O¥- 0365 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2007011973 : AHCA No.: 2007011974 ve Return Receipt Requested: 7004 2890 0000 5525 7460 HEALTH CARE AND RETIREMENT 7004 2890 0000 5525 7514 CORPORATION OF AMERICA d/b/a 7004 2890 0000 5525 7521 HEARTLAND HEALTH CARE - PROSPERITY OAKS, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the State of Florida, Agency for Health Care Administration (hereinafter “AHCA”), by and through’ the undersigned counsel, and files this administrative complaint against Health Care and Retirement corporation of America d/b/a Heartland Health Care - Prosperity Oaks (hereinafter “Heartland Health Care - Prosperity Oaks”) pursuant to Chapter 400, Part II and Section 120-60, Florida Statutes, (2006) hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $2,500.00 pursuant to Sections 400.23(8) (b), Florida Statutes (2006), [AHCA No.: 2007011973]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes (2006), [AHCA No. 2007011974]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes (2006), and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Palm Beach County pursuant to Section 120.57, Florida Statutes (2006), and Rule 28-106.207, Florida Administrative Code (2006). PARTIES 5. AHCA is the ‘regulatory authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes (2006), and Rule 59A-4, Florida Administrative Code. 6. Heartland Health Care - Prosperity Oaks operates a 120-bed skilled nursing facility located at 11375 Prosperity Farms Road, Palm Beach Gardens, Florida 33410. Heartland Health Care - Prosperity Oaks is licensed as a skilled nursing facility under license number 1212096. Heartland Health Care - Prosperity Oaks 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. COUNT I HEARTLAND HEALTH CARE - PROSPERITY OAKS FAILED TO PROVIDE CARE AND SERVICES TO RESIDENTS. SECTION 400.102, FLORIDA STATUTES SECTION 400.022(1) (1), FLORIDA STATUTES RULE 59A-4.019, FLORIDA ADMINISTRATIVE CODE (HEALTH AND SAFETY OF RESIDENT STANDARDS) CLASS II 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Heartland Health Care - Prosperity Oaks was cited with one (1) Class II deficiency found during a licensure survey that was conducted from September 10, 2007 to September 12, 2007. 9. A licensure survey was conducted from September 10, 2007 to September 12, 2007. Based on observation, record review and interview, it was determined the facility failed to provide care and services to 2 of 23 sampled residents (Resident #8 and #15). The facility did not assess and provide the necessary care and services in a timely manner following a fall which resulted in a hip fracture for Resident #8, the resident suffered pain and decreased mobility during a 5-day delay in treatment. The facility failed to ensure adequate supervision to prevent injuries from a fall, which was avoidable, that resulted in a hip fracture for Resident #15. Findings include the following. 10. Resident #8 was admitted to the facility on 9/26/2006 with the diagnosis of Cerebrovascular Accident (CVA). 11. On 9/10/07 at 12:30 PM, Resident #8 was observed sitting in a wheelchair in his/her room. The Resident was unable to move his/her right arm due to paralysis. The resident responded to a greeting stating "I'm fine." The resident was again observed in his/her room sitting in wheelchair during lunch on 9/11/07 at 1210 PM. The resident was not able to converse other than with “yes” or “no” answers. 12. The resident was asked if he/she remembers falling and sustaining hip fracture. The resident answered yes. The resident was asked if he/she is now able to walk. The resident said yes. The resident was observed ambulating with physical therapist at 12:30 PM on 9/11/07, using a cane. 13. A Minimum Data Set (MDS) assessment was completed on 10/6/2006. The MDS coded the resident as having memory impairment and modified skills for decision making. The MDS also documented that the resident required physical assistance of at least two (2) persons for transferring between chair and bed. A MDS dated 4/25/07 coded the resident as having no cognitive or memory deficits. The MDS also documented that the resident required minimal assistance from 1 person for transferring between chair and bed. 14. Physical therapy evaluation on 9/27/2006 documented "resident presents with impulsive behavior, very impaired balance and perception, requires 2-3 persons for mobility." Speech therapy evaluation of the resident on 9/27/2006 documented "Severe expressive aphasia." Occupational therapy notes dated 10/11/2006 documented "resident has difficulty making needs known." 15. A Nursing plan of care completed on 9/27/2006 documented that the resident was at risk for falls, and required assistance for activities of daily living. The listed approaches included use of proper assistive device, assist with toileting as requested, re-orientation/cueing as needed, assist with daily care as needed, ensure proper body alignment when in bed or chair and reposition frequently. 16. Review of these plans of care through 5/2/2007 listed additional approaches of: low bed with mats, toilet resident upon rising, before meals and at bedtime, bladder patterning, and transfer with assistance of one (1). There was no plan of care for impaired communication. 17. A nurse's note, dated 6/2/2007 at 8 PM, documented: The Nursing Assistant stated that while transferring resident from the shower chair to the wheelchair, he/she had to lower the resident to the floor. An assessment was done and there was no sign of apparent injury. The resident was assisted back to the wheelchair. 18. The doctor was notified. All safety and comfort measures maintained; will continue to observe. 19. Nurses' notes documented resident complained of right leg pain on 6/2/07 at 10:45 PM and was given medication. A physician's telephone order was written on 6/2/07 at 11 PM for "X-ray to right leg/ankle." 20. On 6/3/07 at 9 AM the resident had complaint of pain documented with Tylenol given. On 6/3/07 at 5:55 PM nurse's note documented an X-ray of the right leg/ankle was done and that the resident had no complaint of pain or discomfort. An X-ray result dated 6/3/07 reported arthritis of the right ankle and normal tibia and fibula. 21. There was no other documentation in the nurses' notes that the resident was assessed or treated for pain. 22. A physician's telephone order was written on 6/7/07 for "X-ray to right hip and pelvis." 23. The facility received a faxed report of the x-ray results on 6/7/07 at 21:38 hours (9:38 PM), documenting an intertrochanteric fracture of the right hip. A nurse's note dated 6/7/07 at 10:45 PM documented that the X-ray report was received. The nurse's note further documented that the report was faxed to the doctor at 11:15 PM and that a call was placed to the doctor via answering service to which there was no answer. 24. On 6/8/2007 at 8:30 AM a physician's order was given for the resident to be transferred to an acute care hospital for treatment of the hip fracture. 25. Nurse's notes on 6/8/07 documented as a "late entry" that the physical therapist reported that the resident was having muscle spasms to the right leg and complained of knee pain the day before. The physician was notified and the nurse was told that the resident would be seen the following morning. There was no documentation that the resident was seen by the physician. 26. Review of the Medication Administration Record (MAR) revealed that the resident received acetaminophen (pain reliever) daily on 6/4, 6/5, 6/6, 6/7 and 6/8/07. Medication notes on the MAR on 6/4/07 documented resident complained of leg spasms. Notes on 6/7/07 documented medicine given for right leg pain. There was no other medication note documented to indicate the purpose for which the pain reliever was administered. 27. An interview was conducted with the Director of Physical Therapy (PT) on 9/11/07 at 12:15 PM and revealed the following: The PT director stated that the resident was admitted with severe expressive aphasia and had a difficult time making needs known. The resident had improved and was walking with supervision until the resident sustained a slip and fall in June. 28. An interview was conducted with the facility's Administrator/Risk Manager on 9/12/07 at 1:25 PM. The Administrator was asked what assessment had been completed of the resident after falling on 6/2/07 and prior to the X-ray of the pelvis and hip. The Administrator stated that the resident was ambulatory after each of his/her prior falls, but was not ambulatory after the fall on 6/2/07 due to pain. The Administrator was then asked if there was documentation of the pain and decreased mobility. The Administrator replied that the documentation was not there to support what really took place. 29. A review of the clinical record for Resident #15 revealed that the resident was originally admitted to _ the facility on 4/16/1999 and was readmitted to the facility on 3/22/2007 after a brief hospitalization for an Open Reduction Internal Fixation of a left hip fracture. 30. The resident also had diagnoses that included Dementia, history of Cerebrovascular Accident (CVA) with the left sided weakness. 31. A 1/29/2007 Annual Minimum Data Set (MDS) documented that the resident had short and long term memory problems and was moderately impaired {decisions poor, cues/supervision required) for decision making regarding tasks of daily life. The resident was limited assistance of one person physical assist for bed mobility, walking in the room, and toilet use. The resident required supervision of one person physical assist for transfers. The resident also had a fall in the last 31 - 180 days. 32. A 8/9/2006 care plan was initiated that identified a problem that the resident needs assist for transfers, is at risk for falls and related injury secondary to old CVA with left hemiparesis. Also identified on this care plan was- the resident's risk factor of "lack of awareness of safe parameters and impulsive behavior. Interventions identified on this care plan were: a. Keep environment free of clutter and obstacles b. Encourage the use of hipsters c. 1 person assist for transfers d. Remind the resident to call for assist e Re-educate re: calling for assistance (12/1/2006) 33. A review of the nurses' notes revealed that on 11/30/2006 at 8:30 PM, the resident was found on the floor in the bathroom. There was no apparent injury to the resident after this fall. The care plan was updated to re-educate the resident, re: calling for assistance. 34. A Falls MDS Rap module was completed on the resident. However there was no nurse's signature or date on this form. The form documented that the resident had incontinence and CVA with hemiparesis, resident received medication that contributed to the fall. The resident exhibited signs and symptoms of acute confusion, the resident wandered without regard to fatigue and the resident had cognitive factors or conditions impacting the resident's risk for falls. 35. The resident has a history of fall or multiple falls, unsteady gait, resident requires the use of an appliance to assist with locomotion (walker, cane, wheelchair) and the resident has the reduced or lost use of a limb (arm or leg). 36. The nurse documented that the resident "received sleeping medication, went to bed then woke up to go to the bathroom. Resident has a history of confusion that might have contributed to fall." 37. A 12/27/2006 8:30 PM nurse's note documented that the resident was out of bed in the bathroom. The resident "fell in sitting position". No apparent injury. 38. A Change in status - Fall Care TIP (Targeted Implementation Plan) was completed for this 12/27/2006 fall. Documented under the section of the Clinical Plan was the following: a. Monitor vital signs. 10 b. Monitor changes in mental status for 72 hours Monitor changes in Activities of Daily Living (ADL) functions or appetite. c. Monitor changes in neurological status. d. Initiate or change device, e.g. mat on floor, clip or sensor alarm. e. Refer to other departments, e.g. rehabilitation therapy, pharmacy or activities. f. Initiate or review and modify interdisciplinary care plan to reduce the risk of fall. g. Recurrence or injury due to fall. 39. The facility failed to update the resident's care plan after this 12/27/2006 fall to reflect the resident's needs as indicated on the Fall Care TIP. The resident sustained two falls on the 3-11 shift within a month, related to not calling for the assistance of the staff for toileting needs. 40. A 3/13/2007 10:45 PM nurse's note documented that "upon entering the resident's room, the resident was lying on the floor on his/her left side. The resident stated that he/she was ambulating to the bed from the bathroom, using his/her cane and fell.” 41. The resident complained of pain to the left hip. The resident was put to bed by the staff. The resident was unable to ll bear weight on his/her left leg. Physician notified and ordered an immediate (stat) X-Ray." 42. A 3/14/2007 Diagnostic Imaging Report of the pelvis documented that the resident had an "intertrochantic displaced fracture of the left femur with superior migration of the distal fragment over -riding." 43. A March Florida ADL worksheet documented daily that the resident was continent for bowels and bladder on the 11-7 and 7-3 shifts and was incontinent of urine on the 3-11 shift. The resident required extensive assistance of one person for transfers, on the 7-3 shift and on the 3-11 shift the resident was independent. The resident required extensive assistance of one person for toileting on the 7-3 shift and limited assistance on the 3-11 shift. 44. A review of the investigation of the fall documented that on 3/13/2007 at approximately 10:50 PM, the resident got up and was ambulating to the bathroom using his/her walker. Resident misstepped and fell on his/her left side. The Resident was ound on the floor by the Certified Nursing Assistant (CNA). Resident sustained a left hip fracture and was sent to an acute care facility for treatment. 45. A statement from the nurse documented that at 10:45 PM nurse was called to room --W. Resident was lying on the floor on his/her left side. The resident was alert and responsive. The 12 resident stated that he/she was coming from the bathroom going to his/her bed and fell. Resident was using his/her cane. Staff picked resident up and put the resident into bed. Resident complained of left hip pain. No other injuries noted. 46. This investigation did not have any documentation concerning the resident's statement of what happened. There was not any documentation as to when the resident was last toileted, or whether the resident's call light was on or off at the time of the fall. Additionally, despite the resident having previous falls and risk factors of "lack of safety awareness and impulsive behavior", the facility did not implement interventions for the resident's assessed need for more supervision/and or monitoring. 47. The resident had multiple attempts of transferring without assistance, increasing periods of confusion and impaired judgment about abilities. The interventions documented were to continue to reeducate the resident to use the call light. 48. An interview was conducted with the resident on 9/11/2007 at 1:45 PM. The resident stated that the staff did not help him/her with toileting and prior to the resident breaking his/her hip, the resident felt that he/she had to toilet him/herself. 49. The resident also stated that the staff did not come fast enough to answer the call light. The resident then stated that he/she was a nurse, so he/she knew what should happen. 50. An interview was conducted with the MDS Coordinator on 9/12/2007 at 10:30AM. Reviewed the resident's MDS and care plan. Discussed with the coordinator concerning the resident's risk factors and the interventions documented. After much discussion, it was confirmed that other interventions were more appropriate for the resident's needs. 51. An interview was conducted on 9/12/2007 at 11:30 AM with the Administrator/Risk Manager. Reviewed the resident's fall. The Administrator felt that the interventions in place were appropriate and re-educating a resident that "lacked safety awareness and had impulsive behavior" was appropriate. 52. The facility wanted to have in place the least restrictive intervention. Discussed with the Administrator the use of censors or alarms that was documented as a monitoring tool on the clinical care plan on the care TIP that was not implemented. The resident was alert with some confusion. Reviewed the investigation with the Administrator. 53. Further documentation on the investigation for corrective action was "upon return to the facility the resident was reassessed and picked up by therapy. Resident re-educated on asking for help when needed. This was an isolated incident." The 14 resident had 2 other documented falls associated with toileting within 90 days of the 3/13/07 fall. 54. The facility failed to address the resident’s assessed needs to prevent further falls. The resident's fall was avoidable. 55. Based on the foregoing facts, Heartland Health Care - Prosperity Oaks violated Section 400.102, Florida Statutes (2006), Section 400.022(1) (1), Florida Statutes (2006), and Rule 59A-4.019, Florida Administrative Code, herein classified as an isolated Class II violation pursuant to Section 400.23(8), Florida Statutes (2006), 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 (2006). DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes (2006), Heartland Health Care - Prosperity Oaks shall post the license in a prominent place that is clear and unobstructed public: view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit “A”

Docket for Case No: 08-000385