, a Certified Mail il Receipt Ol . UG 4] --. * (7003 1010 0000 9715 3269) . STATE OF FLORIDA, Ue ia AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, : Petitioner, , ee - AHCA NOS.: 2007009489 ve. -2007009490 LHL, L.L.C. d/b/a LAFAYETTE HEALTH CARE CENTER, - Respondent. : ; oe / . . ADMINISTRATIVE COMPLAINT | COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION CAHICA?, by and through the undersigned counsel, and files this Administrative Complaint against LHI, L.L.C. d/b/a Lafayette Health Care Center (“Lafayette Health Care Center”), . Pursuant t to Section 120.569, and 120.. 51, Fla. Stat. (2006), alleges: — NATURE 01 OF THE ACTION 1. This is an action to impose one (1) administrative fine in the amount of Two Thousand Five Hundred Dollars ($2,500.00), against Lafayette Health Care Center for one (1) class Il deficiency, pursuant to Section 400.23(8)(b), Fla. Stat, (2006); and Rule 59A- 4.107(5), Fla. Admin. Code (2006). The Agency also intends to impose a conditional rating effective July 11, 2007 through August 22, 2007, pursuant to Section 400. 23(7) Fla. Stat. (2006) case no. 2007009490. JURISDICTION AND VENUE 2... This Agency has jurisdiction pursuant to. 400, Part II and Sections 120.569 and.120.57, Fla. Stat. (2006). 3. Venue “les in Lafayette County, Mayo, Florida, pursuant to Section 120.57 Fla. Stat. (2006) Rule 59A4, Fla. Admin. Code (2006), and Section 28.1 106. 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 II, Fla. Stat. (2006), and Chapter 59A-4, Fla. Admin. Code (2006). ~ Lpfayette Health Care Center isa forpfofit corporation, whose 60- bed nursing: home fcity is located at 512 W. Main Street, Mayo, Florida 32066. Lafayette Health Care Ceriter is licerised as nursing home license #SNF130470971, certificate number #14646, effective August 23, 2007 through April 30, 2009. Lafayette Health Care ‘Center 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 LAFAYETTE HEALTH CARE CENTER FAILED TO:ENSURE IMPLEMENTATION OF PHYSICIAN'S ORDERS FOR 3 (#3, #8, AND #12) OF. 17 SAMPLED RESIDENTS. IN THE CASE OF RESIDENT #12, THE FACILITY, AFTER ADMINISTERING CONSTIPATION RELIEVING MEDICATION OUTSIDE OF PHYSICIAN: ‘ORDER’S ALLOWED THE RESIDENT -TO.GO-FIVE DAYS WITHOUT A BM AND WITHOUT ADDITIONAL INTERVENTIONS UNTIL ‘THE RESIDENT EXPERIENCED ABDOMINAL PAIN. AS A RESULT OF RESIDENT #12’S ABDOMINAL PAIN, AN X-RAY WAS ORDERED AND CONFIRMED A DIAGNOSIS OF CONSTIPATION WITH A FINDING OF “LARGE AMOUNTS OF. GAS AND STOOL THROUGHOUT RESIDENT #128 ENTIRE COLON.” STATE TAG N054- FOLLOW PHYSICIAN ORDERS os Section 400.23(8 8)(b), Fla, Stat. (2006) RULES EVALUATION, AND DEFICIENCIES; LICENSURE STATUS Rule 59A-4. 107(5), Fla. Admin. Code (2006) PHYSICIAN SERVICES 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. oe Oe 7. On or about July 11, 2007, AHCA conducted an unannounced licensure survey at the Respondent’s facility. AHCA cited the Respondent based on ‘the findings below, to wit: . ) . a) On or about July 11, 2007, Lafayette Health Care Center fale to’ensure _ : implementation of physician’ s orders for 3 (#3, #8, and #12) of 17 sampled residents In the case of resident #12, the facility, after administering constipation relieving medication outside of physician order $ allowed the resident to go five days without a BM. and without additional interventions until the resident experienced abdominal pain. As a result of resident #12’s abdominal pain, an xray was ordered and confirmed : av diagnosis of constipation with a finding of “large amounts of gas and stool throughout resident #12's entire colon.” The Findings include: 1.) Record review revealed ‘resident #12 with the following diagnoses: Demenia, Hypertension, Arthritis, Congestive Heart Failure / Cardiac insufficiency, Insomnia, Atypical Angina and Organic Brain Syndrome. Resident #12's current quartetly Minimum Data Set with an assessment reference date of 06/05/07 revealed that although the resident is continent of bowel he/she Tequires extensive assist in transferring to the toilet with one person physical assist and is: ona scheduled toileting plan. Review of physiciin orders from February 2007 through July 2007 revealed the resident consistently received an iron supplement’ (Ferrous Sulfate) and pain medication (Hydrocodone/APAP) both of which are known to have the side effect of constipation as per.the Lexi-Comp Geriatric Dosage Handbook 12" Edition. A physician order was documented to "record bowel movements each shift." Resident #12' record included a Care Plan, initially dated 01/04/2006, for Constipation which includes the following interventions: Monitor and document bowel movements; stool softeners as ordered to avoid straining or constipation; toilet every 2 hours and as needed; additional interventions noted on 02/21/06 - ‘Colace as ordered; 02/03/06 - Fruit and: Fiber as ordered, however, the ‘intervention was marked through with d/c: (discontinued) documented next to it! There was no d/c date referenced. On 03/23/07 Magnesium Citrate is indicated as having been added to the Care Plan. . Physician Orders from March 2007 to July 2007 revealed the resident was ordered the following medications for constipation: ~. -Diocto 60mg/15ml syrup (for Colace 60mg/ 15m) 25mg by mouth twice a day for constipation Ex-Lax chocolate - 2 squares as needed for constipation Milk of Magnesia (MOM) suspension -. 30ml by mouth as needed for constipation if no bowel movement in Z days Enema RTU 133 ml (for Fleet Enema) - - rectally as needed for constipation if no bowel movement in 3 days Bisacodyl suppositories 10mg insert one suppository rectally every 3rd day after supper if no bowel movement Magnesium Citrate 1/2 bottle as needed for constipation (written 03/ 23/07) On 07/10/07, during a 10:44 AM interview with the Assistant Director of Nursing and the Director of Nursing, it was revealed that’ resident bowel movements are typically documented by Certified Nursing Assistants (CNA) on the resident's care flow record and this information’is given to the licensed nursing staff who record it on the resident's Medication Administration Record (MAR). Continued review of resident #12's record revealed the following: : The resident flow record indicates the resident with "medium” BMs on the evening , of 02/26/07 and during the day on 02/27/07.- : Le The resident was without bowel movements (BMs) on 02/28/1 07, 03/01 07, and 03/02/07 according to the flow record and the MARs. The ‘resident was. given 2 squares of Exlax on 0/01/07. Neither the MAR or Nurse's notes indicate results. The MAR of 03/02/07 indicated resident #12 was given 30 ml of MOM as "no BM times 8 days. Neither the MAR or Nurse's notes indicate results. On 03/04/07 at.1:30 PM, facility staff proceeded outside of the physician « orders by giving the resident an enema even though the flow record and the MAR indicate '. the resident had a BM on 03/02/07. The MAR indicated. the tesident received a Fleet enema duet "crying out on the toilet" . The 03/ 04/ 07 flow ‘record indicates a "small" BM on the | evening shift, : documented as between 2: 00 PM and 10: 00 PM on a the MAR. - On 03/ 04/ 07 at 11:45 PM, facility staff proceeded outside of the + physician orders _. by giving the resident a Bisacodyl Supplement even though the flow record and MAR indicate the resident had a BM on 03/04/07 between the hours of 2:00 PM and 10:00 PM. The MAR indicates that resident #12 received a Bisacodyl _ Suppository due to "liquid results only from enema." Neither the MAR or Nurse’ S note indicate results from the Bisacodyl Suppository. On 03/05/07, facility staff again, according to MAR resident #12: provided 30 ml of MOM for constipation. Neither the MAR or Nurse! Ss Notes indicate results, The flow record and MAR report the resident was without BMs on 03/ 05/ 07 and 03/06/07. On 03/07/07 at 9:00 PM resident #12 was checked for | impaction, with none located. The flow record and MAR report the resident was without BMs on 03/ 07/07 and 03/08/07. On 03/09/07 at 6:00PM the physician was contacted and an abdominal xTay was ordered. ; 1 On 03/09/07 at 9:00 PM an enema was given with no results. 1 O©n03/10/07 the abdominal x-ray was conducted. / . The final xray report found: "The gas pattern of the stomach and small bowel is normal, but there is a large amount of gas and stool throughout the entire colon." The impression: Constipation. : 1. On 03/ 10/07 the.physician was notified of the findings and he ordered ¥ bottle of magnesium citrate to be given. There is no indication-on the MAR that it was given however, on the final xray report the nurse documents it was "given." . 1 The flow record and MAR teport the resident was without BMs on 03/10/07. 0 .On 03/11/07 the: flow record indicated the resident with 2 large BMs on the evening shift, documented as between 2:00 PM and 10:00 PM on the MAR. On 07/11/07, during a meeting from 10:24 AM to 10:57 AM with the DON, ADON, MDS coordinator and Administrator, the DON confirmed that resident #12's flow tecord and MAR indicates the resident had BMs on 02/28/07 and.03/01/07 and that “facility staff provided the resident with 30 ml on 03/02/07 even though the physician's order was for.30 ml MOM after two days without a BM. The DON confirmed the flow sheet Of 03/04/07 indicated ’a "small" BM in the evening. The MAR indicated a BM on 03/04/07 between 2:00 PM and 10:00 PM. The DON confirmed that documentation on the MAR dated 03/04/07 at 11:45 PM revealed the resident received a Bisacodyl Suppository due to "liquid results only from enema" (provided on 03/04/07 at 1:30 PM). The DON ‘confirmed there was no evidence that the resident had a BM from 03/04/07 (with the exception of "liquid results only from enema") until 03/11/ 07; and only after the resident received an enema on 03/09/07 and 4a bottle of Magnesium . Citrate on 03/10/07. . The. DON was unable to provide an explanation as to why facility staff provided ‘constipation medication when the records indicated BMs. She was also unable to inform as to why facility staff waited until 03/09/07 to contact the resident's physician. - Even though documentation on the 03/04/07 MAR indicate the'resident was given an enema because he/she was "crying out on the toilet’ and this enema provided only liquid results. The DON was also unable to provide an explanation as to why after giving an enema and a suppository on 03/04/07, and MOM on 03/05/07, none of which provided results, the facility staff attempted no additional interventions until 03/09/07 after contacting the physician. The DON confirmed the physician was contacted on 03/09/07 due to the resident experiencing abdominal pain. 2.) Continued review of resident #12's record revealed the following: Resident flow record and MARS indicate the resident was again ‘without BMs on 03/20/07, 03/21/07, 03/22/07, and 03/23/07. '- Q. There was no indication on the MARs or on the Nurse's notes ‘that thé resident's care plan and physician ordered medication interventions were put in place.’ 1 The resident did not receive the MOM if no bowel movement in 2 days. 1 . The resident did not receive an enema if no BM in 3 days ; : 1 The resident did not receive a suppository after supper on the cha day if, no BM. f On 03/23/07, the facility received a new order of 4 ‘bottle of Mag. Citrate for . constipation. 1 The flow records revealed that on 03/24/07 and 1 03/35/ 07 the c resent had large BMs on the day and the evening shift. On 07/11/07, during a meeting from 10:24 AM to 10:57 AM with the DON, ADON, MDS coordinator and Administrator, the DON confirmed that the facility staff did not implement the resident #12's constipation care plan nor did they provide medications to prevent constipation as ordered by the physician. The DON was unable | to, provide - an-explanation as to why staff was not following the physician’ S orders, . . 3) Record review revealed tesident #3 with the following diagnoses: Depression, ; Hypertension, Hyperlipidemia, Coronary Artery Disease, Osteoporosis, and. Dementia. Resident #3! '§- current ‘significant change Minimum Data Set with an: assessment refeténce date-of 06/26/07 revealed that the resident is incontinent of bowel and that he/she is totally dependant on staff for toileting. Resident #3 wears incontinent briefs and.is on a scheduled toileting plan.’ Review of physician orders from May 2007 through July 2007 revealed the. resident routinely receives an iron supplement (Dexferrum), medication’. for Anxiety (Lorazepam), medication for Alzheimer ' s (Risperdal), ‘all of which are known to have the possible side effect of constipation as per the Lexi-Comp. Geriatric’ Dosage Handbook 12 Edition. A physician order was documented to’ "record bowel movements each shift." ‘Resident #3's record included a Care Plan, initially dated 03/02/07, for Constipation which includes the following interventions: Monitor and document bowel movements; stool softeners as ordered to avoid straining or constipation; toilet every 2 hours and as needed; Miralax once daily as ordered, Dulcolax Suppository as need and: as ordered, Enema as needed as ordered and MOM as needed as ordered. ; Physician Orders from May 2007 through July 2007 revealed the resident was ordered the following medications for constipation: Glycolax powder (for miralax powder) 17 GR daily for constipation’ Milk of Magnesia (MOM) suspension - 30ml by mouth as needed for constipation if no bowel movement in 2 days . so, ; : Enema RTU 133 ml (for Fleet Enema) - rectally as needed for constipation if no bowel movement in 3 days oe an Bisacodyl suppositories 10mg insert one suppository rectally every 3rd day after supper if no bowel movement ; : : On 07/10/07, during a 10:44 AM interview with the Assistant Director of Nursing . and the Director. of Nursing, it. was revealed that resident. bowel movements are _ typically documented by Certified Nursing Assistants (CNA) on the resident's care flow record and this information is given to the licensed nursing staff who record it on the resident s Medication Administration Record (MAR). Continued review of resident #3's record revealed the following: 1 . Resident’ flow record and MARS indicate the resident was without BMs on : 05/27/07, 05/28/07, 05/29/07, 05/30/07, and 05/31/07. ]. There was no indication on the MARs or on the Nurse 's notes that the resident's care plan and physician ordered interventions were put in place. 1 The resident did not receive the MOM if no bowel movement in 2 days. 1 The resident did not receive an enema if no BM in 3 days “D The resident did not receive a suppository after supper on the 3 day if no BM. On 07/11/07, during a meeting from 10:24 AM to 10:57 AM with the DON, ADON, MDS coordinator and Administrator, the DON confirmed that the facility staff did not implement the resident #3's constipation care plan nor did they provide medications to prevent constipation as ordered by the physician. The DON was unable to provide an explanation as to why staff were not following the physician's orders. . 4.) Record review revealed resident #8 with the following diagnoses: Severe Anemia, Alzheimer's, Hypertension, History of Colon Cancer, ASCD, History of Cataracts Resident #8 's current quarterly Minimum Data Set with'an assessment reference date of 04/08/07 revealed that the resident is incontinent of bowel and that he/she. is totally dependant on staff for toileting. Resident #8 wears incontinent briefs and is on a scheduled toileting plan. Review of physician orders from May 2007 through July 2007 revealed the resident routinely receives a multivitamin and medication for Alzheimer's (Namenda), both of which are known to have the possible side effect of constipation as per the Lexi-Comp Geriatric Dosage Handbook 12" Edition. A physician order indicated to “record bowel movements each shift." ~ , , ; Resident #8's record included a Care Plan, initially dated 03/20/06, for ‘Constipation which includes the following interventions: Monitor and document bowel movements; stool softeners as ordered to avoid straining or constipation; toilet every 2 hours‘and as : needed. ; ony : Physician Orders from May. 2007 through July 2007 tevealed the resident was ordered the following medications for constipation: rn ne Milk of Magnesia (MOM) suspension - 30ml by mouth as needed for constipation ifno bowel movement in 2 days aa Le : Enema RTU 133 ml (for Fleet Enema) - rectally as needed for constipation if no bowel movement in 3 days ae : cee ; Bisacodyl suppositories 10mg insert one suppository. rectally every 3rd‘ day after supper if no bowel movement vs eae On 07/10/07, during a 10:44AM interview with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), it was revealed that -tesident bowel movements are typically documented by Certified Nursing Assistants. (CNA) on the . tésident's care flow record and this information is given to the licensed ‘nursing staff who record it on the resident's Medication Administration Record (MAR). : Continued review of resident #8's record revealed the following: - 05/21/07, 05/22/07, 05/23/07, 05/24/07, 05/25/07, and 05/26/07. -’ D There was no indication on the MARs or on the Nurse's notes that the resident 's , care plan and physician ordered medication interventions were put in place. . qt “Resident flow record and MARS indicate the. resident was without BMs on I. ‘The resident did not receive the MOM if no bowel movement in 2 days. 1 The resident did not receive an-enema if no BM in 3 days ; a 1 The resident did not receive a suppository after supper on the 3™ day if no BM. - 1 .On 05/27/07 in the evening, a "medium" BM was indicated on the resident's flow tecord . : : CO aE . On 07/11/07, during a meeting from 10:24 AM to 10:57 AM with the DON, ADON, MDS coordinator and Administrator, the DON confirmed that the facility staff did not implement the resident #8's constipation care plan nor did they provide medications to prevent constipation as ordered by the physician. The DON was. unable to provide an explanation as to why staff members were not following the physician's orders. 8. The regulatory provisions of the Fla. Stat. (2006) that is pertinent to this alleged violation read as follows: 400.23 Rules; evaluation and deficiencies; and licensure status- (8)(b) A’ class II deficiency is a deficiency that the agency “determines has compromised the resident's ability to maintain or reach his or her highest . practicable physical, mental, and psychosocial well-being, as defined by:an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II.deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for-a patterned deficiency, and $7,500 for a widespread deficiency: The fine amount shall be doubled for each deficiency if the facility.was previously cited for one or more class I or class II deficiencies during the last annual inspection’ ot any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. + ok oF 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. In. addition to license categories authorized under part II of chapter 408, the. agency shall assign a licensure status of standard or conditional to each nursing home. 59A-4.107 Physician Services, (5) All physician orders shall be followed as prescribed, and if not followed, the Teason shall be recorded on the resident’s medical record during that shift. oe ox 9. The violation alleged herein constitutes a class II deficiency, and warrants a fine of $2,500.00 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 $2,500.00 10 PRAYER FOR RELIEF _ WHEREFORE, the Petitioner, State. of . Florida Agency for Heald Care | Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count L 2. ‘Assess against Lafayette Health Care Center an administrative fine in the amount of $2,500.00 for the violations cited above. 3. Assess. against Lafayette Health Care Center a: conditional license in accordance with Section 400.23(7), Florida Statutes (2007). 4. Grant such other relief as the court deems is just and proper. ae Respondent i is notified that it has a right to request an administrative’ heating pursitant to Section 120.569, Florida Statutes (2006). 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 oO. . 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. Il Respectfully Submitted this _/ 7: of Bpbe mb rx, 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 | I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail on / / B of i be , 2007 to Richard D. Wisdahl, Administrator, Lafayette Health Care Center, 512 W. Main Street, Mayo, Florida 32066 Michael O. Mathis, Esquire 12 Return Recie; {Endorsement Hoque, Restricted Dai (Endorsement Hoddinea 7003 L040 O000 9725 3249 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 ~ so that we can return the card to you, @ Attach this card to the back of the mailpiece, or on the front If space permits. © Agent CO Addressee GC. Date of Delivery B. Received by (Ryintad Nara) y oy am D. Is delivery acidress different from item 17 D Yes \f YES, anter delivery address balow: ONo ian . TL BaAswe ervice N qe, ss \Ns * noertea Mail _ (1 Express Mall RE ' aden aX —_ . As, CO Registered C1 Return Rerelpt for Merchandise Gat insured Mail 1 G.0.0. 4, Restiicted Delivery? (Extra Fee) 0 Yes 2. Article Number , A (Transfer fram service label) 7003 14010 no00 4715 3eb4 PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1085

Docket for Case No: 07-004637