STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, Ox U 4 Ta AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2008007523 (Fine) 2008007524 (CL) MELBOURNE TERRACE RCC, LLC d/b/a MELBOURNE TERRACE REHABILITATION CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against MELBOURNE TERRACE RCC, LLC d/b/a MELBOURNE TERRACE REHABILITATION CENTER (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57 Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is 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 (2007), based upon one uncorrected Class III deficiency and to assign conditional licensure status beginning on May 28, 2008, pursuant to Section 400.23(7)(b), Florida Statutes (2007). The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. JURISDICTION AND VENUE 1, The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Section 20.42, Chapter 120, and Chapter 400, Part II, Florida Statutes (2007). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. 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 II, Florida Statutes (2007) and Chapter 59A-4, Florida Administrative Code. 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 (2007); assign a conditional license pursuant to Section 400.23(7), F lorida Statutes (2007); and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Florida Statutes (2007). 5. Respondent operates a 120-bed nursing home, located at 251 Florida Avenue, Melbourne, Florida 32901, and is licensed as a skilled nursing facility, license number 13400962. Respondent 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 Ensure The Right To Adequate And Appropriate Health Care in Violation Of Section 400.022(1)(1), Florida Statutes (2007) 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5). 7. Pursuant to Florida law, all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. Section 400.022(1)(1), Florida Statutes (2007). 8. On or about Apri! 21, 2008 through April 24, 2008, the Agency conducted an Annual Survey of Respondent’s facility. 9. Based on observation, interview, and record review, the facility failed to provide appropriate pressure ulcer care and services for two (2) residents, Resident number three (3) and Resident number eleven (11), and did not provide appropriate contact isolation infection control precautions for one (1) resident with a methicillin resistant staff aureus pressure ulcer infection for one (1) resident in a sample of twenty-three (23) residents, Resident number nine (9). 10. A review of Resident number three’s (3) medical record revealed diagnoses including adult failure to thrive, cerebral palsy, and contractures in his/her legs and arms. According to the March 27, 2008 Minimum Data Set assessment, Resident number three (3) required extensive to total assistance of a staff person with all activities of daily living. 11. Nursing notes dated March 14, 2008 revealed that Resident number three (3) had been readmitted to the facility on March 14, 2008 from the hospital with intact heels. 12. Areview of the "Weekly Skin Integrity Check" assessment dated April 14, 2008 revealed a change in the condition of Resident number three’s (3) heels as follows: "heels, soft mushy". A continued review of Resident number three’s (3) "Weekly Skin Integrity Check" assessments for the preceding four (4) weeks revealed that Resident number three’s (3) heels had been intact on March 17, 2008; March 24, 2008; March 31, 2008, and April 7, 2008. 13. A review of the physician's orders and nurse's notes from April 14, 2008 to date revealed that the physician had not been notified and treatment orders had not been obtained for the mushy heels. A review of the April 2008 treatment administration record did not reveal any treatments being performed for Resident number three’s (3) heels. 14. An observation of Resident number three’s (3) right and left heel assessment with the unit manager on April 21, 2008 at about 1:00 p.m. revealed both heels to be blanchable without an open wound, yet mushy and cool with a whitish pink discoloration over the affected areas. An observation at this time also revealed that Resident number three (3) did not have on any heel protectors nor had Resident number three’s (3) heels been floated off of the bed. 15. An interview with the unit manager at about 1:10 p.m. on April 21, 2008, confirmed that the physician had not been notified of the mushy heels. The unit manager stated that the nurse who identified the stage I pressure ulcers on April 17, 2008 should have notified the physician and obtained treatment orders. A stage I pressure ulcer is an observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. 16. After the above interview, the facility measured the boggy areas on Resident number three’s (3) heels and obtained treatment orders. The left heel measured at 2.5 centimeters (cm) in length by 2.5 cm in width. The right heel measured at 3.0 cm in length by 2.5 cm in width. Orders were obtained to apply skin prep every shift to both heels and float the heels while in bed. 17. Anobservation of Resident number three (3) on April 22, 2008 at 9:45 a.m. revealed the resident in bed and Resident number three’s (3) héels had not been floated. 18. A review of the March 2008 Infection Control Log revealed that Resident number nine (9) had stage IV pressure ulcer wounds infected with methicillin resistant staff aureus and proteus mirabilis. A stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers. 19. Anobservation of Resident number nine’s (9) two (2) stage IV buttock pressure ulcer dressing changes and treatments on April 22, 2008 at 2:15 p.m. with Resident number nine’s (9) nurse, the wound care nurse, and the 3:00 p.m.-11:00 p.m. nursing supervisor revealed that Resident number nine (9) received continuous wound vacuum treatments for both pressure ulcers. The wound vacuum's tubing and drainage collection chamber contained dark red liquid drainage. The collection chamber was about one-third full with about 200 milliliters of bloody drainage from the wounds. There was no sign on the door that alerted staff and visitors to see the nurse prior to entering the room. There were no red biohazard bags in Resident number nine’s (9) room to contain biohazard waste. There were no yellow bags in the room for contaminated linen. 20. During the above observation, when Resident number nine’s (9) nurse removed the old dressings and wound vacuum tubing, multiple drops of reddish liquid drainage from within the tubing splattered onto the floor beside Resident number nine’s (9) bed at the nurse's feet . The nurse performing the dressing change and treatment was not wearing a gown to protect her clothing from drainage splatter. The nurse's holding the resident on his/her side during the treatment did not wear protective gowns. She threw the old dressings with bloody tubing into a single clear trash bag in the resident's bathroom trash can. The nurse did not use a red biohazard bag to dispose of the bloody dressings and wound vacuum tubing. The pressure ulcers and old dressings had a strong pungent odor indicative of a continuing infection. The nurse validated the odor. Also during the observation, after the old dressings had been removed from the resident's buttocks, bloody drainage was allowed to run down his/her side onto a mattress pad. The contaminated mattress pad was thrown into the regular laundry. 21. On April 22, 2008 at 4:00 p.m., approximately two (2) hours after the pressure ulcer treatment observation of Resident number nine’s (9) floor where the bloody drainage had fallen revealed that the splatter drops had dried and the floor had not been cleaned/or sanitized. At this same time, the nurse was observed throwing a clear trash bag with the wound vacuum collection container inside into a regular large trash can located inside the dirty utility room. At this same time, the clear bag of bloody dressings and wound vacuum tubing was confirmed to have also been thrown into the same regular trash can rather than inside of the biohazard trash can in the dirty utility room. 22. An interview with the infection control coordinator/director of nursing at approximately 4:05 p.m. on April 22, 2008 stated that Resident number nine (9) was on contact isolation. She stated that the facility did not use signs on resident doors to contact the nurse before entering the room when they were on contact or droplet isolation. She stated that red and yellow bags should have been utilized for Resident number nine (9) and that a gown should have been worn during the pressure ulcer dressing change and treatment. She stated that the facility does not use isolation carts with personal protective equipment inside or outside the rooms of residents with contact and droplet isolation precautions. An interview with the nurse at about this same time stated she did not know that the resident needed to be on contact isolation precautions. 23. A review of the facility's infection control policy regarding "Contact Isolation" revealed that contact precautions shall be used in addition to Standard Precautions for residents with specific infections that can be transmitted by direct and indirect contact. It also revealed that a gown should be worn when entering the room if it is anticipated that clothing will have potential substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident's wound drainage is not contained. 24. Resident number eleven (11) was admitted to the facility on March 14, 2008 with a diagnosis of bladder cancer with probable metastasis, diabetes, anemia, depression, osteoarthritis and hypertension. During the survey process Resident number eleven (11) was accepted by hospice for care and services on April 23, 2008. 25. On April 16, 2008 a stage II pressure sore measuring 4 cm. (centimeters) by 0.5cm. by 0.5cm. was found on Resident number eleven’s (11) coccyx and the treatment of a DuoDerm patch was applied to the area. The dressing was to be changed every three (3) days. This wound was assessed and measured by a licensed practical nurse. 26. On April 23, 2008 at 10:00 a.m. a wound care dressing change was performed by a staff licensed practical nurse and the wound was found to be larger with a small amount of exudate and 20% slough to the base of the wound. The area around the pressure sore was excoriated. 27. The nurse was questioned regarding any improvement or worsening of the sore as they had done the dressing change on April 21, 2008 and the nurse replied, "No" "It appeared the same". When the nurse was asked if she had formalized wound care experience, she replied "No". 28. Upon leaving Resident number eleven’s (11) room, the facility's regional nurse was asked by the surveyor to evaluate Resident number eleven’s (11) wounds as she was in the area. The unit manager was asked if she had seen Resident number eleven’s (11) wound and stated "No". 29. Resident number eleven’s (11) physician's advanced registered nurse practitioner was also available at the time and both people went to evaluate the wound. They found the wound to measure 3.5em x 1.5cm. x 0.3cm with 100% slough and staged it at a "4", and the proper treatment was initiated for the wound and excoriation. 30. A review of Resident number eleven’s (11) care plan for skin integrity dated April 16, 2008 indicated that the resident should be turned and repositioned as needed and a doctor's order dated April 17, 2008 requested that the resident be turned frequently. 31. | Observations of Resident number eleven (11) on April 22, 2008 at 1:00 p.m., April 23, 2008 at 9:00 a.m., 11:00 a.m., and again on April 24, 2008 at 11:00 a.m. found the resident to be on his/her back. This observation was discussed with the unit manager at approximately 12:00 p.m. and she confirmed that she had not seen Resident number eleven (11) in any other position except on his/her back. 32. | 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 400.23(8)(c), Florida Statutes (2007). 33. The Agency provided Respondent with a mandatory correction date of May 16, 2008. 34. | Onor about May 28, 2008 the Agency conducted a Follow-Up Survey to the Annual Survey of the Respondent’s facility. 35. Based on observation, interview and record review, the facility failed to provide appropriate pressure ulcer care and services and did not provide appropriate intravenous dressing care and services for one (1) of twelve (12) sampled residents, Resident number nine (9). 36. On May 28, 2008 at about 1:00 p.m. after an observation of a treatment and dressing change for paraplegic Resident number nine’s (9) right heel pressure ulcer, a random observation of Resident number nine’s (9) left lower leg revealed a gauze dressing wrapped around the calf covering about half of his/her lower leg. A white plastic air boot with Velcro straps surrounded the left foot reaching about half-way up the calf resting on top of the dressing. The left calf gauze dressing had not been dated nor initialed. 37. During the observation, when asked the purpose of the dressing, the nurse replied that she did not know why the dressing was on and/or who had done it. She stated that the left calf had a newly healed pressure ulcer for which skin prep was being applied daily, but to her knowledge it had healed and only a scar remained. She stated that the pressure ulcer had resulted from an ill- fitting leg brace for leg contractures which had been sent out to be repaired. When asked to remove the dressing, the nurse did so. An observation of the left calf revealed an approximate dime sized decompressed intact purplish red blood blister located on the mid-lateral aspect of the left calf above an intact scarred area. 38. During an interview with Resident number nine (9) at the observation, he/she stated that the left air boot often slipped up and down his/her lower leg and calf area while being turned side to side by the staff in order to relieve pressure off of his/her buttock pressure ulcers that he/she was admitted with. Resident number nine (9) also stated that the air boot did not always stay in position when he/she had leg spasms that made Resident number nine’s (9) legs jump. An observation of the white plastic air boot's top reinforced seam revealed that it felt stiffer than the main body of the boot. Resident number nine (9) stated that he/she thought it had been at least a couple of weeks since the air boot had been placed on the left foot. Resident number nine’s (9) most recent minimum data set assessment dated May 14, 2008 revealed that he/she had no long or short term memory problems. It also revealed that Resident number nine (9) required total assistance from two staff persons for bed mobility, transfers, and bathing. 39. Upon request, the unit manager also observed the wound at the May 28, 2008, 1:00 p.m. observation time. She stated that she did not know about the new wound and did not have any idea who had wrapped the left calf with the gauze dressing nor who had placed the left air boot on Resident number nine (9). She also stated that five (5) days earlier, on May 22, 2008, while conducting wound rounds with the wound care physician; the dime sized wound had not been on the left calf, just an area of scarring from the old pressure ulcer. The unit manager did not recall if the air boot had been on the left foot at that time. She stated that Resident number nine’s (9) skin had been very fragile and that the new wound looked like a blood blister that had collapsed. The unit manager stated that the blood blister could have potentially been caused by the left air boot if it had been slipping and not staying in place. 40. A review of the treatment administration record dated May 2008 revealed a treatment order for an air boot to be applied to paraplegic Resident number nine’s (9) right foot. However, the treatment administration record did not reveal an order for an air boot treatment to the left foot and heel. It did reveal an order for Resident number nine’s (9) left heel, which did not have a pressure ulcer, to only have skin prep applied for protection every shift. A review of the May 22, 2008 wound care physician notes did not reveal the presence of a new dime sized wound. It did confirm that Resident number nine (9) had a scarred over area on the left calf from a stage IV pressure wound which needed to be closely monitored by the facility staff. 41. A review of all nurse's notes, physician's orders, and wound physician notes with the unit manager dated in May 2008 did not reveal any documentation to indicate that a physician had been notified of the new pressure area. They did not reveal orders for the application of the dressing to the left calf nor application of the air boot to the left foot. 42. An interview with the unit manager on May 28, 2008 at about 3:00 p.m. validated that the physician should have been notified immediately upon the identification of the new wound in order to obtain treatment orders. The unit manager also validated that left calf dressing and the air boot should not have been applied without physician notification and orders. 43. A review of a nurse's note for paraplegic Resident number nine (9) on May 5, 2008 at 9:00 p.m. revealed that a mid-line intravenous catheter had been placed into Resident number nine’s (9) right upper arm by an intravenous therapy consultant. Resident number nine (9) had a methicillin resistant staphylococcus aureus infection in a buttock pressure ulcer and intravenous antibiotic therapy had been ordered. 44. On May 28, 2008 at approximately 1:30 p.m., an observation of the transparent dressing dated May 28, 2008 which covered the intravenous midline catheter insertion site revealed that the bottom edge of the dressing had been situated directly over the top of the catheter's connection hub. This placement of the dressing did not allow for the lower edge of the dressing to come in contact with the skin on either side of the connection hub. A non-occlusive intravenous midline dressing has the potential for germs to enter the intravenous insertion site and cause an infection of the intravenous line. 45. An interview and observation of the intravenous dressing with the unit manager and the director of nursing on May 28, 2008 at 1:30 p.m. confirmed that the edge of the dressing should not be placed on top of the intravenous catheter's connection hub because it did not allow for an occlusive seal and protection against risk of infection. 46. | 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 400.23(8)(c), Florida Statutes (2007). 47. A Class III deficiency is subject to a civil penalty of one thousand dollars ($1,000.00) for an isolated deficiency, two thousand dollars ($2,000.00) for a patterned deficiency, and three thousand dollars ($3,000.00) for a widespread deficiency. 48... Based upon the above findings, the Respondent’s actions, inactions or conduct constituted an uncorrected Class III isolated deficiency pursuant to Section 400.23(8)(c), Florida Statutes (2007). 49. The Agency provided Respondent with a mandatory correction date of June 19, 2008. WHEREFORE, 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 (2007). COUNT I Assignment Of Conditional Licensure Status Pursuant To Section 400.23(7)(b), Florida Statutes (2007) 50. The Agency re-alleges and incorporates by reference the allegations in Count I. 51. The Agency is authorized to assign a conditional licensure status to skilled nursing facilities pursuant to Section 400.23(7), Florida Statutes (2007). 52. Due to the presence of one (1) Class Il isolated 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 (2007), and the rules adopted by the Agency. 53. The Agency assigned the Respondent conditional licensure status with an action effective date of May 28, 2008. The original certificate for the conditional license is attached as Exhibit A 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 beginning May 28, 2008 pursuant to Section 400.23(7)(b), Florida Statutes (2007). 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. 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 beginning May 28, 2008. 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 3baay of Seagrt @ mbe-« _, 2008. Onncd Ror “, Andrea M. Lang, Senior Attorréy Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3203 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 RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED 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 Administrative Complaint and Election of Rights form were served to: C T Corporation System, Registered Agent for Melbourne Terrace RCC, LLC d/b/a Melbourne Terrace Rehabilitation Center, 1200 South Pine Island Road, Plantation, Florida 33324, by United States Certified Mail, Return Receipt No. 7007 1490 0004 1620 6797 and to Kenneth D. Nichols, Administrator, Melbourne Terrace RCC, LLC d/b/a Melbourne Terrace Rehabilitation Center, 251 Florida Avenue, Melbourne, Florida 32901, by United States Certified Mail, Return Receipt No. 7006 2760 0003 1537 3402 on this 3k day of Se at errb£13008. Qadea MN. ¥ Bong — Andrea M. Lang, Senior Attorney Florida Bar No. 0364568 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3203 Copies furnished to: Kenneth D. Nichols, Administrator Melbourne Terrace RCC, LLC d/b/a Melbourne Terrace Rehabilitation Center 251 Florida Avenue Melbourne, Florida 32901 (US. Certified Mail) Andrea M. Lang, Senior Attorney Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (Interoffice Mail) C T Corporation System, Registered Agent for Melbourne Terrace RCC, LLC d/b/a Melbourne Terrace Rehabilitation Center 1200 South Pine Island Road Plantation, Florida 33324 (U.S. Certified Mail) Joel Libby, Field Office Manager Agency for Health Care Administration Hurston South Tower 400 W. Robinson, #8309 Orlando, Florida 32801 (U.S. Mail) _ Exhibit A Original Certificate of Conditional License For Melbourne Terrace RCC, LLC d/b/a Melbourne Terrace Rehabilitation Center Certificate No. 15232 License No. SNF13400962

Docket for Case No: 08-004972