff making rounds into the rooms. The resident indicated that he/she wanted to get up. The CNA stated that the resident would have to wait. At 7:06 a.m. the resident continued yelling for assistance and requesting to get up. There was staff present in the halls. At 7:10 a.m. the resident was still calling for help. A CNA entered the room and assisted the resident out of bed. The resident was observed calling out for assistance for 25 minutes. 107. During observation of the South Unit on April 6, 2006 at 11:50 a.m., Resident #48 was observed in a wheelchair in the doorway of the dayroom facing into the dayroom and away from the nurses station. The resident was calling continuously “someone please come here.” A call light was also ringing. There was no staff in sight of the nurses’ station. At 11:52 a.m. treatment nurse #26 walked by the resident to the nurses’ station and 40 answered a phone. The resident continued to call out “help me.” There remained no staff present until approximately 11:55 a.m., when a CNA came and pushed the resident to the dining room. The resident was quiet once she was assisted. 108. On April 5, 2006 at 5:25 p.m., Resident #47 requested to speak with the surveyors. He stated that the facility has been short-staffed since a change in management approximately one year ago. He further stated that the staff is slow to answer call lights. 109. During an interview with Resident #3 on April 6, 2006. at approximately 2:00 p.m., Resident #3 reported that “pain medications are late all of the time and the morning is the worst, but the nurses are slow because there is not enough of them and they have so many to help.” Resident #3 went on to further state that the result of receiving pain medications late causes worsening of the pain. Resident #3 is coded on his/her most recent MDS (minimum data set) from 2/17/05 in section B4 as having a cognitive level of 1 (modified independence). Resident #3 was admitted to Hospice on 3/29/06 due to terminal pain. 110. Based on the foregoing facts, Respondent violated Section 400.23(3), Florida Statutes (2005), which states that *...f{a] minimum certified nursing assistant staffing of ... 2.6 hours of direct care per resident per day ...Beginning January 1, 2002, no facility shall staff below one certified nursing 41 assistant per 20 residents, and a minimum licensed nursing staff of 1.0 hour of direct resident care per resident per day but never below one licensed nurse per 40 residents.” This constitutes a widespread, Class I violation, as defined in Section 400.23 (8) (a), Florida Statutes (2005), which carries an assessed fine of $15,000.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes (2005). WHEREFORE, the Agency demands the following relief: 1. Enter factual and legal findings in favor of the Agency on Count I; 2. Impose a fine in the amount of $15,000.00. COUNT IT FAILURE TO FOLLOW PHYSICIANS’ ORDERS AS PRESCRIBED RULE 59A-4.107(5), FLORIDA ADMINISTRATIVE CODE (2005) ISOLATED CLASS II DEFICIENCY 111. AHCA re-alleges and incorporates (1) through (5) as fully set forth herein. The facts are as follows: 112. Record review for Resident #6 revealed a physician’s order noted on the April order sheet as well as March and February, that the resident was to have a fasting blood sugar (FBS) performed every month. The resident had a diagnosis of Insulin Dependent Diabetes Mellitus and received medication for 42 “this diagnosis (Lantus 100U per milliliter vial, 10 units every evening). Furthétr review revealed there were no laboratory results of the FBS’s for the months of March or April noted on the chart at the time of the survey. 113. During an interview with the facility Registered Nurse (RN) unit manager revealed that the laboratory results should be in the residents’ record. The lab results were not provided at the time of the survey. 114. Observation on April 3, 2006 at 8:15 p.m. revealed Resident #13 lying in bed with head of bed (HOB) slightly elevated with side rails up on both sides. The Diabetic feeding tube was turned off. Resident was not positioned correctly in bed and had fallen down in the bed. The resident was exposing himself/herself with the door open to the hallway. The resident. had oxygen via nasal cannual, which was not applied properly to the nares, instead the nasal cannual was on the resident’s cheek. The resident was breathing heavily. The call light was hanging down out of reach. The call light was pushed by the surveyor. A CNA responded and asked the resident if he/she was having problems breathing. The resident was asked to blink if having problems breathing. The CNA stated “you are having trouble breathing” and the door to the room was shut. 115. Resident #13 was admitted to the facility on March 17, 2006. A review of the medical record on April 5, 2006, revealed 43 that the resident was to have Resource Diabetic 55 cc/hr continuously. There is not a physician order as of April 3, , 2006, to stop the tube feeding. The nurse notes did not document why the tube feeding was stopped on April 3, 2006 at 8:15 p.m. ‘The head of the bed was not elevated 30 to 45 degrees per the facility policy. 116. Record review of Resident #8’s laboratory results revealed that on March 3, 2006, blood was drawn from Resident #8 fora Mysoline level. The results of the Mysoline levels were completed and the report date was noted to be March 4, 2006 at 1:39 a.m. The results revealed a critical high Mysoline level of 16.8 meg/ml. The reference range is 5-12 meg/ml. The result of this lab test was faxed to the physician and a telephone order was received on March 4, 2006 at 10:00 a.m. to repeat the Mysoline level in 2 weeks. Upon further review of resident #8'’s Laboratory results, the repeated Mysoline level could not be found in the medical record. An interview conducted with the RN on April 4, 2006 at 3:10 p.m. revealed that the order for the repeat Mysoline level “did not get done.” 117. Observation of Resident #1 on April 4, 2006 at 10:00 a.m. revealed a reddened area on the right upper arm under a clear patch. The resident was again observed on April 6, 2006 at 11:55 a.m. with the area on the right upper arm still red (appeared to be a rash). A clear patch was also present on the 44 right upper arm overlapping into the reddened area. The clear patch was approximately 1 to 1% inches lower than when observed on April 4, 2006. During an interview conducted with Resident #1 on April 6, 2006 at approximately 11:55 a.m., Resident #1 stated that the area did itch, but she had not reported it to the nurse. The resident then stated that a CNA had seen the area and had said she (CNA) would let the nurse know. 118. Review of Resident #1’s Medication Administration Record on April 6, 2006 at 12:00 p.m. revealed that the patch had been changed on April 5, 2006 at 6:00 a.m. Review of Resident #1’s Physician’s Orders dated March 11, 2006, revealed that the order for Duragesic patch states to “rotate sites.” 119. Observation made of Resident #11 on April 6, 2006 at approximately 10:05 a.m. revealed staff #15 failing to check residual prior to giving medications or water flush. Observation of Resident #11 on April 6, 2006 at approximately 2:00 p.m. revealed that resident was lying in bed with the head of the bed approximately 20 degrees, it was also noted that Resident #11 was positioned off of the pillows at the head of the bed and was only elevated approximately 5 to 10 degrees. A second observation made by a second surveyor on April 6, 2006 at approximately 2:30 p.m. revealed Resident #11 was in the same position. 45 120. Record review of Resident #11’s clinical chart shows physician orders dated April 2006 for Fibersource HN (high nitrogen) tube feeding formula at 50 cc/hr for ten hours per day, to keep the HOB (head of bed) elevated at least 35 degrees at all times and to check residual every shift. Review of nursing notes dated in January, February, and March revealed that on January 4, 2006, “gastric residual of 10cc this p.m., will hold tube feeding”; on January 7, 2006 it stated “residual of 60cc noted at 9:15 p.m., feeding stopped”; on February 17, 2006, “resident has hyperactive bowel sounds and 60cc of residual”; on February 23, 2006, “60cc residual at 12:00 a.m.”; and on March 11, 2006, “tube feeding decreased to 50cc/hr due to daily residual.” It is noted that not other notes through April 5, 2006 state anything about residuals. 121. During an interview with Staff #15 on April 6, 2006 at approximately 1:30 p.m., Staff #15 reports documenting residuals in the nursing notes and not other place would they be documented if not in the nursing notes. When shown the physician order to “check residuals every shift”, Staff #15 stated if they were checked it would be documented in the nursing notes. 122. Record review of Resident #7’s physician orders dated April 2006, revealed an order for Health Shake with meals. Continuous observation of Resident #7 on April 4, 2006 at lunch, 46 April 5, 2006 at lunch, and April 5, 2006 at dinner revealed not Health Shakes ever given or offered to Resident #7. 123. Based on the foregoing facts, Respondent violated Rule 59A-4.107(5), Florida Administrative Code, which states that “[AJ11 physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift.” This constitutes an isolated, Class II violation, as defined in Section 400.23 (8) (b), Florida Statutes (2005), which carries an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes (2005). WHEREFORE, the Agency demands the following relief: 1. Enter factual and legal findings in favor of the Agency on Count ITI; 2. Impose a fine in the amount of $2,500.00. COUNT III FAILURE TO FOLLOW RESIDENT CARE PLAN SECTION 400.022(1) (1) (2005) ISOLATED CLASS II DEFICIENCY 124. AHCA re-alleges and incorporates (1) through (5) as fully set forth herein. 47 125. Based on observation, interviews, and record reviews the facility failed to ensure the resident care plan was followed for 5 of 49 (#8, #7, #9, #10, #30) residents. 126. Resident #9 has a care plan for falls, which states to apply the lap buddy while resident is in a wheelchair. The care plan is dated May 23, 2005 with the last update done on December 18, 2005. A review of the medical records revealed that the resident fell on March 19, 2006 and was found sitting on the floor beside his/her wheelchair. There is not any documentation of the lap buddy being in use as per the resident care plan. Review of Resident #9’s care plan titled “Cries frequently r/t cognitive impairment” and “combative behavior” states the resident is to be kept in an area where frequent observation is possible. 127. On April 3, 2006 at 8:35 p.m., resident #9 was observed in his/her wheelchair in the main hallway in front of the dining room. This hallway is the furthest from both nurse stations and does not contain any resident rooms. This hallway is not visible from the nurse stations. The resident was self- propelling in the wheelchair and attempting to open closed doors. There was no staff present. 128. During observation on April 5, 2006 at 3:50 p.m., Resident #9 was observed in the hallway in front of the dining room, self-propelling in wheelchair to the 800 hall to the South 48 Unit and proceeding down the 500 hall to the North Unit without supervision. On April 5, 2006 at 5:40 p.m. Resident #9 was observed self-propelling in wheelchair to the end of the 400 hall to the exit door. A deliver person opened the door, the alarm sounded, and staff removed Resident #9 away from the door and back to the nurses’ station on the North Unit. On April 7, 2006 at 4:30 p.m. Resident #9 was observed self-propelling in the wheelchair to the South Unit nurses’ station. An observation of resident #9 in his wheelchair at 8:13 P.M. on 4/5/06 wandering up the halls without staff monitoring. The resident is care planned for close monitoring related to wandering and elopement behaviors. 129. Resident #9 resides on the 200 hall of the North Unit. Record review of Resident #9's care plan revealed resident is to be closely monitored due to being identified as a wanderer and risk of elopement. The resident was not being monitored during the above observations. The facility failed to follow the resident care plan. 130. A review of the care plan for Resident #9 revealed a care plan for risk of elopement. The interventions include photograph resident and place in medical record. This photograph was not in the réesident’s medical record. The elopement plan states to check the wander-guard daily for active batteries. During an interview with the LPN and the Medical 49 Records Director (who is a nurse) on April 5, 2006 at 10:15 a.m. they stated the wander-quards are checked daily for batteries. They stated the nursing supervisors complete this check and record it in a log book. A review of the log book for April 2006 revealed Resident #9 and 6 other residents with a wander- guard. The devices were not tested on April 1%, 2™, and 4™, 2006. A review of the log for March 2006 revealed Resident #9 and 7 other residents with a wander-guard. The wander-guards were not tested on March 4%, 5%, 18%, 19°", and 237%, 2006. The Medical Record Director and LPN confirmed the lack of . documentation and stated the wander-guard batteries are to be checked daily. . 131. Resident #10 has a care plan for falls and is to have % lap tray when in the wheelchair. The resident fell on March 16, 2006 from his/her wheelchair. During an interview with LPN #22 on April 4, 2006 at 2:45 p.m. the LPN stated the resident did not have the % lap tray on when he/she fell from the wheelchair, sustaining head injuries. 132. During observation on April 4, 2006 at 1:05 p.m. CNA #29 was observed in Resident #10’s room at meal time. The resident stated “leave me alone.” The CNA insisted the resident had to eat and stated “have to eat something.” The resident then stated “I don’t have to do nothing.” The resident attempts to go back to sleep. The CNA continues repositioning the 50 resident as the resident protests. The CNA then puts the head of the bed up and begins to feed the resident. The: resident was striking out with his/her fists and refusing to eat. The CNA states “come on sweetie you need to eat.” The resident again , states “leave me alone.” After approximately 5 minutes of the resident's refusal to eat and the CNA’s insistence, the CNA stops and removes the tray from the room. A review of the resident care plan related to altered though process states “If the resident resists care leave for 10 minutes and attempt again.” 133. A review of the care plan for Resident #30 revealed that Resident #30 is to be monitored for pain and provided interventions for pain as ordered. The resident is ordered Morphine Sulfate routinely to control pain. On April 5, 2006 at 6:00 p.m. the resident did not receive his/her pain medication as ordered. 134. Record review of Resident #7’s care plan dated April 2006 revealed “Ted hose to Right leg.” Observations made of Resident #7 on 4/3/06 at 9:00 p.m., 4/4/06 at 7:35 a.m., 4/4/06 at-8:55 a.m., 4/4/06 at 12:00 p.m., 4/4/06 at 3:15 p.m., 4/5/06 -at 12:25 p.m., 4/5/06 at 5:35 p.m., and 4/6/06 at 10:00 a.m. revealed no Ted hose on residents right leg. 135. During an interview with Resident #7’s daughter on April 6, 2006 at approximately 10:00 a.m., she reports visiting 51 Resident #7 daily and never seeing Ted hose on Resident #7’s right leg. 136. Record review of Resident #8’s Minimum Data Set (MDS) dated January 29, 2006, which was completed due to a significant change in the resident’s health status, revealed pain coded as 2/3 (pain daily) /(times when pain is horrible or excruciating). A review of resident #8’s care plan revealed a plan in place for pain (initiated on 1/19/06) stating that staff will place the resident in a position of comfort with precautions, monitor pain on scale of 1-5, and medicate as ordered. Further record review revealed a physician’s order, dated 1/24/06, for Lortab 10/500 — 1 tablet to be given every 4 hours as needed for pain. A review of Resident #8’s controlled drug record revealed that the resident had been medicated 68 times from 3/1/06 to 4/6/06. A review of Resident #8’s Pain Intervention Flowsheet (FSE 3-6-2) revealed that the flowsheet had been filled out 18 of the 68 times that the Lortab was administered. A review of Resident #8's progress notes revealed 9 nursing notes from 3/2/06 to 4/6/06 of Resident #8 being medicated with no evidence of pain monitoring. 137. A review of the facility’s Pain Management and Comfort Promotion policy revealed that the Pain Intervention Flowsheet would be completed as needed to record and monitor resident response to interventions. 52 138. During an interview conducted on April 6, 2006 at 4:20 p.m. with the Unit Manager it was confirmed that the Pain Intervention Flowsheet for Resident #8 was not completed for April 2006. ‘139. Based on the foregoing facts, Respondent violated Section 400.022(1) (1), Florida Statutes (2005), which states that “[t]he right to receive adequate and appropriate health care and protective and support services, including social services; metal health services, if available; planned recreational activities; and therapeutic and rehabilitative- services consistent with the resident care plan...” This constitutes an isolated, Class II violation, as defined in Section 400.23 (8) (b), Florida Statutes (2005), which carries an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes (2005). WHEREFORE, the Agency demands the following relief: 1. Enter factual and legal findings in favor of the Agency on Count IIT; 2. Impose a fine in the amount of $2,500.00. 140. Additionally, pursuant to Section 400.19(3), Florida Statutes (2005), a $6000.00 survey fee is statutorily authorized. 53 CLAIM FOR RELIEF WHEREFORE; the Petitioner, State of. Florida, Agency for Health Care Administration, requests the following relief: 1. Make factual and legal finding in favor of the Agency on Counts I through III. 2. Assess against Respondent administrative fines of §20,000.00. 3. Assess a survey fee of $6000.00. 4. Assess attorney’s fees and costs; and 5, All other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the at tached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAL LURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, 54 Kenng W. Gieseking, Esq. Agency/ for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 922-5873 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof has been sent by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 2000, to Registered Agent, Corporation Services Company, 1201 Hays Street, Tallahassee, Florida 32301-2525 and 7004 1160 0003 3739 1997 Emerald Shores‘ Health Care Associates, LLC, 626 N. Tyndall Parkway, Callaway, Florida 32404 on this the OA aay of November 2006. Kenneth’W./ Gieseking, Esquire Copies furnished to: Barbara Alford Field Office Manager Division of Health Quality Assurance (Interoffice Mail) 55 Oe ow li zx sé, seal So — og S&S ? NE Hae “. § S35 = S32 Lo gQ S Tt SENDER: COMPLETE THIS SECTION ® Complete items ‘1,2, and:3, Also complete - item 4 if Restricted Delivery‘is desired. . “-™ Print your name and address on the reverse '_.80 that we can return the card -to you, ™ Attach this card to-the back of the mailpiece, or on the front if space permits. COMPLETE THIS SECTION ON DELIVERY A.. Signature TMA PN Oia B. Ffec; me Printed Name) C. Date of D m ver { “b- O Age Reaisteree B, 4 Co dorackon mn ‘130) Nays St. Tatlanassee, Fe 3080!- vices Co. D. is delivery address different from tem-17 [1 Yes IF YES, enter delivery address below: [© No 3. Service Type -EXCertified Mail (1 Express Mall O Registered OD Return Receipt for Merche D insured Mai =O G.0.0. | 4, Restricted Delivery? (Extra Fee) O ves 2._Article Number. : i ~ PE

Docket for Case No: 06-004754