STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, ; vs. Case Nos. 2009014482 2009014486 BEAM MANGEMENT, LLC, d/b/a HARMONY HEALTHCARE AND 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 Beam Management, LLC d/b/a Harmony Healthcare and Rehabilitation Center (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing December 23, 2009 and ending J anuary 22, 2010, impose an administrative fine in the amount of twenty-seven thousand five hundred dollars ($27,500.00), impose a two year survey cycle and assess a survey fee of six thousand dollars ($6,000.00) based upon Respondent being cited for two State Class I deficiencies. JURISDICTION AND VENUE 1, The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2009). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. Filed June 2, 2010 2:01 PM Division of Administrative Hearings. 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 2600 Courtland Street, Sarasota, FL 34237, and is licensed as a skilled nursing facility license number 130471036, 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. C T. 054 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That 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. 8. That on or about December 23, 2009, the Agency completed a complaint survey of Respondent’s facility. 9. That based upon observation, interview, and the review of records, Respondent failed to follow physician orders for treatment, medications, and monitoring for nine (9) of fifteen (15) sampled residents, the same being contrary to law and which has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. 10. That Petitioner’s representative reviewed Respondent’s records regarding resident number two (2) during the survey and noted as follows: a. The resident was admitted to the facility on October 21, 2009; b. Medical history included diagnoses of dementia and respiratory failure; c. The resident had a tracheostomy and was admitted to the facility on a ventilator; d. A physician’s telephone order dated October 21, 2009, recorded by Respondent's respiratory therapy director, mandated that staff maintain the resident’s oxygen level at ninety percent (90%), suction the resident every four (4) hours and’ as needed, complete trach care twice daily, and monitor oxygen saturation levels every two (2) hours and as needed (PRN); e. The resident was admitted to the facility at approximately 5:00 PM on October 21, 2009; f, On said date, Respondent’s Respiratory Care Flow Sheet reflects as follows: i. Oxygen saturation levels were completed at 5:05 PM and 8:30 PM; ii, These times are not in accord with the order mandated saturation checks every two (2) hours; iii. There is no documentation that reflects that the prescribed suctioning of every four (4) hours was conducted; g. The Respondent’s Respiratory Care Flow Sheet dated October 22, 2009 reflects as follows: i. Oxygen saturation levels were completed at 1:17 AM, 7:35 AM, 9:50 AM, 2:18 PM, and 8:09 PM; ii. These times ate not tn accord with the order mandated saturation checks li. every two (2) hours; iii. Suctioning was conducted four (4) times on October 22, 2009 which is not consistent with the prescribed suctioning every four (4) hours; h. The Respondent’s Respiratory Care Flow Sheet dated October 23, 2009 reflects as follows: i, Oxygen saturation levels were completed at 12:58 AM and 4:49 AM; ii, These times are not in accord with the order mandated saturation checks every two (2) hours; iii. Suctioning was conducted one (1) time on October 23, 2009 at 12:58AM which is not consistent with the prescribed suctioning every four (4) hours; i. The resident coded, or stopped breathing and heart stopped, at 8:05 AM; j. A respiratory therapy note dated October 23, 2009 at 8:05 AM reflects that the resident coded, was bagged at one hundred percent (100%) oxygen for twenty- five (25) minutes and respiratory therapy continued suctioning copious amounts of pink sticky thick secretions, k, There is no documentation that Respondent’s respiratory therapy staff assessed the resident from 4:49 AM October 23, 2009 until 8:05 AM; |. Nursing notes related to the resident do not reflect any nursing assessment from October 22, 2009 at 2:30 PM until the resident coded on October 23, 2009 with the note documenting that a call to emergency 911 was placed and the resident pronounced dead at 8:15 AM. That Petitioner’s representative interviewed Respondent’s director of nursing during the survey regarding resident number two (2) who indicated that oxygen saturation levels were not recorded every two (2) hours as ordered. 12. That Petitioner’s representative interviewed Respondent’s assistant director of respiratory therapy during the survey who indicated that she did not know why physician orders were not followed as the same relate to oxygen saturation and suctioning. 13. That Petitioner’s representative reviewed Respondent's records regarding resident number fifteen (15) during the survey and noted as follows: a, b. The resident was admitted to the facility on February 12, 2009 from the hospital; The resident had a tracheostomy and was ventilator dependent, The resident’s diagnosis included chronic respiratory failure, Physician’s orders of February 12, 2009 required no food by mouth (NPO); The resident was receiving speech therapy for swallowing and a trial of three (3) meals a day of mechanical soft food with thin liquids was ordered on February 13, 2009; On February 19, 2009, and order was written changing thin liquids to nectar thickened liquids A nurse’s note dated February 21, 2009 at 1:40 PM documents that the respiratory therapist noted vomit from the tracheostomy and chunks of pears were on the resident’s gown; A nurse’s note of February 22, 2009, no time noted, recited “Held PM meal because resfident] -had difficulty with lunch and RT (respiratory therapy) suctioned bits of cherry from {] trach. Res[ident] continues on peg tube feeding” On February 24, 2009 the physician ordered the resident return to no food by mouth (NPO); A nurse’s note of February 28, 2009 of 11:10 PM recites in part “resident had a change of condition and was desating (oxygen level decreasing). Respiratory therapy called for nurse.to call 911,” . A nurse’s note of February 28, 2009 of 11:15 PM documents that the resident was sent to the hospital via stretcher; A note of Match 1, 2009 at 1:30 AM documents that the hospital called to report that the resident had expired; . The Transfer Form, dated February 28, 2009, and sent with the resident when transported to the hospital, documents the resident’s oxygen level, heart rate, blood pressure, temperature, change in mental status and oxygen sats while crossed through with “error” written in parenthesis above the entry is “Choked on cookie earlier in the day.” . The resident’s ventilator record flow sheet for February 28, 2009 reflected as follows: i. At 9:00 Pm the resident had green sputum from the trach; ii. On the reverse of the form is a note dated February 28, 2009 at 10:15 PM which reads in part “Called in pt (patient) room by [registered nurse]. Pt had brown + black sec (secretions) from under the trach dressing. Pt had been given a chocolate chip cookie. Pt was NPO.” ili. The note also note that the resident was suctioned of a large amount of brown and black secretions and when suctioned qa second time the secretions turned to green and yellow which was normal for the resident, oO, iv. The note ends documenting the EMS was called and the resident transported to the hospital; The hospital emergency care center report reflects that the resident arrived at the hospital on February 28, 2009 at 11:40 Pm for a mental status change after choking on a cookie; The hospital history and physical states in part “The history as given per Harmony Healthcare is that the patient was eating a cookie at approximately 10:30 PM, choked on the cookie, and had a mental status change, hypoxemia (decreased oxygen in the blood). They could not get [] SAT (oxygen saturation) above 83% at the facility. Normal 02 SAT is between 95 and 100%.’ The resident was under a February 24, 2009 order requiring no food by mouth on February 28, 2009, 14, That Petitioner’s representative reviewed Respondent’s records regarding resident number nine (9) during the survey and noted as follows: a b. The resident was admitted to the facility on June 18, 2009; Diagnoses included acute respiratory failure, chronic airway obstruction, obesity, and anxiety; Hand written orders from respiratory therapy signed by the physician and dated June 18, 2009 included ventilator settings, ventilator checks every four (4) hours, trach care q shift, and trach change every thirty (30) days, These orders were not carried over, or carried inaccurately, in subsequent monthly physician orders; Comparing the physician’s order with July, August, September, October, November and December 2009 reflected the following: i. Xopenix 1.25 mg/3 ml contents of one vile via neb 4 times a day was ordered; ii, Respiratory flow sheets beginning August 25, 2009 reflect that the Xopenix was listed as ordered every six (6) hours as needed and does not list the routine dosage ordered by the physician; iii, Respiratory flow sheets for the months of September and October contain an incomplete order which reads “Xop 1.25 q6 pm” iv. The respiratory flow sheets include documentation that reads “Xop prn” f. Physician’s orders dated October 28, 2009 require the change of trach Shiley size 6 every 30 days to be continued; g. The resident’s respiratory flow sheets and respiratory treatment sheets do not reflect that the resident’s trach had ever been changed since admission; h. Respiratory treatment sheets reflect that trach care is to be performed every eight | (8) hours; i. The eight (8) hour increments are defined on the treatment sheets as “7 AM and 7 PM” j. There is no documentation that trach care was completed every eight (8) hours. 15, . That Petitioner’s representative interviewed Respondent’s respiratory manager during the survey regarding resident number nine (9) who indicated as follows: a.. She confirmed that there was no documentation in the record reflecting when the resident’s trach had been changed or ifit had ever been changed; b. That the physician’s order for Xopenix QID was being given in the PM; c. That a recommendation to change the prn had been given but was not followed up, therefore the order for routine nebulizers was not being done; d. She confirmed that the order for trach care to be done q8 hours was being done q shift and was only done two (2) times a day as the staff works twelve (12) hour shifts e. The wound care physician had noted that the resident had a fungal infection to the trach area and the respiratory manager could not rule out the cause of the infection as the trach care was not being done as frequently as ordered by the physician; f, The vent settings initially ordered on the resident’s admission had not been reordered each month when the resident’s monthly orders were renewed. 16, That Petitioner’s representative reviewed Respondent’s records regarding resident number ten (10) during the survey and noted as follows: a, The resident was admitted to the facility on September 18, 2009, b. Diagnoses included acute respiratory failure, hypertension, trans cerebral ischemia, anemia, and schizophrenia; c. The resident was dependent on a mechanical ventilator for breathing purposes related to the diagnosis of respiratory failure; d. Physician’s orders include an order upon admission of September 18, 2009 for Albuterol 0.83 mg/ml solution — use one vial via nebulizer every four (4) hours; e. The resident’s medication administration record refers this medication to respiratory therapy to be administered; f. The respiratory treatment record for the resident reflect as follows: i, Eighteen (18) prescribed doses were not initialed as administered between ii, iii. September 18 through 30, 2009; Twenty-one (21) prescribed doses were not initialed as administered in the month of October; No November record was available for review; The December 2009 respiratory treatment sheet indicates Albuterol 0.5 cc TID (three times daily), however no physician’s order changing the dosage or number of administrations prescribed on September 18, 2009 could be located; A total of sixty-six (66) prescribed doses of the nebulizer treatment were not initialed as given, 17. That Petitioner’s representative interviewed Respondent's respiratory manager during the survey regarding resident number ten (10) who indicated as follows: a. There is no documentation that the resident’s trach had been changed on a monthly basis as required by Respondent’s policy and procedure; b. Blank areas on the treatment sheet for trach care to be performed every shift were blank and she could not confirm the care had been performed as scheduled; c. The incompleteness of the transcriptions was confirmed and she was unsure why the order had been completely changed in December 2009; d. Respiratory therapists call physicians regarding the status of residents or the need to change treatment, however they do not always write them down when they get verbal orders from a physician. 18. That Petitioner’s representative reviewed Respondent’s records regarding resident number eleven (11) during the survey and noted as follows: . The resident was admitted to the facility on March 11, 2008; . Diagnoses included acute respiratory failure, anxiety, sleep apnea, psychosis, pheumonia, depression, and atrial fibrillation; . The resident was sent to the hospital for a brief visit and returned within 24 hours on March 27, 2009; . A July 28, 2009 verbal physician’s order required “Duoneb q4 PRN” . A telephone order of September 9, 2009 changed the nebulizer order to “Q4h PRN Duoneb” A October 28, 2009 physician’s order reads “continue trach care BID, change Shiley #8.0 XLT trach every 30 days. Suction q2 hours” . None of these orders are noted on the monthly physician’s order sheets; . Therefore, beginning the month following these orders, there were no orders for nebulizer treatments, trach care, trach change and suction parameters; There is no documentation that the trach was changed or that the resident’s trach was suctioned every two (2) hours as ordered; The resident’s respiratory flow sheets contain documentation of the nebulizer treatment as “alb & Atrovent PRN” or “Duo PRN” which is an incomplete order ' transcription of the above; . The resident’s medication administration records reflect the following: i, In June, August, and October 2009, there was an incomplete transcription of “duoneb PRN” ii, In July, November, and December 2009, there was an incomplete transcription of “0.5 cc Albuterol & 0.5 mg Ipratropium Bromide PRN’ iii, vi. vii. viii. In September 2009, there was an incomplete transcription of “DUO PRN” A second page of the respiratory treatment records reflect documentation for the monthly change of the resident’s trach, ‘These areas to document the change of the trach are blank and not initialed as completed for June, July, September, October, November, and December 2009; The only documented trach change for the resident was in August 2009; Also listed on the treatment records is trach care every shift timed for 7:00 Am and 7:00 PM; There are numerous times where the timed trach care slots are blank and circled which indicate the care not provided with July 2009 with cleven (11) blanks, August 2009 with nine (9) blanks, September 2009 with three (3) blanks, October 2009 with eleven (11) blanks, and November 2009 with seven (7) blanks; . These records are incomplete and inadequate to determine if prescribed nebulizer treatments were provided. 19, That Petitioner’s representative interviewed Respondent's respiratory manager during the survey regarding resident number eleven (11) who indicated as follows: a. She confirmed the incomplete documentation addressed above; b. Therapists had been trained differently and she did not understand why they took short cuts and documented incompletely; ¢. She was unable to determine whether the resident’s trach had been changed other than in August 2009. 20, That Petitioner’s representative reviewed Respondent’s records regarding resident number six (6) during the survey and noted as follows: a. The resident was readmitted to the facility on December 5, 2009; b, Diagnoses included acute respiratory failure, chronic respiratory failure, and anoxic brain failure; c, A physician’s order dated December 5, 2009 required albuterol 2.5 mg. via. nebulizer every six hours; d. Nursing medication administration records did not reflect the prescribed albuterol. 21. That Petitioner’s representative interviewed Respondents director of nursing during the survey regarding resident number six (6) who indicated ‘that the resident’s nebulizer treatments are administered by the respiratory therapist. 22. That Petitioner’s representative interviewed Respondent’s director of respiratory services during the survey regarding resident number six (6) who: a. Produced a flow sheet documented by physical therapists reflecting the administration of Albuterol q4h PRN around the clock from December 5 through December 22, 2009 at 3:00 AM, 7:00 AM, 1100 AM, 3:00 PM, 7:00 PM, and 11:00 PM; b. She confirmed that the documented administered dosages did not reflect the last ordered dosages of Albuterol by the physician. 23, That Petitioner’s representative reviewed Respondent's records regarding resident number seven (7) during the survey and noted as follows: a. The resident was admitted to the facility on September 24, 2009; b. Diagnoses include acute respiratory failure, paralysis agitans, chronic airway 13 obstruction, and senile dementia; . Physician’s orders for December 2009 include an order for Albutero! 0.83 mg/ml _ solution use 1 vial via nebulizer every six hours, the order dated December 5, 2009; . The resident’s nursing medication administration records do not reflect the administration of Albuterol; , Treatment administration records did not reflect monthly trach care q shift and trach change every month for October, November, and December 2009; Trach care q shift was not documented as completed on September 26 - 7 PM shift, September 29 L 7 AM shift, OctoberS — 7 AM shift, October 8 ~ 7 PM shift, October 15 — 7 AM shift, October 21 — 7 AM shift, October 26 through October 28 ~ 7 PM shift, November 1 - & am and 7 PM shifts, November 2 — 7 PM shift, November 6 ~ 7 AM shift, November 23 — 7 PM shift, November 25 - 7 AM shift, and November 27 — 7 AM shift. That Petitioner’s representative interviewed Respondent’s director of nursing during ‘the survey regarding resident number seven (7) who indicated that the resident’s nebulizer treatments are administered by the respiratory therapist. That Petitioner’s representative interviewed Respondent’s director of respiratory services during the survey regarding resident number seven (7) who: a. Produced a medication flow sheet completed by Respondent’s physical therapists documenting Albuterol q6 hours though absent from the record was any indication of the quantity of Albuterol administered; b. Confirmed incomplete records documenting the completion of ordered trach care. 26, That Petitioner’s representative reviewed Respondent’s records regarding resident number four (4) during the survey and noted as follows: a. The resident’s medical history reflects the resident has insulin dependent diabetes mellitus; b. December 2009 physician orders include orders for Novolin R 100 units/ml to be injected subcutaneously per sliding scale instructions three (3) times daily at 6:30 AM, 4:30 PM, and 9:00 pm; c, The resident’s December 2009 medication administration record reflects as follows: iii. On December 7, 2009 at 4:30 PM blood sugar is documented at 212 which would require three (3) units insulin coverage under the prescribed sliding scale however no amount of insulin coverage is documented nor is the site of any injection documented; ii, On December 9, 16, 17, and 18, 2009 at 4:30 PM no blood sugar level is documented nor is any insulin coverage under the prescribed sliding scale or the site of any injection documented, On December 16, 17, and 18, 2009 at 9:00 PM no blood sugar level is documented nor is any insulin coverage under the prescribed sliding scale or the site of any injection documented; On December 17, and 19, 2009 at 6:30 AM no blood sugar level is documented nor is any insulin coverage under the prescribed sliding scale or the site of any injection documented; d. Nursing notes from December 7 through 20, 2009 reflect no documentation related to the resident’s blood sugar levels or insulin coverage. 27. That Petitioner’s representative interviewed Respondent’s director of nursing and licensed practical nurse unit coordinator during the survey regarding resident number four (4) and they were unaware of as failure to document as identified above with the director of nursing adding “Regarding the insulin, there is no proof that doctor’s orders were followed for those days.” 28. That Petitioner’s representative reviewed Respondent’s records regarding resident number three (3) during the survey and noted as follows: a. b. The resident was admitted to the facility on October 7, 2009; Admitting diagnoses included Sepsis and the resident had an intravenous access port, Signed physician orders dated October 8, 2009 directed that the intravenous port was to be flushed with saline, and the saline flush to be followed with 5 ces of 100 units per 1 ml heparin flush every twelve (12) hours; On October 22, 2009, “See NO (new order)” is written on the resident’s medication administration record; No further entries on the medication administration record reflects the heparin flush; Physician’s orders dated October 22 through October 29, 2009 do not contain any directions or alterations of the prescribed heparin flush; On October 29, 2009, a physician’s order changing the flush schedule to three (3) times a day is noted; The resident’s medication administration records beginning October 9, 2009 have the entries for administration of heparin circled for 6:00 AM and 6:00 PM including October 22, 2009; i. The only related entry in nurse’s notes is an October 11, 2009 at 6:00 AM which states “Med not available.” 29. That Petitioner’s representative interviewed Respondent’s unit coordinator during the survey regarding resident number three (3) who indicated as follows: a. That the circles on the medication administration record indicate that the resident did not get the prescribed medication; b. That heparin flush is available in the facility’s emergency drug kit and staff needs to be better educated as to the contents of the emergency kit. 30. That Petitioner’s representative interviewed Respondent’s director of nursing during the survey regarding resident number three (3) who indicated “Regarding the heparin flush, 7 cannot show you that we followed doctor’s orders,” 31. That the above reflects Respondent’s failure to follow physician’s orders as prescribed or to document the reason for such non-compliance at the time of the non-compliance as required by law in the failure to: a. Perform oxygen saturation checks and suctioning for patient number two (2) as ordered by the resident’s physician; b. Ensure that resident number fifteen (15) was not provided food by mouth as ordered by the resident’s physician; c. Ensure that prescribed trach changes were performed, that prescribed medications were timely and appropriately administered, and that trach care was performed as prescribed; d. Administer prescribed medications via nebulizer or to provide trach care for resident number ten (10); e. Provide ordered medication and perform trach care as prescribed for resident number eleven (11); f. Provide the administration of prescribed dosages of medication for resident number six (6); g. Provide trach care and administration of prescribed medication as prescribed for resident number (7); h. Provide prescribed care and services, including insulin administration, for resident number four (4); i, Provide prescribed medications including heparin flush for resident number three (3). 32, That the Agency determined that this deficient practice presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility and cited Respondent for a State Class I Patterned deficient practice. 33, That the above constitutes a patterned deficient State Class I deficiency, WHEREFORE, the Agency seeks to impose an administrative fine in the amount of twelve thousand five hundred dollars ($12,500.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400,23(8)(a), Florida Statutes (2009). COUNT II(N60) 34, The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 35, That pursuant to Florida law, the administrator of each nursing home will designate one full time registered nurse as a Director of Nursing who shall be responsible and accountable for the supervision and administration of the total nursing services program. When a director of nursing is delegated institutional responsibilities, a full time qualified registered nurse shall be designated to serve as Assistant Director of Nursing. In a facility with a census of 121 or more residents, an RN must be designated as an Assistant Director of Nursing.Rule 59A-4.108(1), Floirda Administrative Code. 36, That on or about December 23, 2009, the Agency completed a complaint survey of Respondent’s facility. 37. That based upon interview and the review of records, Respondent facility failed to ensure - that its director of nursing was responsible and accountable for the supervision and administration of the total nursing services program where multiple identified failures were identified, the same being contrary to law. 38. That Petitioner’s representative reviewed Respondent's resident medical records with Respondents director of nursing and director of respiratory therapy during the survey and noted that all eight (8) residents in the facility who were on ventilators did not have current physician’s orders. 39, That Petitioner’s representative interviewed Respondent's director of nursing during the survey who indicated as follows: a, That the facility had transitioned from an outside vendor providing respiratory therapy to in house employees providing respiratory services in June 2009, b. Nursing chart checks are conducted at the end of every month and it had not been _ realized that respiratory therapy orders were not included in the identified charts; c. Quality assurance had not discussed the transition from third party providers for respiratory therapy to in house staff providing said services. 40. That Petitioner’s representative reviewed the personnel record of employee number two (2) during the survey and noted as follows: a. That the employee had completed an application on October 24, 2008 for the position of Restorative Assistant Director of Nursing; b. The application identified the facility’s director of nursing as a “friend or relative working for us” c. The application disclosed that the applicant had a driving under the influence charge in 2004; d. The page of the application entitled “Applicant Contact Results,” “interview Results.” “Test Results,” and “Reference Check Results” remained blank; e. Included was what appeared to be an original document with a web site header and dated footer of November 12, 2008 with a license verification date of November 12, 2008 listing the applicant/employee’s license activity as “suspended/active.” f. Included was a photocopied document without a header, footer, or license . verification date which lists the applicant/employee’s license status as “clear active” and includes the applicant/employee’s license number and license expiration date of April 30, 2009; g. A Florida State Criminal Background report dated November 3, 2008 for the applicant/employee lists a driving under the influence misdemeanor in the first degree of January 15, 2005; 20 h. On the customer comments section of the criminal background report is the following: “The hit status of this report was changed to clear by Harmony on 11/3/08 Cleared by [the name of the Respondent's director of nursing].” 41. That Petitioner’s representative interviewed Respondent's director of nursing during the survey regarding employee number two (2) and the director of nursing indicated as follows: a. b. She knew the employee from a previous job and “brought her over.” The human resources staff member who worked for Respondent in November 2008 is no longer with Respondent and had not brought the driving under the influence charge to the director of nursing’s attention, The employee “never never” told her that the employee was in the Impaired Program for Nurses and the director of nursing had never asked the employee; She could not get on “the system (Florida Department of Law enforcement)” and did not “clear” the employee’s criminal history; As a result of an employee assault on the facility property in July 2009, the Florida Board of Nursing was notified; During the investigation, the Florida Board of Nursing brought the employee’s suspended license status to the attention of the facility in the second week of November; The employee was terminated on November 16, 2009; She acknowledges that the employee was employed by the facility while the employee’s license was suspended in 2008, however she was unaware of the situation and unaware of the employee’s past disciplinary history including diversion of narcotics; 21 i. The employee had told her only of discipline related to a late fee. 42, That employee number five (5) was hired by Respondent on June 2, 2009 and had a conviction of driving under the influence and had a suspended driver's license. 43, That Petitioner’s representative interviewed employee number five (5) during the survey who indicated that he was not aware that he had to report convictions for driving under the influence to the Board of Nursing. 44. That Petitioner’s representative interviewed Respondent’s director of nursing during the survey regarding employee number five (5) who indicated that she was aware of the employee’s convictions and had not inquired if he had reported the conviction to the Board of Nursing. 45, That the Nurse Practice Act, Section 464.001 Florida Statutes (2009), et seq., provides as follows: “The following acts constitute grounds for denial of a license or disciplinary action, as specified in s. 456.072...” Section 464.018(1), Florida Statutes (2009). Chapter 456, Florida Statutes provides in part “The following acts shall constitute grounds for which the disciplinary actions specified in subsection (2) may be taken .., Except as provided in s. 465.016, failing to report to the department any person who the licensee knows is in violation of this chapter, the chapter regulating the alleged violator, or the rules of the department or the board... Aiding, assisting, procuring, employing, or advising any unlicensed person or entity to practice a profession contrary to this chapter, the chapter regulating the profession, or the rules of the department or the board... Failing to report to the board, or the department if there is no board, in writing within 30 days after the licensee has been convicted or found guilty of, or entered a plea of nolo contendere to, regardless of adjudication, a crime in any jurisdiction... Sections 456.072(i), G) and (x), Florida Statutes (2009). 46. That Petitioner’s representative interviewed Respondent’s director of nursing during the 22 survey regarding an incident in which a resident who was ordered no food by mouth was given a cookie (resident number fifteen [15] discussed above) and the director of nursing indicated as follows: a, There was no internal investigation of the matter; b, No required adverse incident reports were prepared or forwarded as required by . law; c. She was aware of the incident; d. She did not follow up with the risk manager, who was employed with a suspended license, to ensure that all issues related to the event were investigated and reported. 47. That Petitioner’s representative reviewed resident records during the survey and noted as follows: a. Employees numbered one (1), six (6), ten (10), eleven (11), and twenty-eight (28) signed off as having administered antibiotics and or flushing the left subclavian central line from December 15 through December 22, 2009; b. Employees numbered one (1), six (6), nine (9), ten (10), eleven (11), twenty-eight (28), and twenty-nine (29) signed off as having administered a saline flush through a peripherally inserted central catheter line at intervals between September 19 and September 30, 2009. 48. Pursuant to Florida law, he purpose of [Rule 6489-12, Floirda Administrative Code] is to protect the public by ensuring the availability of intravenous therapy and its competent administration in the care of the ill, injured or the infirm, In keeping with the purpose, this rule authorizes the qualified licensed practical nurse to administer those aspects of intravenous 23 therapy within the scope of practice of the licensed practical nurse, enumerates those aspects of intravenous therapy outside the scope of practice of the licensed practical nurse, and sets out the educational and/or competency verification necessary to administer, under direction, limited forms of intravenous therapy. Rule 64B9-12, Floirda Administrative Code 49. Pursuant to Florida law, - Central Lines - The Board recognizes that through appropriate education and training, a Licensed Practical Nurse is capable of performing intravenous therapy via central lines under the direction of a registered professional nurse as defined in subsection 64B9-12.002(2), F.A.C, Appropriate education. and training requires a minimum of four (4) hours of instruction. The requisite four (4) hours of instruction may be included as part of the thirty (30) hours required for intravenous therapy education specified in subsection (4) of this rule. The education and training required in this subsection shall include, at a minimum, didactic and clinical practicum instruction in the following areas: (a) Central venous anatomy and physiology; (b) CVL site assessment; (c) CVL dressing and cap changes; (d) CVL flushing; (e) CVL medication and fluid administration; (f) CVL blood drawing; and (g) CVL complications and remedial measures. Upon completion of the intravenous therapy training via central lines, the Licensed Practical Nurse shall be assessed on both theoretical knowledge and practice, as well as clinical practice and competence. The clinical practice assessment must be witnesses by a Registered Nurse who shall file a proficiency statement regarding the Licensed Practical Nurse’s ability to perform intravenous therapy via central lines. The proficiency statement shall be kept in the Licensed Practical Nurse’s personnel file. Rule 64B9-12.005(2), Floirda Administrative Code. 50. That Petitioner’s representative reviewed Respondent’s personnel files during the survey and noted as follows: 24 a, Employee number one (1): The employee is a licensed practical nurse; i. The employee was hired on March 5, 2008; iii. Absent from the file was any documentation that the employee had completed the thirty (30) hour intravenous course; Absent from the file was any competency statement for intravenous or central venous lines. b. Employee number six (6): The employee is a licensed practical nurse; . The employee was hired on January 6, 2009; iii. Absent from the file was any documentation that the employee had completed the thirty (30) hour intravenous course; Absent from the file was any competency statement for intravenous or central venous lines. c, Employee number nine (9): . The employee is a licensed practical nurse; i, The employee was hired on March 26, 2008; iii, The file documented that the employee had completed the thirty (30) hour intravenous course; Absent ftom the file was any competency statement for intravenous or central venous lines. d. Employee number ten (10): i, The employee is a licensed practical nurse; 25 ii. The employee was hired on August 1, 2007; i; Absent from the file was any documentation that the employee had completed the thirty (30) hour intravenous course; Absent from the file was any competency statement for intravenous or central venous lines. e, Employee number eleven (11): The employee is a licensed practical nurse; ii, The employee was hired on September 17, 2009; iii, The file documented that the employee had completed the thirty (30) hour intravenous course; Absent from the file was any competency statement for intravenous or central venous lines. f. Employee number twenty-eight (28): The employee is a licensed practical nurse, i, The employee was hired on August 18, 2009; iii, Absent from the file was any documentation that the employee had completed the thirty (30) hour intravenous course; Absent from the file was any competency statement for intravenous or central venous lines. g. Employee number twenty-nine (29); i. ii. tii. The employee is a licensed practical nurse; The employee was hired on September 15, 2009, Absent from the file was any documentation that the employee had 26 completed the thirty (30) hour intravenous course; iv. Absent from the file was any competency statement for intravenous or central venous lines. 51. That Petitioner’s representative interviewed Respondent’s director of nursing during the . survey regarding nursing competencies and the director of nursing indicated as follows: a. b. That of the twelve (12) licensed practical nurses listed as certified for intravenous care and services, only two (2) have a certificate for central venous lines and only one (1) for intravenous; There have been no competencies or evaluations for any of the licensed practical nurses in the past year. 52. That the above reflects Respondent’s failure to ensure that its director of nursing maintained responsiblity and accountablity for the supervision and administration of the total nursing services program where the director of nursing failed to: a, Ensure that current physician’s orders were obtained and maintained for residents who are receiving ventilator care; Ensure that professional staff members have been appropriately screened for employment; Ensure that professional staff possess and maintain appropriate licensure upon and during employment; Ensure that all licensed staff comply with liensure requirements; Ensure that adverse incidents, including an incident in which the provision of food to a resident with physician orders prohibiting food by mouth resulted in hospitalization, are investigated and reported in compliance with minimum 27 requirements of law and facility policy; f. Ensure that licensed staff possess competencies in areas of care provded by Respondent’s agents. 53. The above reflect, individually and collectively, that Respondent’s director of nursing failed to adequately supervise and administer the total nursing services program 54. That the Agency determined that this deficient practice presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility and cited Respondent for a State Class I Widespread deficient practice. 55. That the above constitutes a widespread deficient State Class | deficiency. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of fifteen thousand dollars ($15,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2009). COUNT III 56. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Counts | and II of this Complaint as if fully set forth herein. 57. Based upon Respondent’s two State Class I deficiencies, Respondent 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)(a), Florida Statutes (2009). 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 December 23, 2009 and ending January 22, 2010. 28 COUNT IV 58. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count | as if fully set forth herein. 59, Respondent has been cited for one (1) State Class I deficiency and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of six thousand dollars ($6,000) pursuant to Section 400,19(3), Florida Statutes (2009). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two yeats and impose a survey fee in the amount of six thousand dollars ($6,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400,19(3), Florida Statutes (2009). Respectfully submitted this ¢ | day of April, 2010. J. Walsh II, Esquire Bar, No, 566365 Affency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat, (2008), Respondent shall post the most current license in a prominent place that is in clear and unobstructed public view, at or near, the place where residents are being admitted to the facility. 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. 29 All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873, RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR 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: 7009 3410 0000 0172 5913 on April