FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST HOLLY BENSON os GOVERNOR SECRETARY, ~ O, "e ”. oS October 17, 2008 a YS D | . aN Ro ee Anna Small, Esq. Broad and Cassel 215 South Monroe St. #400 P.O. Drawer 11300 Tallahassee, FL 32302 RE: AHCA vs. West Palm Beach Health Care Associates, LLC, d/b/a Azalea Court Case Nos. 2008010591 / 2008010592 Dear Ms. Small: Pursuant to our conversation, | am forwarding to you the Administrative Complaint on n the above referenced facility and case numbers. Thank you for accepting this service. Please feel free to contact me if I can be of further assistance. Sincerel¥, 7 Thomas J. Walsh Senior Attorney TJW/ln Enclosure: Administrative Complaint Headquarters Area Office 2727 Mahan Drive Tallahassee, FL 32308 http://ahca.myflorida.com 525 Mirror Lake Drive, N. Sebring Building, #330H St. Petersburg, FL 33701 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Ge Petitioner, Case No. 2008010591 (fiady.., 2008010592 (cond.) vs. WEST PALM BEACH HEALTH CARE ASSOCIATES, LLC, d/b/a AZALEA COURT, 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 WEST PALM BEACH HEALTH CARE ASSOCIATES, LLC, d/b/a AZALEA COURT (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2008), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing August 8, 2008 and ending September 8, 2008, and to impose an administrative fine of ten thousand dollars ($10,000.00), based upon Respondent being cited for two (2) State Class II deficiencies. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2008). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapters 400, Part II, and 408, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 120-bed nursing home, located at 5065 Wallis Road, West Palm Beach, FL 33415, and is licensed as a skilled nursing facility license number 1198096. 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with ail applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, an intentional or negligent act materially affecting the health or safety of residents of the facility shall be grounds for action by the agency against a licensee. § 400.102(1)(a), Florida Statutes (2008). 8. That Florida law provides that 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...the right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints... § 400.022, Florida Statutes (2008). 9. That on or about August 8, 2008, the Agency conducted a Complaint Survey (CCR#2008009381) of the Respondent facility. 10. That based upon the review of records, interview, and observation, Respondent failed to provide adequate and appropriate health care and protective and support services to meet needs of a resident with a cast and wound on the lower leg, the same being contrary to law. 11. That Petitioner’s representative reviewed Respondent’s records regarding resident number one (1) during the survey and noted as follows: a. The resident was admitted to the facility on July 16, 2008 from a local hospital; b. The resident suffered a contusion of the left hip following a fall at home July 14, 2008; c. The resident has diagnoses of status post cerebral vascular accident (CVA) with left sided weakness, spinal stenosis and status post left hip replacement; d. The resident had a history of falls as well as various other medical conditions; e. The Patient Transfer and Continuity of Care (Form CF-MED 3008), completed upon admission from the hospital revealed the resident has a wound on the dorsum (top of) left foot and an open wound above the right eye from the fall; f. The initial nursing assessment documented in the progress note on July 16, 2008 at 5:00 P.M. revealed the resident has an open area left dorsum with peri-wound necrotic black tissue; . The Weekly Wound Report dated July 16, 2008 identified the wound as 1 x 1 centimeters (cm); . The physician’s order, dated July 16, 2008, directs to cleanse open area on the left dorsum with normal saline, apply Dermagel dressing, then wrap with ace bandage, every 3 days until healed; The resident’s Treatment Administration Records (TAR) for July and August 2008 revealed documentation that the wound care was only done on July 16, 20, 24, and 31, 2008, and August 6, 2008; The wound care was directed to be completed every three (3) days, however the Respondent did not perform the care in the intervals as ordered; . A nursing progress note dated July 17, 2008, reflects that the resident had an x-ray of the left foot and ankle and was diagnosed with a fracture of the left tibia and fibula; The resident was transferred to a local hospital on July 18, 2008 at 12:30 A.M. and returned to the facility at 5:30 A.M. on July 18, 2008; . The resident had a left posterior splint with an ace wrap upon return to the facility; . On July 22, 2008 the resident went to the orthopedic physician's office at 9:00 A.M. and the physician's note indicates a cast was applied to the left lower leg; ._ There was no documentation in the nurse's notes when the resident returned to the facility; . The next nurse's note written was on July 23, 2008 at 6:00 A.M. where the nurse writes the resident has a cast to the left lower leg. 12. That Petitioner’s representative interviewed Respondent’s assistant director of nursing and administrator on August 8, 2008 who indicated that the orthopedist of resident number one (1) had cut a window in the cast so that wound care could be completed. 13. That Petitioner’s representative interviewed Respondent’s risk manager and assistant director of nursing on August 8, 2008 who indicated as follows: a. That at the time of the investigation the medical record lacked documentation of a plan of care for the cast; b. The risk manager insisted that the nurses checked the wound each time the dressing was done and was sure the nurses conducted neurovascular checks on the left leg each shift but had not documented their assessments. 14. That Petitioner’s representative noted that the cast was applied to resident number one (1) on July 22, 2008. 15. That Petitioner’s representative reviewed Respondent’s policy on Cast Care which mandated the evaluation of neurovascular status and skin integrity of the casted extremity as follows: a. Every 1-2 hours for the first 24 hours after the cast is applied. b. Every 4 hours for the first 3 days after the day of application. c. Every 8 hours thereafter unless otherwise indicated. 16. That Petitioner’s representative reviewed Respondent’s nurse’s notes for resident number one (1) between July 22, and August 6, 2008 and located no documentation reflecting the conduct of neurovascular and skin integrity status as directed in Respondent’s policy on cast care. 17. That Petitioner’s representative conducted a further review of Respondent’s records regarding resident number one (1) during the survey and noted as follows: On August 4, 2008, the resident’s attending physician writes an order for the resident to be seen by the orthopedist STAT on August 5, 2008; . The physician wrote “Left leg _ (illegible) in a cast plus ulcer, rule out Compartment Syndrome” . On August 5, 2008, the resident went to see the orthopedist that writes left Tibia/Fibula fracture and recommends: Wound care, No weight bearing. Return to office in 2 weeks. . On August 6, 2008 at 10:00 A.M. it is documented that the resident was found on the floor by staff and the nurse writes the cast was loosened by the fall; . Further the note reflects that at that time maggots were noted coming from the bottom and sides of the cast. There is a window on top of the cast for wound care capability. The Advanced Registered Nurse Practitioner (ARNP) was made aware; The ARNP called the orthopedist and the orthopedist advised the nurse practitioner to have the resident seen by the wound care physician STAT. The wound care specialist advised he cannot come STAT to see the resident. The nurse practitioner sent the resident to the Emergency Room at a local hospital for an evaluation; . The cast was removed at the hospital and a posterior splint with an Ace wrap was applied; . The resident returned to the facility at 3:00 P.M. with new orders for wound care; The August 6, 2008 orders from the hospital for the wound care changed the frequency from every three (3) days to daily. The order states after removing the bandage wash the area with soap and water. Use hydrogen peroxide on a cotton swab (Q-tip) to loosen and remove any crust that forms on the wound. After cleaning, apply a thin layer of neosporin or bacitracin ointment or cream. Reapply bandage daily; That on August 8, 2008 at 1:00 P.M., the nurse records lower extremities are swollen and discoloration noted to wound site. The nurse practitioner (ARNP) is notified; The progress note written by the ARNP on August 8, 2008, with no time indicated, documents the nurse’s concerned about wound. Did not personally look at wound as it was just changed; The ARNP orders a wound consult, Doppler study, lab work and wrote new orders for wound care as follows: cleanse with Normal Saline and apply Accuzyme daily. 18. That Petitioner’s representative observed wound care to resident number one (1) on August 8, 2008 from 4:30 P.M. through 5:00 P.M. and noted as follows: a. b. The left foot was swollen; The left leg was concave; The leg from the toes to the back of the knee was red; The wound measured 8 x 20 cm. The wound extended from the dorsal part of the left foot to approximately mid-tibia area, measured 20 cm. in length by nurse; The entire area was necrotic with a yellow eschar area on the left lateral aspect of the wound bed. 19. That Petitioner’s representative noted that, at the time of the investigation, the medical record for resident number one (1) lacked documentation of a reassessment of the wound after the resident returned from the hospital on August 6, 2008. 20. That Petitioner’s representative interviewed Respondent’s assistant director of nursing (ADON) and the risk manager (RM) on August 8, 2008 who indicated as follows: a. They confirmed there were no measurements of the wound of resident number one (1) on the Skin Grid document for August; b. The ADON indicated that weekly Skin Sweeps are done; c. Nurses only document if there is a change in the wound; d. The ADON stated the nurses document about the wound each time the dressings are done, that they write about the wound care in their notes; e. That at the time of the investigation, Respondent did not have any additional documentation other than what was presented on August 8, 2008. 21. That review of Respondent’s Skin Grid shows the wound on the foot of resident number one (1) foot was assessed as follows: a. July 16, 2008 - the wound measured 1 x 1cm. no drainage, no color with redness around wound edges. The area around the wound was red and macerated. b. July 24, 20 - the wound was 4 x 3 cm. c. July 29, 2008 - the wound measured 4 x 6 cm. There was no color, no odor or drainage. The edges were red. The area around the wound was red. 22. That Respondent’s Weekly Wound Report describes the wound on the left dorsal foot of resident number one (1) as follows: a. July 16, 2008 - The wound was 1 x lcm. Stasis stage III. A Dermagel dressing was applied; b. July 29, 2008 - The wound was described as 4 x 6 cm. Stasis stage II. A Dermagel dressing was applied; c. There were no measurements or assessments of the wound documented in August. 23. That Respondent’s weekly Skin Sweeps are to be done on the 3-11 shift and reflected the following regarding resident number one (1): a. July 29, 2008 - documented for the open area on the knee; b. The date of the next skin sweep is illegible. The nurse checked no new impairment; c. August 6, 2008 - There was no new impairment. 24. That Petitioner’s representative reviewed Respondent’s Treatment Record for resident number one (1) for July and August 2008 and noted as follows: a. Wound care was ordered every third day; b. Treatment was documented as done on July 16, 20, 24, 31, and August 6, 2008. 25. That wound care to resident number one (1) was not provided every three (3) days as ordered by the resident’s physician. 26. That Petitioner’s representative telephonically interviewed the orthopedist of resident number one (1) who indicated that he did not see any maggots, denied removing the gel dressing, and he had not made the window larger. 27. That Petitioner’s representative reviewed Respondent’s policy on Skin Care & Management of Cast which included the following: a. Evaluate at least daily the skin around the cast edges; b. Document at least daily: a. Date and time of evaluation; b. Neurovascular status of casted extremity and area distal to cast; c. Skin condition; d. Cast condition; e. Skin care provided, as indicated. 28. That Petitioner’s representative reviewed Respondent’s policy titled Dressing Change, includes a requirement to document the following: a. b. d. e. Date and time of dressing change; Amount of drainage, color and odor: Any unusual appearance of wound or peri-wound area (Refer to Skin Grid for most recent wound appearance); Complaints of pain or discomfort; Resident response to procedure: 29. That absent from Respondent’s records regarding resident number one (1) were the following: Any documentation of Cast Care; Any documentation of wound care as ordered with a cast in place; Any documentation of Dressing Change in accordance with the facility practice and policy; Any care plans to address Cast Care; . Any post-admission documentation of the condition of the wound before and after the cast was removed; f. Any documentation that the neurovascular status and skin integrity checks had been completed fully as per Respondent’s policy and procedure on cast care; g. Any documentation that the resident’s ARNP or the physician was made aware of the condition of the left leg upon return to the facility from the hospital on August 6, 2008 until August 8, 2008; h. Any documentation that a nurse assessed the wound after the resident returned from the August 6, 2008 hospital visit. 30. That Respondent has a duty to provide adequate and appropriate health care to residents and the protections of its policies and procedures. 31. That the above reflects Respondent’s intentional or negligent failure to provide adequate and appropriate health care and protective and support services, including but not limited to the failure to follow Respondent’s policy and procedure regarding the provision of care, by its failure, inter alia, to: a. The failure to provide wound care at intervals ordered by a physician; b. The failure to follow Respondent’s policy and procedure regarding cast care; c. The failure to follow Respondent’s policy and procedure regarding Dressing Change; d. The failure to assess the wound regularly; e. The failure to follow Respondent’s policy and procedure regarding Skin Care and Management of Cast. 32. The Agency determined Respondent had not provided the necessary care and services and had 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 and cited this deficient practice as an 11 isolated State Class II deficiency. 33. That the Agency cited the Respondent for an Isolated Class II violation in accordance with Section 400.23(8)(b), Florida Statutes (2008). 34. The Agency provided Respondent with the mandatory correction date for this deficient practice of September 8, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of " $5,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Florida Statutes (2008). COUNT II 35. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 36. That pursuant to Florida law, the facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment. Rule 59A- 4.109(2), Florida Administrative Code. 37. That Florida law provides, "Resident care plan" means a written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident; the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being; a listing of services provided within or outside the facility to meet those needs; and an explanation of service goals. The resident care plan must be signed by the director of nursing or another registered nurse employed by the facility to whom institutional responsibilities have been delegated and by the resident, the resident's designee, or the resident's legal representative. The facility may not use an agency or temporary registered nurse to satisfy the foregoing requirement and must document the institutional responsibilities that have been delegated to the registered nurse. § 400.021(16), Florida Statutes (2008). 38. That on or about August 8, 2008, the Agency conducted a Complaint Survey (CCR#2008009381) of the Respondent facility. 39. That based upon interviews and the review of records, Respondent failed to ensure a comprehensive plan of care was developed identifying services to attain or maintain the resident’s highest practicable physical, mental and social well-being for a resident who sustained a leg fracture, had a splint and cast applied, and experienced an infestation of maggots to a foot wound, the same being contrary to law. 40. That Petitioner’s representative reviewed Respondent’s records regarding resident number one (1) during the survey and noted as follows: a. The resident was admitted to the facility July 16, 2008 from a local hospital; b. The resident suffered a contusion of the left hip following a fall at home July 14, 2008;The resident has diagnoses of status post cerebral vascular accident (CVA) with left sided weakness, spinal stenosis and status post left hip replacement; c. The resident was admitted with a 1 x 1 centimeter (cm) wound on the dorsum (top of) left foot; d. The initial nursing assessment documented in the progress note of July 16, 2008 at 5:00 P.M. described the wound on the dorsum of the left foot as an open area with peri-wound necrotic black tissue; . The treatment order was to cleanse with Normal Saline and apply Dermagel every 3 days, then wrap; The initial care plan implemented July 16, 2008 had a goal to minimize the risk of skin impairment and identified the skin breakdown to the left dorsum; . The interventions for skin impairment included to inspect skin daily; keep skin clean and dry; and to protect/elevate elbows and heels; . On July 17, 2008, the resident had an x-ray of the left foot and ankle; The resident was diagnosed with a fracture of the left tibia and fibula; The resident was transferred to a local hospital on July 18, 2008 at 12:30 A.M. and returned to the facility at 5:30 A.M. with a posterior splint to the left lower leg; . On July 22, 2008, the resident went to the orthopedic physician's office at 9:00 A.M; The next note entered was written on July 23, 2008 at 6:00 A.M. and documents the resident has a cast to the left lower leg with a window cut into the cast to allow for wound care on top of the left foot; . On July 27, 2008, a comprehensive assessment, Minimum Data Set (MDS), was completed for the resident; . Notes reflect that on August 6, 2008 at 10:00 A.M. the resident was found on the floor by staff; . The nurse documents that the resident’s cast was loosened by the fall and that maggots were noted coming from the bottom and sides of the cast; p. Notes further reflect that the Advanced Registered Nurse Practitioner (ARNP) was made aware and the resident was sent to a local emergency room for an evaluation; q. The cast was removed at the hospital and a posterior splint with an Ace wrap was applied; . r. The patient returned to the facility at 3:00 P.M. with new orders for wound care; s. The resident wore a cast or a posterior splint from July 18 through August 8, 2008. 41. That absent from Respondent’s records was any care plan addressing the care and services for the fracture experienced by resident number one (1), the care for the splint or cast applied to resident number one (1), or the infestation of maggots identified on resident number one (1). 42. That Florida law requires that a plan of care be developed for nursing home residents within seven (7) days of the resident’s comprehensive assessment. 43. That the comprehensive assessment for resident number one (1) was completed on July 27, 2008. 44. That Petitioner’s representative interviewed Respondent's assistant director of nursing and risk manager during the survey who confirmed that care plans as above referenced had not been completed. 45. That the above reflects Respondent’s failure to timely and comprehensively complete plans of care for resident number one (1) as required by law. 46. | The Agency determined Respondent had not provided the necessary care and services and had 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 and cited this deficient practice as an isolated State Class II deficiency. 47. That the Agency cited the Respondent for an Isolated Class II violation in accordance with Section 400.23(8)(b), Florida Statutes (2008). | 48. | The Agency provided Respondent with the mandatory correction date for this deficient - practice of September 8, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Florida Statutes (2008). COUNT TI 49. The Agency re-alleges and incorporates Counts I through II as if fully set forth herein. 50. Based upon Respondent’s two cited State Class II deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Florida Statutes (2008). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2008) commencing August 8, 2008 and ending September 8, 2008. Respectfully submitted this | ?- day of October, 2008. AHCA - Counsel for Petitioner 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 16 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent 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 to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER 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. 7007 1490 0001 6979 1458 on October 1 7, 2008 to Anna Small, Esq., Broad and Cassel, 215 S. Monroe St., #400, P.O. Drawer 11300, Tallahassee, FL 32302. Tho alsh II Seni6f Attorney Copies furnished to: Anna Small, Esq. Arlene Mayo-Davis Thomas J. Walsh II, Esq. Broad and Cassel Field Office Manager Agency for Health Care Admin. 215 South Monroe St. #400 | Agency for Health Care Admin. | 525 Mirror Lake Drive, 330G P.O. Drawer 11300 5150 Linton Blvd., Suite 500 St. Petersburg, Florida 33701 Tallahassee, FL 32302 Delray Beach, Florida 33484 (Interoffice) U.S. Certified Mail) (U.S. Mail)

Docket for Case No: 08-005657