a VB. 0 “| ; DYD | Certified Mail Receipt (7004 1160 0003 3739 9245) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, , : AHCA NOS.: 2007004603 OAKWOOD NURSING CENTER, INC. Respondent. MINISTRATIVE COMPLAINT ADMINISTRATIVE COMPLAIN’ COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION S AL AHCA’), by and through the undersigned counsel, and files this Administrative : Complaint against. Oakwood Nursing Center, Inc. (« Oakwood Nursing Center, Inc.”), pursuant to Section 120.569, and 120.57, Fla. Stat. (2006), alleges: | NATURE OF THE ACTION 1. This is an action to impose one (1) -administrative fine in the amount of Five Thousand Dollars ($5,000.00), against Oakwood Nursing Center, Inc. for one (1). class II deficiency, pursuant to Sections 400.23(8)(b), 400.102(1){a); Fla. Stat. (2006), and Rule 59A-4, Fla. Admin. Code (2006). JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to 400, Part Il and Sections 120.569 and 120.57, Fla. Stat. (2006). pe ion 3. Venue lies in Marion County, Ocala, Florida, pursuant to Section 120.57 Fla. Stat. (2006); Rule 59A-4, Fla. Admin. Code (2006), and Section 28.106.207, Fla. Stat. (2006). . PARTIES 4. AHCA, is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing home facilities pursuant to Chapter 400, Part Il, Fla. Stat. (2006), and Chapter 59A-4, Fla. Admin. Code (2006). 5. | Oakwood Nursing Center, Inc. is a for-profit corporation, whose 133-bed nursing home facility is located at 2021 N.W. First Avenue, Inc., Ocala, Florida. Oakwood Nursing Center, Inc. is licensed as nursing home license #SNF1524096; certificate number #14177, effective January 25, 2007 through March 31, 2007. Oakwood Nursing: Center, Inc. was at all times material hereto, licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT I OAKWOOD NURSING CENTER, INC. FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTIVE DEVICES TO PREVENT A FALL CAUSING 1 (#1) OF 10 SAMPLED RESIDENTS TO BE TRANSFERED TO THE EMERGENCY ROOM WITH A PERIORBITAL FRACTURE. STATE TAG N216-HEALTH AND SAFETY OF RESIDENT Section 400.23(8)(b), Fla. Stat. (2006) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Section 400.102(1)(a), Fla. Stat. (2006) ACTION BY AGENCY AGAINST LICENSEE; GROUNDS ; . ; 6. _ AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. On or about March 1, 2007, AHCA conducted. an unannounced recertification survey at the Respondent’s facility. AHCA cited the Respondent based on the findings below, to wit: a.) Onor about January 25, 2007, Oakwood Nursing Center failed to ensure that 1 (Resident #9) of 26 sampled residents, reviewed necessary service and care to maintain acceptable parameters of body weight. This failure resulted in the: resident _ sustaining an unplanned weight loss of 35 Ibs. b.) During an unannounced follow-up on or about March 1, 2007, Oakwood vce net Nursing Center, Inc. failed to provide adequate supervision and assistive devices to prevent “a fall causing 1 (#1) of 10 sampled residents to be transferred to the emergency room with a - -* periorbital fracture. The Findings include: During initial tour of the facility on 02/28/07 at 10:30 AM, resident #1 was observed lying in bed with a bruise covering the right side of his/her face below the eye and down to his/her chin, sutures were observed below the right eye. Interview with the Director of Nurses (DON) on 03/01/07 at 9:30 AM revealed that resident #1 had fallen on Saturday, 02/24/07, late in the evening, but that she had just found out about it yesterday, 02/28/07 and that she had submitted a 1 day adverse incident report when she found out. When questioned further about the events that led to the resident's fall, she stated that the resident was found on “his/her side in the atrium. The DON had ‘not begun an investigation into the incident, but stated she felt it was an adverse incident because they usually place the resident in a Geri chair near the nurses’ station in the evening, but that resident was found on the floor in the atrium floor. The DON indicated that she had a question about the location of the Certified Nurses Assistant (CNA). When asked what the DON thought adverse incident meant, she stated an incident that could have been prevented. Review of the resident #1's medical record revealed that he/she was admitted to the facility on 11/07/06. A nurse's note dated 11/08/06 3 AM states the resident to have an unsteady gait and a history of falls. ue Review of a 11/23/06 nurse's note for resident #1 revealed a 10 PM entry "Noticed a bruise on Left forehead origin unknown. Resident states hit head on bed." Review of a 12/19/06 nurse's note for resident #1 revealed a 7 AM entry “While doing count and getting report the CNA reported to me or us this resident is on the floor on (his/her) knees and bleeding, (he/she) was assisted by the staff development nurse." The note continued "Resident stated to me my head and my back hurt has a hematoma on the back of the head." The resident was sent to the Emergency room. Review of a 12/20/06 nurse's note for resident #1 revealed a 8:20 AM entry "Resident found laying on floor by bed, propped up on elbows." It continues “flat mole on upper mid back bleeding." ; ; Review of a 12/23/06 nurse's note for resident #1 revealed a 2 PM entry “Resident was obsetved lying on (his/her) right side next to (his/ her) bed on the floor, small laceration noted on left side of eyebrow." = Review of a 01/12/07 nurse's note for resident #1 revealed a 5 PM entry."Resident came to the nurses’ station walking- Observed small 1/4 inch cut on right forehead." Review of a 02/17/07 nurse's note for resident #1 revealed a 7 AM entry "Resident found sitting on floor at 4 AM end of (his/her) bed. (He/She) stated (he/she) was walking and lost my balance, now leave me alone." : Review of a 02/21/07 nurse's note for resident #1 revealed a 7:30 PM entry "Resident was found on the floor sitting in an upright at the foot of the bed." Review of a 02/24/07 nurse's note for resident #1 revealed a 11:30 PM entry "Resident lying on the floor on right side in TV viewing area of atrium - 0 loss of consciousness- demonstrates adequate range of motion all extremities- assisted to (his/Het) feet and pat in an easy chair resident sustained laceration to the outer orbit of the right eye small amount of bleeding wound cleansed with normal saline- moist dressing applied- call placed to 911 for transport to emergency room for evaluation and treatment." Continued review of resident #1's medical record revealed a "Fall Assessment" document with the original assessment dated 11/ 07/06 with a total score of "7" not representing a high risk for falls even though the nurse's note dated 11/08/06 the day after his/her admission states that resident #1 has a history of falls. : Further review of this document revealed that a score of 10 or above represents a high risk for falls. Continued record review revealed only one other date where resident 1's fall risk was assessed. The Assessment was dated 12/22/06, and he/she received a score of 12, putting him/her at high risk. However, continued review failed to reveal that any additional interventions were implemented to prevent falls. Review of resident #1's care plan dated 11/ 27/06 and reviewed 02/22/07 revealed the only interventions added or changed in the three months since the resident was admitted, and after all of the above mentioned falls, was a low bed with floor mats that was ordered on 02/22/07. However, upon continued review, of the. nurses’ notes for resident #1, a note dated 12/24/06 at 10 PM documents "low bed with mat on the floor for resident safety." The facility policy for falls was’ requested of the administrator, at 12 PM on 03/01/07, and a policy for "Incidents and Accidents" was received. At this time, the ‘administrator stated that the facility does not have a specific policy for falls. Review of the policy for Incidents and Accidents revealed that it is not specific to falls. Further review revealed no guidance to the staff to assess or reevaluate the resident's risk, pattern of falls, or how to, or how often to implement changes to keep the resident safe, and prevent falls. Interview with resident #1's Hospice nursé on 03/0 1/07 at 1:30 PM revealed that she has never seen resident #1 in a Geri chair and believes the resident would not stay in it. She continued on to state that she had thought that possibly a Merri walker would help. : 8. The regulatory provisions of the Fla. Stat. (2006) that are pertinent to this | alleged violation read as follows: . 400.23 Rules; evaluation and deficiencies; and licensure status- (b) Acclass Il 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 licensure; grounds~ (1)(a) An intentional or negligent act materially affecting the health or safety of residents of the facility. 9. The violation alleged herein constitutes an class II deficiency, and warrants a fine of $5,000.00 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 $5,000.00 Respondent is notified that it has a right to request an administrative hearing.pursuant to Section 120.569, Florida Statutes (2006). Specific options for administrative action ate set out in the attached Election of Rights (one page) and explained in ‘the -attached _ Explanation of Rights (one page). ee ae All requests for hearing shall be made. to the Agency for Health Care Admini delivered to the Agency for Health Care Administration, Building 3,. Mahan Drive, Tallahassee, Florida 32308; Michael ©. 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. Respectfully Submitted this QF, of / fay 2007, Leon County, Tallahassee, Florida. 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 | HEREBY CERTIFY that a true and correct copy of the foregoing has been served ton eal tiny of by certified mail. on al day of lay ___, 2007 to Robert E. Ritter, Oakwood -_————1. a SY ee Michael O. 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Docket for Case No: 07-002831