STATE OF AGENCY ADMINIS Peti VS, ST. ANNE ST. ANNE} STATE OF FLORIDA “Dp tf AGENCY FOR HEALTH CARE ADMINISTRATION “43. 4 sono OY-0T9- OR HEALTH CARE Og OS RATION, ae tel f, tioner, Case Nos. 2007009915 (Fine) 2007009919 (CL) S NURSING CENTER, S RESIDENCE, INC., Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the tandersigned counsel, and files this Administrative Complaint against ST. ANNE’S NURSING CENTER, ST. ANNE’S RESIDENCE INC. (hereinafter “Respondent”), pursuant to Sections 12.569 and 120.57 Florida Statutes (2006), and alleges: This NATURE OF THE ACTION lis an action against a skilled nursing facility to impose an administrative fine of ONE THOUSAND DOLLARS ($1,000.00) pursuant to Section 400.23(8)(c), Florida Statutes (2006), based upon gne uncorrected Class III deficiency and assign conditional licensure status beginning on May 14, 7007, and ending on August 28, 2007, pursuant to Section 400.23(7)(b), Florida Statutes (2006). The original certificate for the conditional license is attached as Exhibit A and is incorporated|by reference. The original certificate for the standard license is attached as Exhibit B and is incorpprated by reference. JURISDICTION AND VENUE 1. The |Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2006). 2. The|Agency has jurisdiction over the Respondent pursuant to Section 20.42, Chapter 120, and Chaptey 400, Part I, Florida Statutes (2006). 3. Venhe lies pursuant to Rule 28-1 06.207, Florida Administrative Code (2006). PARTIES 4, The |Agency is the regulatory authority responsible for the licensure of skilled nursing facilities and the enforcement of all applicable federal and state statutes, regulations and rules governing skilled nursing facilities pursuant to Chapter 400, Part Il, Florida Statutes (2006) and Chapter 594-4, Florida Administrative Code (2006). The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to Sections 400.121, and 400.23, Florida Statutes (2006); assign a conditional license pursuant to Section 400.23(7), Florida Statutes (2006); and Assess costs related to the investigation and prosecution of this case pursuant to Section 400/121, Florida Statutes (2006). . 5. Respbndent operates a 240-bed nursing home, located at 11855 Quail Roost Drive, Miami, Florida 33177, and is licensed as a skilled nursing facility, license number 1515096. 6. Resppndent was at all times material hereto, a licensed skilled nursing facility under the licensing authority of the Agency, and was required to comply with all applicable state rules, regulations and statutes. COUNT I The Respondent Failed To Follow Physician Orders In Violation Of Rule 59A-4.107(5), Florida Administrative Code (2006) 7. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6). 8. Pursuant to Florida law, all 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. Rule 59A-4.107(5), Florida Administrative Code (2006). 9. On pr about May 14, 2007, the Agency conducted a Complaint Investigation (CCR# 200700481B) at Respondent’s facility. 10. Based on record review, review of facility policy and interview, the facility failed to ensure that physician orders were followed specific to the failure to hold administration of insulin for a blood sugay of less than 70 mg for one (1) of five (5) sampled residents, Resident number one (1). The failure fo follow physician's orders in a resident's status contributed to a further decline of blood sugar|to a critically low level resulting in compromised physical and mental changes in Resident number one’s (1) health condition. 11. Profpssional Standard of Care is defined in Section 766.102 Florida Statutes (2006) as, "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers." 12. The Florida Nurse Practice Act, Section 464.003 Florida Statutes (2006) defines the "practice of professional nursing" as "the performance of those acts requiring substantial specialized Knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to, the administrations of medications and treatments as prescribed or authorized by a duly licensed practitioner.’? “Practice of practical nursing" means the performance of selected acts, including the administratidn of treatments and medications, in the care of the ill, injured, or infirmed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of 4 registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. 13. Resident number one’s (1) clinical record indicated the resident had a diagnosis which included, byt was not limited to, diabetes mellitus, morbid obesity, arteriosclerotic heart disease and atrial fibrillation. A review of the April 2007 physician orders revealed the resident had humalog 75/25 insulin ordered in the morning and the evening. The morning and evening doses of insulin had specific blood sugar parameters, which stated when the nurse should not administer the insulin. The specific parameters were to hold the insulin for blood sugar below 70. The normal blood sugar range is 70-110. As of April 12, 2007 the orders for the humalog 75/25 insulin were as follows: The morning dose was 30 units and the evening dose was 42 units. Resident number one (1) also had| the antidiabetic medication Actos 45 mg ordered daily at 9:00 a.m. According to the Drug Information Handbook for Nursing 2007 (Turkoski, Lance, Bonfiglio, 2007) Actos mechanism pf action is lowering the blood glucose by improving target cell response to insulin. 14. ResiHent number one’s (1) clinical record had a nursing note dated April 16, 2007 at 6:00 a.m., which|stated the following: "Call light assessable. Respirations even. No bowel movements. Foley in plate to straight drainage, tubing free of kinks, draining dark amber urine. Blood sugar 45. Residenj alert and oriented times 3 and denies distress or discomfort. Skin warm and dry. One four ounce glass juice offered and blood sugar rechecked at half hour later. Blood sugar 41. - Resident still alert and oriented times 3 and denies discomfort of any kind. Denies feeling faint or dizzy. Skin warm and dry. Medicated with Novolin 70/30 per standard order and another glass of Juice offered and. taken. Blood sugar rechecked half hour later. Blood sugar 78. No change in his/her condition. Pulse 88 with regular rhythm, respirations 22, blood pressure 170/100." There was no documentation that the physician was contacted about the low blood sugar results of 45 and 41, yet the imsulin was given after the juice was given. 15. A reyiew of Resident number one’s (1) April 2007 medication administration record revealed humalog 75/25 insulin 42 units was documented with initials as administered on April 16, 2007 in the morning. Novolin 70/30 insulin was not documented on the medication administration record. Novolin 70/30 was never ordered. The nurse administered the morning insulin although Resident number one (1) had had blood sugars assessed twice below 70. The order specified that the insulin should be held if the blood sugar was below 70. There was no documentation which indicated the physician was contacted. 16. A reWView of the facility policy entitled blood glucose monitoring revealed “treatment of critically low glucose levels shall depend on physician orders and may include transfer to the nearest Emergency Department.” There was no documentation in Resident number one’s (1) clinical record indicating the nurse contacted the physician about the critically low glucose (blood sugar) level of 45 and 41 at 6:00 a.m. on April 16, 2007. 17. The following nursing note after the April 16, 2007, 6:00 a.m. entry was at 11:35 a.m. This 11:35 a.m. nursing note stated the following: “Received resident in bed noted resident with slurred speech, left eye pupil fixed, right eye pupil dilated. Resident unable to state or make complaints yoiced. Blood pressure 136/69, respirations 20, oxygen saturation 95% with 2 liters of oxygen via nasal cannula. Blood sugar 23. Gave 1 ml of glucagon IM. At 11:40 a.m. Blood sugar 31. M.D. (medical doctor) notified. New orders received to repeat glucagon 1 mg IM times 3 until blood sugar js above 60. 911 notified. Family made aware. Nurse at bedside.” 18. A review of Resident number one’s (1) verbal physician orders revealed an April 16, 2007, 9:00 a.m. order for the following: Glucagon 1 mg IM (intramuscular) now repeat times three until blood sugar {s above 60; stat (right away) PT/INR (laboratory tests); D50 half amp; DSW at 40cc/hour for twenty-four (24) hours; check blood sugar every two (2) hours for twenty-four (24) hours, and Hold insulins until blood sugar is WNL (within normal limits). 19. According to the Drug Information Handbook for Nursing 2007 (Turkoski, Lance, Bonfiglio, 2007) the mechanism of action for glucagon is to raise blood glucose levels. 20. The following nursing note after the April 16, 2007, 11:35 a.m. entry was at 11:45 a.m. This 11:45 a.m. nursing note stated the following: “Gave 1ml of glucagon at 11:45 a.m. Blood sugar after,|51. New orders received from M.D. Nurse at bedside.” The next nursing note was at 11:50 a.m.,|which stated the following: “Gave tml of glucagon at 11:50 a.m. Blood sugar is 61. Paramedics arrived. Started an IV (intravenous) site and infused D5 W at 40cc/hour. Resident able to speak clgarly. Pupils PERRLA (pupils equal responsive reactive to light, accommodation). Blood sugar 64. Blood pressure 117/70. Heart rate 69. Oxygen saturation 96% at 2 liters of oxygen via nasal cannula. Respirations 18. Resident did not go to hospital. Resident in stable condition. Will continpe to monitor resident." 21. | Ardview of Resident number one’s (1) April 2007 medication administration record revealed that three (3) doses of glucagon 1 mg were administered as addressed in the nursing notes. The morning dose of Actos 45 mg was documented as administered at 9:00 a.m. on April 16, 2007. Blood sugar assessment was done at 11:00 a.m. with a result of 23; 1:00 p.m. with a result of 100; 3:00 p.m. with a result of 65, and 5:00 p.m. with a result of 103. 22, The/following nursing note after the April 16, 2007 note had an illegible date and time documented because it was written over. The nursing note started with the illegible date and then in the middle of the note it continued with the entry being dated as April 17, 2007. 23. A certified nursing assistant note called “CHS-Meal and Fluid Detail Report indicated an entry dated April 16, 2007, 11:30 a.m. percent of breakfast consumed was 100% and fluid intake was 240ccs| 24. An interview with the Risk Manager who was a licensed nurse on May 14, 2007 at approximately 12:30 p.m. was conducted. The surveyor reviewed Resident number one’s (1) clinical reeqrd and the nursing notes for April 16, 2007 with the Risk Manager. The Risk Manager indicated the Risk Manager had helped the staff that morning. The Risk Manager indicated the Risk Manager was not aware that the nurse had administered the routine morning insulin to Resident number one (1) on April 16, 2007 although the blood sugars were low. The Risk Manager indicated the Risk Manager would not have given the insulin to the resident. 25. Anipterview with the Director of Nursing who was a licensed nurse on May 14, 2007 at 3:15 p.m. was conducted. The surveyor reviewed Resident number one’s (1) clinical record and the nursing notqs for April 16, 2007 with the Director of Nursing. The Director of Nursing indicated the Directoz| of Nursing would not have given the insulin to the resident. 26. Resident number one’s (1) clinical record had a nursing note dated March 31, 2007 at 7:00 a.m. which read “At 3:00 a.m. blood sugar 160 medicated with regular insulin 3 units.” A review of the April |2007 orders and April medication administration record revealed that there was no insulin sliding scale coverage ordered for blood sugars below 201. There was no additional verbal order which|documented insulin coverage should be given to the resident at that time. An interview with the Director of Nursing on May 14, 2007 at 3:15 p.m. was conducted. The surveyor reyiewed Resident number ones (1) clinical record and the nursing notes for March 31, 2007 with the Director of Nursing. The Director of Nursing confirmed that there was no documented] order which indicated the resident should have received insulin coverage for the blood sugar of 160. 27. The Agency determined that this deficient practice will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision offservices. The Agency cited the Respondent for a Class III deficiency as set forth in Section 400/23(8)(c), Florida Statutes (2006). 28. The Agency provided Respondent with a mandatory correction date of June 14, 2007. 29. Onjor about June 28, 2007, the Agency conducted an unannounced visit regarding the Complaint |Investigation (CCR#2007004813) of Respondent’s facility. 30. Based on record review and interview, the facility failed to ensure that physician orders were followed specific to the failure to administer insulin as ordered; failure to administer insulin coverage as ordered; failure to contact the physician when the insulin was not administered for five (5) of five (5) sampled residents who required routine insulin medication; Resident number one (1), Resident number two (2), Resident number three (3), Resident number four (4), and Resident number five (5). The failure to follow physician's orders and promptly report the resident’s status can potentially place the resident at risk for a decline in health and altered blood sugar results. 31. Professional Standard of Care is defined in Section 766.102 Florida Statutes (2006) as, "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers." 32. The|Florida Nurse Practice Act, Section 464.003 Florida Statutes (2006) defines the “practice of|professional nursing" as "the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to, the administrations of medications and treatments as prescribed or authorized by a duly licensed practitioner!” "Practice of practical nursing" as the performance of selected acts, including the administratipn of treatments and medications, in the care of the ill, injured, or infirmed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. 33. Resident number one’s (1) clinical record included, but was not limited to, a diagnosis of Diabetes Mellitus. A current June 2007 physician’s orders included accuchecks for blood sugars at 6:00 a.m., 12:00 p.m., 4:30 p.m. and 9:00 p.m. Novolin 70/30 insulin with the dosage of 35 units was ordered every morning, and the dosage of 25 units was ordered every evening. At 12:00 p.m. Humulin Rjinsulin with the dosage of 10 units was ordered daily. There was an insulin sliding scale for Novolin regular ordered for blood sugar results as follows: 200-300=10 units; 301- 400=15 units; 401-500=20 units, and greater than 500 call the physician. The insulin sliding scale was for the accuchecks conducted at 6:00 a.m., 4:30 p.m. and 9:00 p.m. 34. A review of Resident number one’s (1) current June 2007 medication administration record revealed the following: On June 13, 2007 at 6:00 a.m. the resident’s accucheck result was 105. On June 14/2007 at 6:00 a.m. the resident’s accucheck result was 77. There was no routine morning insulin. Novolin 70/30 with the dosage of 35 units was administered to the resident on June 13, 2007 and June 14, 2007. There was no physician's order to hold the routine morning insulin if th¢ accucheck result was at a certain level. There was no documentation in the resident's medication administration record or clinical record indicating that the physician was contacted about the morning Novolin 70/30 insulin not being administered as ordered. There was no routine morning insplin administered on June 23, 2007 at 6:00 a.m. There was no routine evening insulin administered on June 24, 2007 at 4:30 p.m. On June 19, 2007 at 6:00 a.m., on June 23, 2007 at 6:00 a.m., and on June 24, 2007 at 4:30 p.m. there was no documentation indicating the resident's accucheck results. There was no documentation in the resident's medication administration record or clinical record indicating the reason why the routine insulin for the moming of June 23, 2007 was not administered; the reason why the routine insulin for the evening of June 24, 2007 was not administered, and the reason why the June 19, 2007 at 6:00 a.m., June 23, 2007 at 6:00 a.m. and the June 24, 2007 at 4:30 p.m. accuchecks were not done. There was no documentation indicating that the physician was contacted about the routine insulin not being given as ordered for June 23, 2007 at 6:00 a.m. and on June 24, 2007 at 4:30 p.m., and that the June 24, 2007, at 4:30 p.m. accucheck was not done. 35. An jnterview with the day nurse caring for Resident number one (1) on June 28, 2007 at 3:00 p.m. revealed if the resident's morning blood sugar is 100 then the routine morning insulin should not be given. The resident's blood sugar should be rechecked at breakfast time and then administer the routine insulin with breakfast. If the resident's blood sugar is less than 100 and the resident is rot eating, then there is glucagon and glucose gel available in the emergency medication kit should it be needed. Resident number one’s (1) clinical record did not include orders to hold the insulin if the blood sugar is 100 or less. 36. An dbservation of the medication room on the first floor on June 28, 2007 at 3:00 p.m. revealed there was an emergency kit with a contents list which included glucagon injection 1mg/vial andl insta-glucose 31 gram. 37. Anipterview with the nurse manager, Risk Manager and the Director of Nursing on June 28, 2007 at #:30 p.m. confirmed there was no documentation reflecting that the resident was administered the routine morning insulin on June 13, 2007, June 14, 2007, and June 23, 2007. There was nb documentation indicating that the physician was notified about the routine moming insulin not being given as ordered. There was no documentation reflecting that the accuchecks were done for June 19, 2007 at 6:00 a.m., June 23, 2007 at 6:00 a.m. and June 24, 2007 at 4:30 p.m. The nutse manager indicated that the resident often goes out of the facility on pass on the weekend and that this may be the reason why the accucheck was not done on June 24, 2007 at 4:30 p.m. 38. Resident number two’s (2) clinical record included, but was not limited to, a diagnosis of chronic obstructive pulmonary disease and fractured femur. A current June 2007 physician's order included Npvolog insulin 10 units with breakfast and lunch, and Novolog insulin 5 units with dinner. Acduchecks for blood sugar results were ordered before meals at 6:30 a.m., 11:00 a.m., and 4:00 p.m. ahd at bedtime at 9:00 p.m. An insulin sliding scale for the accucheck results included Novolog coverage as follows: 201-250= 2 units; 251-300=3 units; 301-350=5 units; 351-400=8 units; 401-450=11 units, and if greater than 300 call the physician. 39. A review of Resident number two’s (2) current June 2007 medication administration record revealed there was no routine evening insulin administered to the resident on June 22, 2007 at 4:30 p.m. The acpucheck result at that time was 70. There was no documentation in the medication | administratipn record or the resident's clinical record as to why the resident was not administered the routine ¢vening insulin on June 22, 2007. A snack was given at 4:00 p.m. At 9:00 p.m. on June 22, 2007 tha accucheck result was 285. There was no documentation in the medication administration record or the resident's clinical record indicating that insulin coverage according to the sliding stale was given. A nursing note dated June 22, 2007 revealed the resident's accucheck was 354 at 1/1:30 a.m. There was no documentation in the nursing note or on the medication administration record, which indicated that insulin coverage was administered according to the sliding scale] There was no routine evening insulin administered to the resident on June 26, 2007 at 4:30 p.m. The accucheck result at that time was 79. There was no documentation in the medication administration record or the resident's clinical record indicating the physician was contacted about the resident'y accucheck being 79 and that the routine evening insulin was held. The accucheck result was 547 on June 26, 2007 at 9:00 p.m. with 11 units of insulin administered. There was no documentation in the medication administration record or clinical record which indicated that the physician was notified of the elevated accucheck result. The insulin sliding scale did not specify to give 11 units of insulin for an accucheck result of 527. The orders stated to call the physician for accuchecks|greater than 300. The insulin sliding scale specified accuchecks for 401-450 give 11 units of inswlin, but the resident’s accucheck was greater than 450. There were no 6:00 a.m. accucheck results documented for June 24, 2007, June 25, 2007 and June 26, 2007. The routine lantus insulin ordered with breakfast was administered on June 25, 2007 and June 26, 2007. There was no accucheck result for June 24, 2007 (4:00 p.m.) documented, but the Novolog insulin 5 units was given at dinner (4:30 p.m.). 40. An ihterview with the evening nurse caring for Resident number two (2) on June 28, 2007 at 5:25 p.m.revealed that there is no order to call the physician if the resident's blood sugar is less than 70-75. |The evening nurse indicated it was a nursing judgment whether to give or not give the routine everjing insulin dose. The physician should be contacted if the routine insulin is not given. The resident should be given food if the accucheck is low. The nurse indicated glucagon injection is available if the resident cannot swallow, and glucose gel is available if the resident can swallow. The accuchack should be rechecked if it was low. Resident number two’s (2) clinical record did not include orders to hold the insulin if the blood sugar was less than 70 or 75. There was no documentatipn that the physician was contacted about the June 22, 2007 and June 26, 2007 routine evening insulin not being given. 41. Aninterview with the nursing supervisor on June 28, 2007 at approximately 5:30 p.m. revealed that it was difficult to read the accucheck results written on the medication administration record. The nurses’ documentation of the accuchecks were written in different ways, such as vertically, hq¢rizontally or written over in the spaces provided for the date, time, result, coverage and site. 42. Resident number three’s (3) clinical record included, but was not limited to, a diagnosis of cellulitis of the foot, decubitus ulcer and convulsions. The current June 2007 physician's orders included an| Actos 30mg tablet once a day and accuchecks ordered two times a day (6:30 a.m. and 4:30 p.m.). |An insulin sliding scale of novolin regular insulin for the following accucheck results read: 200-300=10 units; 301-400 =15 units; 401-500=20 units, and greater than 500 call the physician. The current June 2007 physician order sheet and the current June 2007 medication administration record had “discontinued (“d/cd " ) written next to the insulin sliding scale. A review of Resident number three’s (3) clinical record revealed there was no official order documented indicating that the insulin sliding scale was discontinued as of May 14, 2007. The May 2007 medication administration record had “discontinued” written next to the insulin sliding scale beginring on May 14, 2007. Although “discontinued” was written next to insulin sliding scale on the|June 2007 medication administration record, the nurse administered the insulin coverage to [Resident number three (3). On June 20, 2007 at 4:30 p.m., a review revealed the resident's accucheck result was 345. There was no documentation in the medication administration record or the nursing notes indicating that insulin coverage was administered to the resident. 43. An interview with the nursing supervisor on June 28, 2007 at approximately 6:00 p.m. revealed that the word “discontinue " ("d/cd" ) should not have been written on the June 2007 physician order sheet and the June 2007 medication administration record for Resident number three (3) bedause there was no official order which documented that it should be discontinued. The nursing|supervisor confirmed that the nurses continued to administer insulin coverage according tothe sliding scale although it said “discontinued.” The nursing supervisor confirmed that there was no documentation in the clinical record or medication administration record which indicated th¢ resident got insulin coverage for an accucheck result of 345 on June 20, 2007 at 4:30 p.m. 44. Resident number four’s (4) clinical record included, but was not limited to, a diagnosis of non-organic |psychosis and depressive disorder. A current June 2007 physician's orders included Actos 15mg every morning for diabetes, Novolin NPH insulin 15 units every morning (6:00 a.m.), and Glipizide ER Smg every evening (5:00 p.m.) for diabetes mellitus. A daily accucheck at 6:00 a.m. was ordered with and insulin coverage sliding scales as follows: 150-200=6 units; 201-250= 8 units; 251-3D0=10 units; 301-350=12 units; 351-400= 14 units; 401- 450= 16 units; 451-500=18 units, and greater than 500 call the physician. 45, A reyiew of the current June 2007 medication administration record revealed the June 17, 2007, routine morning dose (6:00 a.m.) of Novolin was not administered. There was no documentatipn indicating the reason why the routine morning insulin was not given. The accucheck result for June 17, 2007 at 6:00 a.m. was 174 and only insulin coverage of Novolin regular insulin 6 units was documented as administered. There was no documentation indicating that the physician was notified that the routine morning insulin was not given. The June 2007 medication ddministration record indicated the June 26, 2007 6:00 a.m. accucheck was initialed but did not document what the accucheck result was. The nursing note did not state what the 6:00 a.m. accucheck was. The Actos was not given on June 19, 2007 and June 26, 2007 but no reason or explanation Was documented on the medication administration record or nursing notes. The Glipizide ER was not given on June 27, 2007, but no reason or explanation was documented on the medication administration record or nursing notes. There was no documentation indicating that the physician was notified that the Actos or Glipizide ER was not given. 46. Resident number five’s (5) clinical record included, but was not limited to, a diagnosis of diabetes mellitus. The current June 2007 physician order sheet included Novolin 70/30 15 units before breakfast (8:00 a.m.), Novolin 70/30 insulin 10 units before dining at 4:30 p.m. and lantus insulin 20 units at bedtime (9:00 p.m.). The aceuchecks were ordered four times a day (6:00 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m.). An insulin coverage sliding scale for Novolog was as follows: 12-160=1 unit; 161-200=2 units; 201-240=3 units; 241-280=4 units; 281-320=5 units; 321-360=6 nits; 361-400=7 units, and greater than 401 call the physician. 47. Are insulin was View of the current June 2007 medication administration record revealed the lantus not given at bedtime on June 23, 2007 and June 25, 2007. There was no documentation in the medidation administration record or the clinical record which indicated the reason why the insulin was for June 23, not given at bedtime or that the physician was contacted about it. The accucheck result 2007 at 9:00 p.m. was 88. The accucheck result for June 25, 2007 at 9:00 p.m. was 294 or 296 with 5 units of Novolog insulin coverage given. 48. Aninterview with the Director of Nursing and Risk Manager on June 28, 2007 at approximatdly 4:30 p.m. and at approximately 8:00 p.m. revealed that the facility has no standing protocol for treating hypoglycemia and hyperglycemia. Each resident's case is individualized. The nurse uses his/her own judgment. The current medication administration record and documentation system used for accuchecks and insulin was in the process of being reevaluated. 49. The Agency determined that this deficient practice will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of|services. The Agency cited the Respondent for a Class III deficiency as set forth in Section 400 50. ACI $2,000 for al 23(8)(c), Florida Statutes (2006). lass III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, patterned deficiency, and $3,000 for a widespread deficiency. 51. Based upon the above findings, the Respondent’s actions, inactions or conduct constituted an uncorrected Class III deficiency pursuant to Section 400.23(8)(c), Florida Statutes (2006). 52. The Agency provided Respondent with a mandatory correction date of August 28, 2007. WHIEREFORE, the Agency intends to impose an administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Sections 400.23(8)(c) and 400.102, Florida Statutes (2006). COUNT I Assignment Of Conditional Licensure Status Pursuant To Section 400.23(7)(b), Florida Statutes (2006) 53. The Agency re-alleges and incorporates by reference the allegations in Count I. 54. The Agency is authorized to assign a conditional license status to skilled nursing facilities pursuant to Section 400.23(7), Florida Statutes (2006). 55. Due Ito the presence of one Class III deficiency that was not corrected within the time established by the Agency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part II, Florida Statutes (2006), and the rules adopted by the Agency. 56. | The Agency assigned the Respondent conditional licensure status with an action effective date of May! 14, 2007. The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. 57. The Agency assigned the Respondent standard licensure status with an action effective date of August 28, 2007. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the Respondent conditional licensure status for the period between the assignment of the conditional license and the standard license pursuant to Section 400.23(7)(b), Florida Statutes (2006). 16 CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency on Count I and Count II. 2. Impose an administrative fine against the Respondent in the amount of ONE THOUSAND DOLLARS ($1,000.00). 3. Assign a conditional license to the Respondent for the period of May 14, 2007, to August 28, 2007. 4. Assess costs related to the investigation and prosecution of this case. 5. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this gM day of Paausigp 2008. 5 Daley Wow Senior Attorney | Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3209 NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA|STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE HAS THE RIGHT TO RETAIN AND BE REPRESENTED BY AN ATTORNEY IN THIS MATTER.| SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS. ALL REQUESTS FOR HEARING SHALL BE MADE AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 922-5873. THE RESRONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT ein BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No: 7006 2150 0004 5871 1009 on Jarmacasty, Lie. 2008 to: Frank Farinélla Jr., Administrator, St. Anne’s Nursing Center, St. e’s ReSidence Inc., 11855 Quail Roost|Drive, Miami, Florida 33177 and by U.S. Certified Mail, Return Receipt No: 7006 2150 0004 $871 1016 to Patrick J. Fitzgerald, Registered Agent for St. Anne’s Nursing Center, St. Anne’s Residence, Inc., 110 Merrick Way, Suite 3-B, Coral Gables, Florida 33134. fiat Bales acobs, Senior Attomey Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3209 18 Copies furnished to: Frank Farihella, Administrator St. Anne’s|Nursing Center, St. Anne’s/Residence, Inc. 11855 Quail Roost Drive Miami, Florida 33177 Mary Daley Jacobs Senior Attorney Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C (U.S. Certified Mail) Fort Myers, Florida 33901 (Interoffice Mail) Patrick J. Hitzgerald, Registered Agent for Kriste J. Mennella St. Anne’s Nursing Center, Field Office Manager St. Anne’s Residence, Inc. 110 Merrick Way, Suite 3-B Agency for Health Care Administration 8355 N. W. 53” Street Coral Gables, Florida 33134 Koger Center (US. Certified Mail) Manchester Building, First Floor Miami, Florida 33166 (U.S. Mail)

Docket for Case No: 08-000725