May 28 2009 13:35 MAY-28-2889 14:48 AGENCY HEALTH CARE ADMIN 856 921 @158 P.@9 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARB ADMINISTRATION, Petitioner, vs. Case Nos. 2009001866 (Fines) 2009001867 (Cond.) CATALINA HEALTH CARE ASSOCIATES, LLC, . d/b/a CATALINA HEALTH CARE 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 Catalina Health Care Associates, LLC, d/b/a Catalina Health Care Center (hereinafter “Respondent’”), pursuant to §§120,569 and 120.57 Florida Statutes (2008), and alleges: NAT OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing January 26, 2009, and impose an administrative fine in the amount of $2,500.00, based upon Respondent being cited for one State Class II deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Flomda Statutes (2008). 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. May 28 2009 13:36 MAY-268-2689 14:48 AGENCY HEALTH CARE ADMIN 654 921 4158 P.18 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 Ommibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapter 408, Part II and Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 120-bed nursing home, located at 820 'N. Clyde Morris Blvd, Daytona Beach, Florida, 32117, and is licensed as a skilled nursing facility (license number 1191096). 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 all applicable rules, and ‘statutes. COUNTI 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. Florida law provides the following: Section 400.022(1)(), F.S.: “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 400.102(1), F.S., “In addition to the grounds listed in part Il of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility” May 28 2009 13:36 _ MAY 26-2883 14:49 AGENCY HEALTH CARE ADMIN 856 921 4158 P.ii 8. The Agency conducted an unannounced complaint investigation on January 26, 2009. 9. Based on. observation, record review and interview, it was determined the facility failed to fulfill its legal duty to provide adequate and appropriate health care for 2 of 3 sampled residents (Resident #1 and Resident #2). This failure to provide adequate and appropmate health care is evidenced by: 1) Nursing staff's failure to effectively assess the type, amount and severity of Resident #1's anxiety and pain and the failure to recognize symptoms of an impending heart attack,which led to a failure to provide the necessary medical care and services to prevent a significant myocardial infarction and therefore materially affected the resident’s health; 2) a nurse operated out of the scope of his/her license by writing an order for a course of treatment which she never verbally received an order from the physician which contributed to the delay of the resident receiving emergency services for a myocardial infarction; and 3) nursing staff failed to adequately monitor Resident #2 for complaints of pain to his/her pacemaker site which could have resulted ina failure to recognize symptoms of a heart attack and failure to seek immediate emergent intervention can result in irreversible heart damage and/or death. 10. ‘The findings related to the facility’s failure to provide adequate health care from resident #1’s record are: a. Closed record review for Resident #1 reveals he/she was admitted to the facility on 1/16/09 with diagnoses including, not limited to, Gastrointestinal Hemorthage, Anemia, Nausea with vomiting, HTN (Hypertension), Hyperlipidemia, Chronic Ischemic Heart Disease, Dizziness and Giddiness. b. Review of the Nursmg Data Collection tool dated 1/16/09 revealed the resident reported pain and had a diagnosis that supported the likelihood of pain; however, the location and severity were not assessed by the admitting nurse. The assessment revealed the resident took Xanax 0.25 mg., however, the nurse failed to gather information from the resident to determine why and how often the resident took Manax. May 28 2009 13:36 MAY-28-2889 14:49 AGENCY HEALTH CARE ADMIN 856 921 4158 P.i2 ¢. A "Discomfort & Pain Identification and Plan of Care" care plan was developed on 1/16/09 at the time of the resident's admission by the nurse; however, the description of the pain was not listed, nor the location or frequency. d. Further review of the record revealed nurses' notes for the dates of 1/16 and notes of 1/17/09 from 12 MN, 3 AM and 6 AM which were uneventful. There were no other notes or an assessment of the resident documented in the clinical record after that until 1/18/09 which revealed at 11:00 AM, the resident complained of "chest pain during the night". There was no assessment by the nightshift nurse regarding the resident's complaints of chest pain. The 1/18/09 note further indicated the MD was notified for a telephone order for astat EKG and cardiac enzymes. Included in the note was that Xanax was given for increased anxicty at 10:00 AM. The note further states Lab and Imaging were notified. e. The next note was for 12:30 PM on 1/18/09 which revealed the physician gave an order to send the resident out to the ER (Emergency Room) for an evaluation. Emergency transport was called and the resident was transported to the ER. The resident complained of dull pain-in the left arm and the son would follow the ambulance to the _ hospital. f. Review of the physician's orders for 1/16/09 includes the following medications: Isosorbide Dinitrate 20 mg. po(by mouth) bid (twice daily), Ferous Sulfate 325 mg. po q (every) d (day), Lisinopril 20 mg. po daily, Imdur 30 mg. po daily, Norvasc 10 mg. po daily, Zetia 10 mg. po daily, Clonidine 0.1 mg. q 6 hr pn, Xanax 0.25 mg. po BID (twice daily) for anxiety, and Temazepam 15 mg. prn (as needed) for insomnia. g. Review of the MAR (Medication Administration Record) for January 2009 reveals the resident was administered Xanax 0.25 mg. at 12:30 AM on 1/18/09 for complaints of increased anxiety and pain. However, the physician did not order Xanax for complaints of pain. May 28 2009 13:37 MAY-28-2889 14:49 AGENCY HEALTH CARE ADMIN 856 921 4158 P.13 h. There was no assessment by the night nurse of the resident's pain. The record did not reflect the location, severity or type of pain the resident was experiencing. There was no assessment by the nurse as to the cause of the resident's anxiety. There was no re- evaluation of the resident's pain or anxiety after the nurse administered the Xanax. 11. The findings related to the facility’s failure to provide adequate health care for resident #1 from interviews regarding resident #1 revealed the following: a. Interview with the resident's son revealed the resident complained of chest pain during the night of January 13, 2009 that was unaddressed. He stated the resident complained of chest pain at 12:30 AM on 1/18/09 and the only response by nursing was giving Resident #1 medication and increasing his/her oxygen. He entered the facility at 9:30 AM on 1/18/09 and no one knew about the resident's chest pain from the night before. He stated that he then informed a nurse who called the phyisician and an outside source to do an EKG and labwork. The technician arrived at the facility to do the EKG, however, the machine didn’t work. A second attempt at a working device was made. Then, emergency services were called and Resident #1 was transported by EMS to the hospital for evaluation. b. Interview with the RM (Risk Manager), ADM (Administrator) and SDC (Stalf Development Coordinator) revealed the RM received a phone call from the Manager on Duty and Nursing Supervisor on 1/18/09 who informed her that resident #1 was not feeling well, that they had called the doctor, and that didn’t have any details. The son had informed them that the resident had complained to him during the night he/she had chest pain and the nurse did nothing about it but had given him/her medication. They were not aware of these concems until the son informed them that morning when he arrived at the facility. They had notified the doctor and had called for the lab to draw cardiac enzymes and the mobile unit o do an EKG. The RM stated she had leamed that the EKG machine didn't work and by the time the tech returned to the facility with the second machine, they had sent the resident out to the hospital. The labs had not come back prior to the resident's departure, rather, at the same time the resident was leaving. The RM stated she May 28 2009 13:37 _MAY-28-2089 14:58 AGENCY HEALTH CARE ADMIN 856 921 4158 conducted an intemal investigation which revealed the night nurse, on 1/18/09, administered a Xanax to the resident at approximately 12:30 AM for complaints of increased anxiety and pain. She stated the nurse did not document an assessment of the resident and that there were no notes in the resident's record on the 7a-3p, 3p-11p shift on the 17th and no notes by the nurse from 11p-7a for the 18th. She stated she learned that the resident suffered an acute MT (Myocardial Infarction) and she was going to investigate concems that the resident was transferred to the hospital following complaints of chest pain over the previous shift. c. During this same interview, the SDC indicated that she was closely involved in this case as well. She stated that she spoke with the nurse who worked that day (1/18/09) who told het that the resident informed a nurse on the night shift that he/she was complaining of chest pain and that she and the nursing supervisor on that day (1/1 8/09) afier learning this, notified the physician and attempted to obtain an EKG and initial cardiac enzymes by outside vendors. She did not see the results of the labs until after the resident left. d. Interview with the Dietary Manager (DM) on 1/26/09 at 3:30 PM revealed she was the manager on duty on 1/18/09. She stated she came to the front desk at about 8:45 AM and learned that the resident's son had come to the facility and had concerns about Resident # 1's care. He was concemed that the resident's call light wasn't being answered and that the resident bad chest pain in the middle of the night that was ignored by the night nurse. The son stated Resident #1 was having shortness of breath and because the call hght was unanswered, Resident #1 asked his/her room mate to press his/her call bell. The nurse had come into the room, turned up the oxygen, gave Resident #1 medication and left the room. e. The DM stated after the resident was transferred to the hospital, she went back into the room and spoke with the resident's room mate who confirmed that Resident #1 did have chest pain in the middle of the night and the call light went unanswered. The room mate pressed his/her call button. It was answered by someone who came in and tumed up P.14 May 28 2009 13:37 ; MAY-28-2889 14:58 AGENCY HEALTH CARE ADMIN 856 921 @158 P.is Resident #1's oxygen, gave her/him medication and then left the room. He/She stated. Resident #1 was in pain for about and hour and then it seemed to subside. f. Interview with the LPN (Licensed Practical Nurse) revealed she had previously taken care of the resident prior to 1/18/09 and during that time, the resident was asymptomatic. She received in report from the off going nurse on the 1 1p-7a shift of 1/18/09 that Resident #1 complained of pain and anxiety and was medicated in the middle of the might with Xanax as the night nurse had heard in a previous report by other nursing staff that . the resident used to take it for pain. There was no documentation in the record to support the nurse's statement that the resident took Xanax for pain. The MAR (Medication Administration Record) of January 2009 documented that the resident took Xanax for anxiety. The LPN did not question the night nurse as to what type of pain the resident experienced the night before. g. The LPN stated that on the moming of 1/18/09, she approached the room of the resident at approximately 8:45 am to distribute medicine. The son was in the room with the resident and stated he had concerns that Resident #1 had chest pain last night without appropriate intervention. The LPN stated she assessed the resident which revealed the resident had back pain, had a history of back pain and that his/her left arm was still aching and was throbbing at times. h. The LPN stated she took vital signs and that she fell the son was coaxing Resident #1. She then called the nursing supervisor who stated that they should call the doctor and get an order for stat cardiac enzymes and an EKG. The LPN stated she phoned the physician at about 9:45 AM (an hour after speaking to the son) and left a message on his answering machine to call back. She did not speak to the doctor herself and did not receive any orders. Without receiving a verbal order from the physician, the LPN wrote a telephone order for a STAT EKG and cardiac enzymes. She called the mobile unit for an ERG and labs. The EX.G tech came to the facility and because the device wasn't printing, he left to get another maching. She stated the resident did not appear in any distress, just tired and left arm still aching. She stated it wasn't until about 12:00 PM that the physician returned May 28 2009 13:38 . MAY-28-2889 14°58 AGENCY HEALTH CARE ADMIN 856 921 4158 P.16 their call and ordered them to‘send the resident out of the facility via 911 Emergency transport. It was at that time that they informed the physician that they were attempting to get cardiac enzymes and an EKG. i. The LPN confirmed that her "assessment" of the resident on 1/18/09 was not documented and there was no evidence in the clinical record that vital signs were ever taken. She confirmed there was no pain assessment, no documentation of interventions or reevaluation of Resident #1 on the 11p-7am shift by the night nurse despite administering the medication to the resident for increased anxiety and pain. j. Interview with the physician revealed he did not give a verbal order for an EKG and cardiac enzymes. When he called the facility back , he was informed of the tests (cardiac enzymes and attempt at EKG). He stated that nursing homes are not acute care institutions and that any time a resident is symptomatic of an Myocardial Infarction they should be immediately sent oui to the Emergency Room. He stated the patient's wait for outside vendors to perform an EKG or labwork could delay the resident being sent out to the hospital. He stated he was not called regarding the resident having chest pain the night before. He stated he had learned that the resident experienced an acute MI while at the nursing home. k. Review of the ED (Emergency Department) notes by the physician dated 1/18/09 revealed the resident arrived at the ER at 12:52 PM complaining of chest pain and pressure at midnight last night. The discomfort lasted one hour and resolved. The resident was now pain-free...and was not transferred for evaluation at the time of the pain. Outpatient cardiac enzymes were checked and found to be markedly elevated. The resident was admitted to the hospital for a recent MI and was already out of the 12 hour window of treatment. Review of the hospital physician's notes of 1/18/09 revealed the resident sustained a significant myocardial infarction. L According to the American Heart Association, morbidity and mortality from MI are significantly reduced if paticnts and bystanders recognize symptoms early, activate the May 28 2009 13:38 MAY-28-2089 14:51 AGENCY HEALTH CARE ADMIN 856 921 4158 P.1? EMS system, and thereby shorten the time to definitive treatment. Trained prehospital personnel can provide life-saving interventions if the patient develops cardiac arrest. The key to improved survival is the availability of early defibrillation. 12. The findings with regard to the Respondent's failure to provide adequate and appropriate health care for resident #2 inlude the following record review: a. Record review revealed Resident #2 was admitted to the facility on 11/21/07 and readmitted back to the facility on 1/02/09 from the hospital. b. Review of the hospital H & P (History and Physical) with an admission date of 12/31/08 revealed the resident presented to the ER for evaluation of chest pain. The resident stated he/she had severe pain in his/her left anterior chest, left shoulder and left arm and it was significantly worse at 6:00 AM. The resident has a hx (history) of HTN (Hypertension) , Hyperlipidemia, A-fib, CHF (Congestive Heart Failure) and Chronic Renal disease. c. Review of the nurse's notes dated 12/31/08 revealed the resident complained of stabbing pain to his/her pacemaker site at 6:30 AM. The nurse notified the physician who indicated to monitor HR (heart rate) and B/P (blood pressure). d. There was no evidence in the clinical record that the resident's HR and BP were ever assessed nor was there a physician's order to monitor the HR and BP. There were no other nurses’ notes the resident was re-evaluated after his/her initial complaints of stabbing pain to the pacemaker site until 9:00 AM which (2 1/2 hours later) which revealed the resident complained of pain in the shoulder (location not identified in this note) and next to the pacemaker and was medicated for pain and anxiety. The resident refused to return to bed, V/S-140/80, 99.3, 80, 18. May 28 2009 13:38 MAY-28-2089 14:51 AGENCY HEALTH CARE ADMIN 856 921 4158 P.18 e. Review of the December 2008 MAR (Medication Administration Record)revealed the resident did receive Oxycodone 5/325 on 12/31/08 and Ativan 0.5 mg. for anxiety; however, there was no re-valuation of the resident's pain after administration of the medication. f There was no evidence in the resident’s record that the physician was called at 6:30 AM when the resident originally complained of stabbing pain to the pace maker site or at 9:00 AM when he/she complained of continued pain at the sitc as well as in the shoulder. Four hours Jaier, at 10:00 AM, the resident stated he/she wanted to go to the hospital. Nurses' notes at this time revealed the resident was assessed and the resident complained of pain at the pacemaker site, radiating down the left arm. The MD was called and ordered the resident to be sent to the ER for evaluation. The notes indicate EVAC was called for transport, next of kin was notified and at 10:10 AM, EVAC arrived and at 10:24 AM, EVAC left the facility with resident. g. The physician's order on record for 12/31/08 was for the resident to be transferred to an acute care hospital. 13. The findings with regard to the Respondents failure to provide adequate and appropriate health care for resident #2 inlude the following interviews: a. Interview with the unit manager revealed there was no documentation to support the resident was monitored after complaining of pacemaker pain between 6:30 am and 9:00 am. She could not find evidence that the resident's HR or BP were obtained. b. Interview with the RM (Risk Manager) revealed that she was directly involved with the resident with regard to the 12/31/08 complaints of stabbing pain around her pacemaker. She usually comes to the facility at about 6:30 AM and was walking past the dining room and the resident was in there. She asked the resident how he/she was doing and the resident stated, "not very well” and indicated he/she had pain at his/her May 28 2009 13:39 MAY-28-2089 14:51 AGENCY HEALTH CARE ADMIN 856 921 4158 P.1i9 pacemaker site. The RM assessed the resident, looked at the pacer site for redness/swelling and stated the resident wasn't having any respiratory distress. Nursing staff was in the middle of shift change and she escorted the resident down to the nurse who was leaving the shift. The RM confirmed her assessment was not documented. She confirmed she was aware that the resident was not sent out to the hospital until 4 hours later. She was not aware there was no indication the resident was closely monitored by nursing after complaints of pain al the pacemaker site between 6:30 am and 9:00 am and between 9:00 am and 10:00 am. 14. The Respondent had a legal duty, pursuant to s. 400.022(1}(1), Florida Statutes, to provide adequate and appropriate health care. The Respondent failed to uphold its legal duty when it failed, among other possible deficient practices, to recognize the symptoms suggestive of a heart attack, when the overnight shift nurse and the LPN failed to conduct an assessment, the failure to document the resident’s pain and symptoms, and when it failed to immediately seek assistance from emergency services for resident #1. Further, the Respondent’s failure materially affected resident #1’s health because resident #1 suffered myocardial infarction, The Respondent failed to uphold its legal duty to resident #2when it failed to assess the resident’s heart rate and blood pressure as requested by the doctor, when it failed to re-evaluate the resident after his/her initial complaints of stabbing pain to the pacemaker site until two and a half hours later, when it failed to monitor the resident for several long periods of time. Further, the Respondent’s failure materially affected resident #2’s health because resident #2 suffered pain at the pacemaker site. Thus, the Agency has the authority, pursuant to s. 400.102(1), F.S., to take action against the Respondent. ) The Agency provided Respondent with the mandatory correction date for this deficient practice of February 26, 2009. May 28 2009 13:39 MAY-28-2889 14:52 AGENCY HEALTH CARE ADMIN 856 921 @158 P28 WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the Stale of Florida, as a result of being cited for one Class IT deficiency pursuant to §§ 400.23(8)(b), 400.022, and 400.102(1), Florida Statutes (2008). COUNT I 12. The Agency re-alleges and incorporates Counts I of this Complaint as if fully set forth herein. 13. Based upon Respondent's cited Isolated State Class II deficiency, it was not in substantial compliance at the time of the survey with criteria established under Chapter 400,Part Hi of Florida Statutes, 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 January 26, 2009. CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: . (A) Make factual and legal findings in favor of the Agency on Count I, and I; (B) Recommend an administrative fine against Respondent in the amount of $2,500 for Count J, an Isolated Class II deficiency; (C) Assign a conditional licensure status commencing January 26, 2009 (D) Assess attorney’s fees and costs; and May 28 2009 13:39 MAY 28-289 14:52 AGENCY HEALTH CARE ADMIN 856 921 4158 P.2i (E) Grant all other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter. 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. Respectfully submitted this AL day of April, 2009. Moke aa Fla. Bar.48084 Agency for Health Care Administration 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) May 28 2009 13:40 MAY-28-2889 14:52 AGENCY HEALTH CARE ADMIN 856 921 @158 P22 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8954 to: Facility Administrator Jo Ann Grasso, Calalina Health Care Center, 820 N. Clyde Moris Blvd., Daytona Beach, Florida 32117, by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8961 to: Owner Catalina Health Care Associates, LLC, 10210 Highland Manor Drive, Suite 410, Tampa, Florida 33610, and by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8978 to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301 on Apnl 24, 2009: hak Hy Mark Hinely Copy furnished to: Rob Dickson, FOM

Docket for Case No: 09-002929