STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. , AHCA Nos. 2016006285 (Fines) 2010006287 (Cond.) RIVERWOOD NURSING CENTER, LLC, 2010006288 (Revoc.) d/b/a Glenwood Nursing 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 RIVERWOOD NURSING CENTER, LLC, d/b/a Glenwood Nursing Center (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate a nursing home in the State of Florida pursuant to §§ 400.121G)(d) and 408.815(1), Florida Statutes (2009), impose an administrative fine of one-hundred seventy-five thousand dollars ($175,000) and a survey fee of six thousand dollars ($6,000), for a total assessment of one-hundred eighty-one thousand dollars ($181,000.00), based upon the citation of seven (7) Class I deficiencies pursuant to §400.23(8)(a), Florida Statutes (2009) and one (1) Class IT deficiency pursuant to §400.23(8)(b), Florida Statutes (2009). Additionally, this is an action to change Respondent’s licensure status from Standard to Conditional commencing April 16, 2010 and ending June 5, 2010. JURISDICTION AND VENDOE 1. The Agency has jurisdiction pursuant to §§ 120.60, Florida Statutes, Chapter 400, . J Filed July 30, 2010 10:20 AM Division of Administrative Hearings. Part Il and Chapter 408, Part Il, Florida Statutes (2009), and Chapter 59A-4, Florida Administrative Code. 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. 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 Il, and 408, Part IJ, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 119-bed nursing home, located at 40 Acme Street, Jacksonville, Florida 32211, and is licensed as a skilled nursing facility (license number 1508095). 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, COUNT I (Tag N048) 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. | 7. Pursuant to Fla. Admin. Code R. 59A-4.1075(2)(d)-5, Florida law provides the following: The facility shall appoint a Medical Director who shall visit the facility at least once a month, The Medical Director shall review all new policies and procedures; review all new incident and new accident reports frorn the facility to identify clinical risk and safety hazards. The Medical Director shall review the most recent grievance logs for any complaints or concerns related to clinical issues. Each visit must be documented in writing by the Medical Director. (3) A physician may be Medical Director of a maximum of 10 nursing homes at any one time. The Medical Director, in an emergency where the health of a resident is in jeopardy and the attending physician or covering physician cannot be located, may assume temporary responsibility of the care of the resident and provide the care deemed necessary. (4) The Medical Director appointed by the facility shall meet at least quarterly with the quality assessment and assurance committee of the facility. (S) The Medical Director appointed by the facility shall participate in the development of the comprehensive care plan for the resident when he/she is also the attending physician of the resident. 8. The Agency conducted an unannounced licensure survey starting April 12, 2010 and ending April 16, 2010. 9. That based on record review and interview, the facility failed to ensure the medical director was responsible for the coordination of care in the facility through development of the residents’ plans of care. 10. That resident received laceration above his/her left eye. Resident fell 4 more times during the same month and sustained injuries to the head, the face and had a broken nose. Cross Referemce to NO54: 11. That based on record review and staff interview, the facility failed to follow physician orders for 1 of 7 sampled residents reviewed for falls that resulted in harm to Resident #76. Cross Reference to NO71: 12. Based on observations, resident record reviews, facility provided documentation, and staff and resident interview, the facility failed to accurately assess and reassess the needs for 5 of 7 residents reviewed for being at risk for falls. 13. That Residents #74, #76, #96, #45, and #91 who had each fallen at least once, did not have fall assessments and/or post fall assessments that would identify the potential causes and interventions in place to prevent a reoccurrence of falls. 14. That three residents, Resident #74, #76 and #96 had a reoccurrence of falls since December, 2009. . Cross Reference to NO74: 15. That based on record review, staff interview and resident interviews, the facility failed to revised the care plans for residents who were at risk for falls, 3 of 7 sampled residents (Residents #76, #45, and #96) and revise the care plan for 2 of 27 sampled residents (Residents #90 and #135) reviewed for weight loss ensuring that staff are aware of the resident's current needs. Cross Reference to N201: 16. That based on observations, record review, resident and staff interviews, the facility neglected to provide care and services to residents identified as "at risk for falls" and injury, develop successful interventions to prevent occurrence and reoccurrence of the falls and to adequately monitor the residents who were at high risk for falls by implementing the written policy and procedures for assessing for falls and their causes for 5 of 7 sampled residents, Residents #74, #76, #45, #96 and #125, who fell at least once, if not repeatedly, in the facility. Resident #76 fell and broke their hip and the facility failed to provide appropriate emergency services. Cross Reference to N216; 17. That based on observations, record review, resident and staff interviews, the facility neglected to provide care and services to residents identified as "at risk for falls" and injury, develop successful interventions to. prevent occurrence and reoccurrence of neglect and to adequately monitor the residents who were at high risk for falls by implementing the written policy and procedures for assessing for falls and their causes for 5 of 7 sampled residents, Residents #74, #76, #45, #96 and #125, who fell at least once, if not repeatedly, in the facility. 18. That Resident #76 fell and broke their hip and the facility failed to provide appropriate emergency services. Cross Reference to N906: 19. That based upon record review, interview, observation, and a review of the facility's Continuous Quality Improvement (CQI) meeting roster, the facility failed to identify and or recognize quality of life and quality of care deficient practices taking place in the facility and they failed to develop and implement plans of action to correct these deficient practices. 20. That this placed all residents at risk for abuse and/or neglect and created a situation that is likely to result in serious injury, harm, impairment, or death requiring immediate corrective action on the part of the facility. 21, That the facility neglected to provide care and services to residents identified as “at tisk for falls" and injury, develop successful interventions to prevent occurrence and reoccurrence of neglect and to adequately monitor the residents who were at high risk for falls by implementing the written policy and procedures for assessing for falls and their causes for 5 of 7 sampled residents, Residents #74, #76, #45, #96 and #125, who fell at least once, if not repeatedly, in the . facility. Resident #76 fell and broke their hip and the facility failed to provide appropriate emergency services. 22.. The above findings reflect Respondent’s failure to provide necessary care and services to avoid physical harm, thus the Respondent’s actions constituted a pattern Class I deficiency, pursuant of § 400.23(8)(a), Florida Statutes(2009). 23. That the Agency provided the Respondent with a mandatory correction date of May 5, 2010. 24. That a Class I deficiency is a deficiency that the agency determines 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. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency. 25. That Respondent had been cited for two (2) Class ‘I deficiencies following an unannounced complaint survey CCR #20100001200 on February 5, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $25,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2009). COUNT Il (Tag N54) 26. The Agency re-alleges and incorporates paragraphs one (1) through five (5) of this Complaint as if fully set forth herein. 27. Pursuant to Fla. Admin. Code R. 59A-4.107(5), Florida law provides the following: (5) 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. 28. The Agency conducted an unannounced licensure survey starting April 12, 2010 and ending April 16, 2010. 29. That based on record review and staff interview, the facility failed to follow physician orders for 1 of 7 sampled residents reviewed for falls that resulted in harm to Resident #76. 30. . That a record review of the medical record for Resident #76 on 4/13/10 at 2:08 PM revealed that he/she had a history of glaucoma, Alzheimer's disease, seizure disorder, anxiety ‘syndrome, psychosis and falls. The resident was disoriented to place and time and ambulated throughout the facility at will. The resident was globally confused with poverty of speech. On 2/24/10 at 5:30 PM the resident "tripped and fell" in the reception area with no injuries related to the fall. 31. That a review of the nurse's notes dated 2/27/10 at 12:50 PM revealed that on 2/27/10 at 9:15 am, another resident had theit legs out and Resident #76 "tripped" over their legs and fell with no injuries. On 2/27/10 at 11:00 am, the resident was ambulating down the hallway when another resident was being placed into a wheelchair. Resident #76 was trying to move out of the way; took a wrong turn and fell with no injuries reported. 32. That the nurse’s notes of 3/2/10 stated that the resident was not in pain. However, there were no notes until 3/13/10 at 4 PM when the resident was noted as limping and an X-ray was ordered. 33. That an interview with the staff nurse on 4/13/10 at 1:58 PM revealed that the resident had numerous falls. | 34, That she stated that the resident had three falls without injury and that the resident was now on a soft belt restraint. 35. That she stated that the Certified Nursing Assistant (CNA) rounded every 2-3 hours to make sure of the location of the resident. 36. That an interview with the CNA on 4/15/10 at 8:01 am revealed that the resident constantly walked back and forth; that he/she will walk over anything since they did not have any safety awareness. 37. That a review of the resident's record revealed that no post fall . evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 38. That on 3/13/10 at 4:00 PM, the staff nurse documented that the resident was ambulating in the hallways and- was limping. 39. That the staff nurse documented that "this time complains of (the resident's) leg but cannot identify which leg." 40, That x-Rays of the left hip was done and at 7:30 PM on 3/13/10 it showed a “unilateral osteoporotic subtle almost invisible impacted fracture of the femoral neck with no dislocation to the joint", 41. That at 7:30 PM the physician was called and the nurse received orders to send the resident to the emergency room. The resident was sent to the emergency room (ER) by stretcher ambulance service. | ‘ 42. That the resident's power of attorney was notified on 3/13/10 and she refused to have the resident seen in the emergency room (ER) without her presence and demanded that the resident be returned to the facility. 43. That the transporting vehicle turned around and brought the resident back to the facility. This procedure was not in keeping with the physician's order to send the resident for emergency treatment. 44. That the POA informed the facility that she would come to the facility the next day (3/14/10) to take the resident to the doctor. 45. That a review of the resident's clinical record, including the social worker's progress notes, did not reveal any documentation of education by the facility staff that indicated they addressed the concerns with the resident and/or the power of attorney regarding the immediate need for an evaluation at the emergency room (ER). The resident remained in the facility on 3/14/10 without being evaluated for the left hip fracture. 46. That the power of attorney (POA) did return to the facility on 3/15/10 and took the resident for medical services. However, there was no doctor's order at that time. The resident was admitted to a local hospital on. 3/15/10 due to the hip fracture. 47. That an interview with the power of attorney (POA) on 4/15/10 at 7:55 PM revealed that she was aware of the left hip fracture and she refused to have the resident seen in the ER because the resident could not speak for herself and that she wanted to be there with the resident. 48. That an interview with the Medical Director on 4/15/10 at 2:48 PM revealed that he wrote an order for the resident to go to the emergency room and that the niece should not have " interfered with what they wanted to do. The medical director stated that they only knew when the resident returned to the facility. | 49. Interview with the Director of Nurses (DON) and Administrator on 4/16/10 at 8:20 am revealed that with the family member, having power of attorney, she can at any time take the resident to the emergency room (ER). 50. That she stated that the family member took the resident in her personal car to the emergency room and that the family members has taken the resident out of the facility many times before. However, the resident needed immediate medical attention and the facility did not ensure that the resident received it. 51. That an interview with the Director of Nurses (DON) and Administrator on 4/16/10 at 8:20 am revealed that with the niece having power of attorney, she can at any time take the resident to the ER. 52. That the DON stated that the niece took the resident in her personal car to the emergency room and that those occasions occurred all of the time in the facility. 53, The above findings reflect Respondent’s failure to identify concerns and develop plans of action to address care and service issues that impacted the health and safety of residents, thus the Respondent’s actions constituted an isolated Class I deficiency, pursuant of § 400.23(8)(a), Florida Statutes (2009). 54. That the Agency provided the Respondent with a mandatory correction date of May 5, 2010. 55. That a Class I deficiency is a deficiency that the agency determines 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. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class 1 or class Ii deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency. 56. That Respondent had been cited for two (2) Class I deficiencies following an unannounced complaint survey CCR #20100001200 on February 5, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $20,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400,23(8)(a), Florida Statutes (2009). COUNT Ul (Tag NO71) 57. The Agency re-alleges and incorporates paragraphs one (1) through five (5) of this Complaint as if fully set forth herein. 58. Pursuant to Fla. Admin. Code R. 59A-4.109(1), Florida law provides the following: each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of: (a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential. (b) A. preliminary nursing evaluation with physician’s orders for immediate care, completed on admission. (c) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment shal] be: 1. Reviewed no less than once every 3 months, 2. Reviewed promptly after a significant change in the resident’s physical or mental condition, 3. Revised as appropriate to assure the continued accuracy of the assessment. 59. The Agency conducted an unannounced licensure survey starting April 12, 2010 _ and ending April 16, 2010. 60, That based on observations, resident record reviews, facility provided documentation, and staff and resident interview, the facility failed to accurately assess and reassess the needs for 5 of 7 residents reviewed for being at risk for falls. 61. That Residents #74, #76; #96, #45, and #91 who had each fallen at least once, did not have fall assessments and/or post fall assessments that would identify the potential causes and interventions in place to prevent a reoccurrence of falls. 62. That three residents, Resident #74, #76 and #96 had a reoccurrence of falls since December, 2009. 63, That this resulted in placing all residents at risk for future occurrences of neglect and created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. 64. Resident #74 That during the initial tour of the facility on 4/12/ 10 at 10 am, Resident #74, a 76 year old weighing 79.8 lbs, was observed self propelling their wheelchair along the South wing hallway with a visible bruised upper cheek and nose. 65, That an interview with a staff member on 4/12/10 at 10:05 am revealed that the resident had fallen over the weekend but staff did not have any further details. Resident #74 was observed on 4/13/10 in the hallway with the bruise more pronounced on both cheeks, forehead and nose, revealing larger bruised areas from the day before. 66. That observations on 4/14/10 revealed the following: . At 9:30 am the resident was not observed in their room. The resident's bed was observed at the lowest height and there were 2 full side rails present which were not raised. . At9:35 am a CNA assigned to the resident was interviewed and revealed that the resident had fallen over the weekend from their bed. She stated that Resident #74 always crawled out of bed at night and had fallen numerous times and enumerated the resident's behavior to include aggressiveness, and scratching staff. When asked how often did the resident exhibit such behavior, the staff stated that it was not daily but the resident did exhibit the behavior sometimes, other times the resident was pleasant. The staff identified the resident as one that needed total care. The staff added that the resident was "all over the facility". The staff also stated that the resident would crawl out of their waist restraint at times. . At 9:40 am the resident was observed in the hallway, self-propelling their wheelchair, with a blue waist restraint tied to the back of the chair. . At 9:40 am in Resident #74's room the CNA showed the surveyor how the resident fell out of bed. The mattress was observed to be shorter than the bed but a filler pad was in place. There was no bed alarm observed on the bed at that time. When asked whether the resident had a bed alarm, the staff said that the resident used to have one but the resident would turn off the device and/or take the device off such that the device would not alarm. The staff confirmed at that time that the resident never had mats at bedside. At 9:45 am the MDS coordinator was interviewed at the South wing nurses’ station regarding what kind of system was in place to prevent falls and injury for Resident #74, The MDS coordinator picked up Resident #74's medical chart and reviewed the "Falls" care plan. The staff revealed that the resident had a bed alarm instituted on 3/11/10 and a soft waist belt restraint on 3/19/10. She said that resident “always crawled over the bed side rails at night". She was asked why resident needed 2 full side rails when. she had the behavior of crawling over the bed rails. She did not respond. Observation with the staff in the resident's room at that time did not reveal the presence of a bed alarm. The staff could not find the alarm. Further interview with the MDS coordinator at this time concerning the most recent fall per the CNA interview and observation of the resident on 4/12/10, the MDS coordinator said that the resident fell on March 19, 2010. When asked if staff was aware that resident had fallen again over this past weekend, the staff said that she was not aware of it, That a review of the nurse’s notes dated 4/11/10 at 11:15 PM confirmed that resident fell forward in their wheelchair in the main dining room and had a bruised forehead and a crooked nose, bleeding from the left nostril. The notes also noted that the Physician was called and an order to transfer to a local hospital was received. Family was notified by phone (answering machine). A request was made for the corresponding incident report. The MDS coordinator said that the Risk manager kept incident reports. At 9:50 am an interview with the Risk manager at the South Hall nurses station revealed that staff was not aware of the 4/11/10 fall until the surveyor asked to see the incident report. The staff revealed that an adverse incident report had not been filed. The staff denied any information from nursing staff about the incident, yet she was able to produce the incident report filed in her mail box from the 3-11 PM nurse after the incident, The risk manager said that she relied on staff reporting any adverse events to her. The staff said that the facility did not have a morning meeting where care issues were discussed. The facility did have a QCI meeting which was held on Wednesdays. 67. That observations in the main dining room was conducted on Monday, 4/12/10 between 11:30 am and 12:30 PM when Resident #74 was eating lunch. Facility staff were present including restorative aides, direct care staff and facility management team. Resident #74 was in full view of all residents and staff present in the dining room at that time. However the staff did not recognize the Caucasian resident with a blue/black bruised face while she was eating. 68. That a review of the incident report completed by the nurse on duty revealed that a CNA going to the "time clock" witnessed the fall. The report revealed that the resident flipped over in the main dining room onto their face while restrained in wheelchair, Crooked bloody nose and bruise to fore head were sustained as documented on the "diagram location of injury". The report further stated that the staff asked the resident what happened and the resident indicated that they were trying to "get up from the wheelchair". 69. That Resident #74 was first admitted to the facility on 3/15/2007 with diagnoses of: UTI, Sepsis; Dementia; Depression; and Hypokalemia. 70. ‘That a review of the most recent annual MDS assessment dated 2/3/10 coded Resident #74, under section G5b and G5d, as using a wheelchair as a primary mode of locomotion and self-wheeled. Section J4a and J4b coded the resident as having a history of falls, within past 30 days and also within past 31-180 days. 71. That the RAP (Resident Assessment Protocol) summary dated 2/5/10 noted that the resident "triggered for falls". The RAP Falls decision summary noted: "Resident at risk for falls, has a history of falls and has impaired safety awareness along with cognition, resident is in a wheelchair at this time, receives daily psych meds, is not displaying any drug related side effects but remains at risk, will proceed to care plan". 72. That a review of the facility's form titled Fall Risk Assessment dated 1/27/10 noted the resident scored 16. A total score of 10 or above placed the resident at a "High Risk" for falls. 73. That the facility did have a plan of care dated 2/9/10 identifying that the resident was at risk for falls related to unsteady gait, impaired bed mobility, and cognition, use of psychoactive medications and attempts to transfer from chair to bed and bed to chair with supervision. A review of the Incident Reports for Resident #74 supplied by the Risk manager revealed that the resident had reported falls as follows: a. On 2/23/10 at 9:30 PM the resident was "found sitting on the floor beside bed, attempting to transfer without assistance. CNA assisting another resident. (Prevention: remind the resident to ask for help.) Investigation report dated for 2/23/10, risk mgr signed (no injury)". According to the Incident Log for February 2010, this fall was unwitnessed. On 3/1/10 at 10 PM the resident was "found sitting on the floor beside bed, attempting to transfer without assistance. CNA assisting a resident in rm 123. (Prevention: constantly remind her to call for assistance when she needs to transfer) Investigation report dated for 3/1/10, signed by risk manager (no injury)". According to the Incident Log for March 2010, this fall was unwitnessed. On 3/4/10 at 7 PM the resident "fell from shower chair while getting bath, resident being physically aggressive. Laceration above the left eye (have 2 CINA assist with bath when resident is aggressive). Investigation report dated for 3/4/10, signed by risk manager (no adverse incident report filed)(first aid applied at NH)". According to the Incident Log for March 2010, this fall was unwitnessed. On. 3/8/10 at 11 PM observed "resident sitting on the floor beside their wheelchair (w/c) by the bedside. SWB (soft waist belt) not on at time of fall. CNA assisting other residents, nurse in station charting. (Prevention: will discuss in CQI) Investigation report dated for 3/8/10, signed by risk manager". According to the Incident Log for March 2010, this fall was unwitnessed. There was no evidence that this fall was discussed in the next CQI meeting which according to facility staff would have taken place on Wednesday, March 10, 2010. f. On 3/10/10 at 9 PM the “resident walked from bed w/o assistance and fell at door, on ground in supine position. CNA assisting other residents. injury: edema on the back of the bed. (Prevention: will put bed alarm on resident while she is in bed, soft waist belt (SWB) was on while in wheelchair. SWB not on at time of fall. Investigation report dated for 3/10/10, signed by risk manager (first aid only, ice applied to raised area)". According to the Incident Log for March 2010, this fall was unwitnessed. g. On 3/11/10 at 12:40 am - "Resident tying on floor beside clothes hamper, lying on back with knees drawn up, noted laceration to right temple. Soft waist belt (SWB ) was not on at the time of fall. (Bed alarm ordered and placed on bed this morning). Investigation report dated for 3/11/10, signed by risk manager". According to the Incident Log for March 2010, this fall was unwitnessed. h. On 3/19/10 at at 11:10 PM - "Resident was found on the floor in front of wheelchair at South 2 Nursing station. Resident was not interviewable due to confusion. Fall occurred during the change of shift. Nose fractured per CT scan. "Possible cause: Resident is very weak and possibly attempted to stand up un- assisted, i. Injury: bruising to face". (Prevention: SWB while up in w/c, bed alarm when resident is in bed.) Investigation report dated for 3/19/10, signed by risk manager (ice applied, resident sent to hospital) (resident actually fell on the 18)", j. According to the Incident Log for March 2010, this fall was unwitnessed. k. On 4/11/10 "the resident flipped over in wheel chair on face while restrained in wheelchair in dining room. (Witnessed by) CNA going to time clock. 1. Injury: bloody nose, bruise to forehead and crooked nose". 74, Despite all these documented falls and the 3/19/10 trip to the hospital, a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 75. That the facility did not have any system in place to adequately care for this resident and to prevent further falls until the survey team identified on-going immediate jeopardy on 4/14/10. The facility instituted a One on One staff monitoring for Resident #74 at 4:30 PM on 4/14/10. The One on One monitoring was due to the survey team identifying the immediate jeopardy situations in regards to this resident having repeated falls without reassessing the resident's condition post falls. 76. ° That areview of the Adverse incident log book revealed that there was not a single adverse investigation filed with the State of Florida on Resident #74. Per facility policy, neurological assessments are completed for 72 hrs after each fall. Review of the neurological flow sheets revealed completed for the following dates only: 3/4/10, 3/5/10, 3/10/10, 3/11/10, 3/12/10 and 3/19/10. Residemt #76 77. That a record review of the medical record for Resident #76 on 4/13/10 at 2:08 PM revealed that he/she had a history of glaucoma, Alzheimer's disease, seizure disorder, anxiety syndrome, psychosis and falls. The resident was disoriented to place and time and ambulated throughout the facility at will. The resident was globally confused with poverty of speech. On 2/24/10 at 5:30 PM the resident "tripped and fell" in the reception area with no injuries related to the fall. 78. That a review of the nurse's notes dated 2/27/10 at 12:50 PM revealed that on 2/27/10 at 9:15 am, another resident had their legs out and Resident #76 "tripped" over their legs and fell with no injuries. On 2/27/10 at 11:00 am, the resident was ambulating down the hallway when another resident was being placed into a wheelchair. Resident #76 was trying to move out of the way; took a wrong turn and fell with no injuries reported. 79. That the nurse’s notes of 3/2/10 stated that the resident was not in pain. However, there were no notes until 3/13/10 at 4 PM when the resident was noted as limping and an X-ray was ordered. 80. That an interview with the staff nurse on 4/13/10 at 1:58 PM revealed that the resident had numerous falls. She stated that the resident had three falls without injury and that the resident was now on a soft belt restraint. She stated that the Certified Nursing Assistant (CNA) rounded every 2-3 hours to make sure of the location of the resident. 81. That an interview with the CNA on 4/15/10 at 8:01 am revealed that the resident constantly walked back and forth; that he/she will walk over anything since they did not have any safety awareness. 82. That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 83, That on 3/13/10 at 4:00 PM, the staff nurse documented that the resident was ambulating in the hallways and was limping. The staff nurse documented that "this time complains of (the resident's) leg but cannot identify which leg." X-Rays of the left hip was done and at 7:30 PM on 3/13/10 it showed a "unilateral osteoporotic subtle almost invisible impacted fracture of the femoral neck with no dislocation to the joint". : 84. That at 7:30 PM the physician was called and the nurse received orders to send the resident to the emergency room. The resident was sent to the emergency room (ER) by stretcher ambulance service. 85. That the resident's power of attorney was notified on 3/ 13/10 and she refused to have the resident seen in the emergency room (ER) without her presence and demanded that the _fesident be returned to the facility. The transporting vehicle turned around and brought the resident back to the facility. 86. That this procedure was not in keepirig with the physician's order to send the resident for emergency treatment. The POA informed the facility that she would come to the facility the next day (3/14/10) to take the resident to the doctor. 87. That a review of the resident's clinical record, including the social worker's progress notes, did not reveal any documentation of education by the facility staff that indicated they addressed the concerns with the resident and/or the power of attorney regarding the immediate need for an evaluation at the emergency room (ER). The resident remained in the facility on 3/14/10 without being evaluated for the left hip fracture. 88. That the power of attorney (POA) did return to the facility on 3/15/10 and took the resident for medical services. However, there was no doctor's order at that time. The resident | was admitted to a local hospital on 3/15/10 due to the hip fracture. 89, That an interview with the power of attorney (POA) on 4/15/10 at 7:55 PM revealed that she was aware of the left hip fracture and she refused to have the resident seen in the ER because the resident could not speak for herself and that she wanted to be there with the resident. 90. That an interview with the Medical Director on 4/15/10 at 2:48 PM revealed that he wrote an order for the resident to go to the emergency room and that the niece should not have interfered with what they wanted to do. The medical director stated that they only knew when the resident returned to the facility. 20 Resident #45 91. That a review of Resident #45's medical record revealed a nurse's note dated 4/1/2010 at 12:30 PM which read “writer was notified that pt (resident) was playing around in dining room lost (their) balance and fell over a chair and tried to grab ahold of another resident and pulled (another resident) down with (him/her). Slight bruising and swelling noted to right middle finger, Tylenol given for pain. meds effective 30 min past admin, res (resident) able to bend and move finger." A nurse's noted written on 4/1/2010 at 1:30 PM read" Critical Phenobarbital level of 50.2, called Advanced Registered Nurse Practitioner (ARNP) order to hold Phenobarbital for two days then resume and report lab in two weeks." A therapeutic anticonvulsant level of phenobarbital in serum is 10 to 25 g/mL. . 92, That a review of adverse reactions for Phenobarbital users includes unsteady gait, slurred speech, fainting, drowsiness, dizziness, restless muscle movement, excitement, irritability, aggression and confusion especially in the elderly. 93, That a review of the Risk Manager's investigation report for the 4/1/2010 fall, she wrote the possible cause of the fall was that the resident was playing around in the dining room when he/she tripped and fell. She lists actions to be taken as "remind the resident to be careful in the dining room, keep hallways and dining room clear and clutter free". The facility had repeatedly assessed the resident as alert with confusion in the medical record, so that the interventions were inappropriate for this resident. They also did not place appropriate intervention on the resident's care plan to implemented. 94. That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 21 95. That a nurse’s note on 4/14/2010 at 2:00 PM read "pt complained of left hand. pain. swollen. pt stated "I fell yesterday" pt Stated (he/she) had pain in left hand. Pt noted to have swelling in left forearm also, Dr order for x-ray. risk manager informed. Tylenol given for pain. pt has confusion and oriented X 1. No signs or symptoms of change in mental status. Pt states (he/she) doesn't know what time, but that (he/she) fell in the dining room. "Resident sent to hospital on 4/15/2010 at 9:45 am. A nurse's note written on 4/15/10 read "called for update, resident admitted with left radial fx and phenobarbital intoxication. " 96. That on 4/14/2010 at 12:59 PM an interview was conducted with the MDS Coordinator. She stated that she only makes care plan changes at time of quarterly review and that the nurses and unit managers were responsible for making changes at all other times. She stated that the Risk Manager was in charge of coming up with new intervention in a fall situation. 97. That on 4/16/2010 at 11:15 am an interview was conducted with the Risk Manager. She agreed that she should have considered the resident's high phenobarbital level reported on 4/1/2010, which can cause slowing of body systems, as a possible cause of the resident's fall and not just that the resident's "fooling around" caused it. She stated she should have taken further action to prevent the resident from falling again until their phenobarbital level was back within normal range. Resident #96 98. That a review of Resident #96's medical record revealed he/she has dementia, glaucoma, was legally blind, and had an extensive history of falls. The resident had had ten falls since December of 2008, two of them with injury. 22 99. That on 12/12/09 at 6:30 am a nurse's note was written that read "walking in hall and heard housekeeper say the resident was on the floor, small laceration on forehead area was cleansed with normal Saline and applied triple antibiotic ointment and bandage. " 100. That on 4/15/2010 at 10:25 am, an interview was conducted with the Risk Manager. She stated the facility had no reports for a incident on 12/12/09 for Resident #96. She stated the facility only had one for 11/12/09, that was for a finding of old bruising. She looked through her log during the interview and stated that it would be listed there if an investigation was done, she stated that no one must have filled out an incident report. 101. That on 4/14/2010 at 1:20 PM an interview was conducted with the Risk Manager when she stated they had "exhausted interventions" for this resident in regards to preventing future falls. However there was no evidence that the facility had tried some of the latest equipment that may have prevented the resident from falling or alerted the staff to the possibility that the resident was in the process of falling. 102. That a record review revealed a nurse's note written 1/28/10 that read "resident found on floor next to bed, unaware of how it happened. Abrasions to RLE (right lower extremities) no other injuries noted." A review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 103. That during multiple observations of the the resident's room during the survey revealed the resident's door was closed and his/her curtain was pulled which would prevent the staff from observing the resident. 104. That on 4/15/2010 at 12:23 PM, in an interview with the resident's LPN (Licensed Practical Nurse), she stated that the resident's door was always closed because his/her roommate closed the door. She agreed that she would not be able to hear the newly placed pressure released bed alarm with the door closed. She said they will just open the door. 105. That on 4/15/2010 at 1:28 PM, an interview was conducted with the MDS coordinator, with the Risk Manager present. She stated that the resident was never evaluated for a One on One monitoring for falls, they only assessed behavior residents for One on One monitoring. Resident #91 106. That a clinical record review of the annual Minimum Data Set (MDS) dated 8/2009 revealed that Resident #91 had fallen within the last 30 days. Review of the quarterly MDS dated 11/2009 and 2/2010 revealed that the resident had fallen within the last 30 days. Clinical record review revealed that Resident #91 fell in April of 2009 and on September 4, 2009. 107. That an interview with the MDS coordinator on 4/15/2010 at 10:45 am revealed that the MDS information for accidents was correct for Resident #91. The quarterly MDS dated 2/22/2010 and 11/2009 and the 8/2009 annual MDS contained documentation of falls within the last 30 days. The MDS coordinator stated that the accident information was normally gathered from research of the nurses' notes, staff interviews and risk manager notes. 108. That an interview with the Risk Manager on 4/15/2010 at 10:50 am revealed that there was one report of a fall for Resident #91 available in the incident log book. Review of the incident report dated 9/04/2009 revealed that Resident #91 fell in the bathroom and sustained an abrasion. There was an investigation by the facility on the same day. There were no incident reports available for the observation periods indicated in the MDS reports for Resident #91. 109. That an interview with the MDS coordinator on 4/15/2010 12:31 PM revealed that there was no documentation of falls for Resident #91 to collaborate the MDS accident 24 information. The MDS coordinator stated that he/she would re-submit the MDS's. 110. That the Agency provided the Respondent with a mandatory correction date of May 5, 2010. 111. That a Class I deficiency is a deficiency that the agency determines 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. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection.. A fine must be levied notwithstanding the correction of the deficiency. . 112. That Respondent had been cited for two (2) Class I deficiencies following an unannounced complaint survey CCR #20100001200 on February 5, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $25,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2009). COUNT IV (Tag NO74) 113. The Agency re-alleges and incorporates paragraphs one (1) through five (5) of this Complaint as if fully set forth herein. 114. Pursuant to Fla. Admin. Code R. 59A-4.109(4), Florida law provides the 25 following: All staff personnel who provide care, and at the resident’s option, private duty nurses or non employees of the facility, shall be knowledgeable of, and have access to, the resident’s plan of care. 115. That based on record review, staff interview and resident interviews, the facility failed to revised the care plans for residents who were at risk for falls, 3 of 7 sampled residents (Residents #76, #45, and #96) and revise the care plan for 2 of 27 sampled residents (Residents #90 and #135) reviewed for weight loss ensuring that staff are aware of the resident's current needs, 116. That this resulted in placing all residents at risk for future occurrences of neglect and created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. Residemt #76 117. That a record review of the medical record for Resident #76 on 4/13/ 10 at 2:08 PM revealed that he/she had a history of glaucoma, Alzheimer's disease, seizure disorder, anxiety syndrome, psychosis and falls. The resident was disoriented to place and time and ambulated throughout the facility at will. The resident was globally confused with poverty of speech. On 2/24/10 at 5:30 PM the resident "tripped and fell" in the reception area with no injuries related to the fall, 118. That a review of the nurse's notes dated 2/27/10 at 12:50 PM revealed that on _ 2/27/10 at 9:15 am, another resident had their legs out and Resident #76 "tripped” over their legs and fell with no injuries. On 2/27/10 at 11:00 am, the resident was ambulating down the hallway when another resident was being placed into a wheelchair. Resident #76 was trying to move out of the way; took a wrong turn and fell with no injuries reported. The nurse’s notes of 3/2/10 26 stated that the resident was not in pain. However, there were no notes until 3/13/10 at 4 PM when the resident was noted as limping and an X-ray was ordered. 119. That an interview with the staff nurse on 4/13/10 at 1:58 PM revealed that the resident had numerous falls. She stated that the resident had three falls without injury and that the resident was now on a soft belt restraint. She stated that the Certified Nursing Assistant (CNA) rounded every 2-3 hours to make sure of the location of the resident. 120. That Resident #76 fell three times in the same month and the facility did not update the care plan to evaluate nursing interventions or to place new interventions in place to prevent further falls in a resident with global confusion and no safety awareness. 121. That an interview with the CNA on 4/15/10 at 8:01 am revealed that the resident constantly walked back and forth; that he/she will walk over anything since they did not have any safety awareness. 122. That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 123. That on 3/13/10 at 4:00 PM, the staff nurse documented that the resident was ambulating in the hallways and was limping. The staff nurse documented that "this time complains of (the resident's) leg but cannot identify which leg." X-Rays of the left hip was done and at 7:30 PM on 3/13/10 it showed a "unilateral osteoporotic subtle almost invisible impacted fracture of the femoral neck with no dislocation to the joint". At 7:30 PM the physician was called and the nurse received orders to send the resident to the emergency room. The resident was sent to the emergency room (ER) by stretcher ambulance service. The resident's power of attorney was notified on 3/13/10 and she refused to have the resident seen in the emergency room 27 (ER) without her presence and demanded that the resident be returned to the facility. The transporting vehicle turned around and brought the resident back to the facility. This procedure was not in keeping with the physician's order to send the resident for emergency treatment. The POA informed the facility that she would come to the facility the next day (3/14/10) to take the resident to the doctor. 124. That a review of the resident's clinical record, including the social worker's progress notes, did not reveal any documentation of education by the facility staff that indicated they addressed the concerns with the resident and/or the power of attomey regarding the immediate need for an evaluation at the emergency room (ER). The resident remained in the facility on 3/14/10 without being evaluated for the left hip fracture. 125. That the power of attorney (POA) did return to the facility on 3/15/10 and took the resident for medical services. However, there was no doctor's order at that time. The resident was admitted to a local hospital on 3/15/10 due to the hip fracture. 126. That an interview with the power of attorney (POA) on 4/15/10 at 7:55 PM revealed that she was aware of the left hip fracture and she refused to have the resident seen in the ER because the resident could not speak for herself and that she wanted to be there with the resident. . 127. That an interview with the Medical Director on 4/15/10 at 2:48 PM revealed that he wrote an order for the resident to go to the emergency room and that the niece should not have interfered with what they wanted to do. The medical director stated that they only knew when the resident returned to the facility. 128. That an interview with the Risk Manager and the MDS Care Coordinator on 4/15/10 at 10:35 am revealed that it was everybody ' s responsibility to update the care plan. 28 Resident #45 129. That a review of Resident #45's medical record revealed a nurse's note dated 4/1/2010 at 12:30 PM which read "writer was notified that pt (resident) was playing around in dining room lost (their) balance and fell over a chair and tried to grab ahold of another resident and pulled (another resident) down with (him/her). Slight bruising and swelling noted to right middle finger, Tylenol given for pain. meds effective 30 min past admin, res (resident) able to bend and move finger." A nurse 's noted written on 4/1/2010 at 1:30 PM read" Critical Phenobarbital level of 50.2, called Advanced Registered Nurse Practitioner (ARNP) order to hold Phenobarbital for two days then resume and report lab in two weeks. " A therapeutic anticonvulsant level of phenobarbital in serum is 10 to 25 pg/mL. 130, That a review of adverse reactions for Phenobarbital users includes unsteady gait, slurred speech, fainting, drowsiness, dizziness, restless muscle movement, excitement, irritability, aggression and confusion especially in the elderly. 131. That a review of the Risk Manager's investigation report for the 4/1/2010 fall, she wrote the possible cause of the fall was that the resident was playing around in the dining room when he/she tripped and fell. She lists actions to be taken as "remind the resident to be careful in the dining room, keep hallways and dining room clear and clutter free". The facility had repeatedly assessed the resident as alert with confusion in the medical record, so that the interventions were inappropriate for this resident. They also did not place appropriate intervention on the resident's care plan to implemented. 132. That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 29 133, That a nurse’s note on 4/14/2010 at 2:00 PM read "pt complained of left hand pain. swollen. pt stated "I fell yesterday" pt Stated (he/she) had pain in left hand. Pt noted to have swelling in left forearm also. Dr order for x-ray. risk manager informed. Tylenol given for pain. pt has confusion and oriented X 1. No signs or symptoms of change in mental status. Pt states (he/she) doesn't know what time, but that (he/she) fell in the dining room. "Resident sent to hospital on 4/15/2010 at 9:45 am. A nurse's note written on 4/15/10 read “called for update, resident admitted with left radial fx and phenobarbital intoxication. “ 134. That on 4/14/2010 at 12:59 PM an interview was conducted with the MDS Coordinator. She stated that she only makes care plan changes at time of quarterly review and that the nurses and unit managers were responsible for making changes at all other times. She stated that the Risk Manager was in charge of coming up with new intervention in a fall situation. 135. That on 4/16/2010 at 11:15 am an interview was conducted with the Risk Manager. She agreed that she should have considered the resident's high phenobarbital level reported on 4/1/2010, which can cause slowing of body systems, as a possible cause of the resident's fall and not just that the resident's "fooling around" caused it. She stated she should have taken further action to prevent the resident from falling again until their phenobarbital level was back within normal range. 30 Resident #96 136. That a review of Resident #96's medical record revealed he/she has dementia, glaucoma, was legally blind, and had an extensive history of falls. The resident had had ten falls since December of 2008, two of them with injury. 137. That on 12/12/09 at 6:30 am a nurse's note was written that read "walking in hall and heard housekeeper say the resident was on the floor, small laceration on forehead area was cleansed with normal Saline and applied triple antibiotic ointment and bandage. " 138. That on 4/15/2010 at 10:25 am, an interview was conducted with the Risk Manager: She stated the facility had no reports for a incident on 12/12/09 for Resident #96. She stated the facility only had one for 11/12/09, that was for a finding of old bruising. She looked through her log during the interview and stated that it would be listed there if an investigation was done, she stated that no one must have filled out an incident report. 139. That on 4/14/2010 at 1:20 PM an interview was conducted with the Risk Manager when she stated they had “exhausted interventions” for this resident in regards to preventing future falls. However there was no evidence that the facility had tried some of the latest equipment that may have prevented the resident from falling or alerted the staff to the possibility that the resident was in the process of falling. 140. That a record review revealed a nurse's note written 1/28/10 that read "resident found on floor next to bed, unaware of how it happened. Abrasions to RLE (right lower extremities) no other injuries noted." A review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 31 141. That during multiple observations of the the resident's room during the survey revealed the resident's door was closed and his/her curtain was pulled which would prevent the staff from observing the resident. 142. That on 4/15/2010 at 12:23 PM, in an interview with the Resident '.s LPN (Licensed Practical Nurse), she stated that the resident ' s door was always closed because his/her roommate closed the door. She agreed that she would not be able to hear the newly placed pressure released bed alarm with the door closed. She said they will just open the door. 143. That on 4/15/2010 at 1:28 PM, an interview was conducted with the MDS coordinator, with the Risk Manager present. She stated that the resident was never evaluated for a One on One monitoring for falls, they only assessed behavior residents for One on One monitoring. Resident #90 144. That Resident #90 was observed in their room at 8:30 am 4/14/10 eating breakfast. The resident was served 4 half pieces of toast with butter and jelly, scrambled eggs with ham, 4oz grits, 40z orange juice, 80z regular milk and a cup of coffee. The resident ate about 50% of the meal. 145. That a review of admitting diagnosis for Resident #90 revealed diagnoses, Dementia and Bipolar. 146. A review of the facility's weight record revealed the following documented weights: 12/3/09 - 122.4 Ibs 1/2/10 - 136 Ibs 2/4/10 - 134.2 Ibs 3/1/10 - 125 Ibs 32 4/3/10 122.8 Ibs. 147. That the quarterly MDS dated 3/8/10 coded section K2 with the resident's height as 66 ins and weighing 125 Ibs. K3 coded as the resident having a significant weight loss. 148. That there were no dietary notes until 4/16/10 about the significant weight loss of 3/8/10. 149. That an interview with the dietitian on 4/16/10 at 11 am revealed that the resident took VHC daily with Medpass, Diet was regular with large portions. The dietary manager said at 11:30 am on 4/16/10 that bedtime snacks were offered daily but this was not observed. 150. That, the dietitian reviewed the resident's clinical record on 4/16/10 recognizing the lack of intervention to care for the resident who had had a significant weight loss 3/8/10. 151. That a care plan dated 12/16/09 revealed the problem stated "resident at risk for weight loss". ¢ Goal: will maintain present weight +/- 3% thru next review. ° Admission weight was 122 lbs. o Goal:Provide diet; ® Provide snack that complies with diet restrictions; © Monitor intake, offer alternate; o Monitor weight at least monthly; and e. Assist with meals as needed. 152. That the care plan dated 12/16/09 was not updated to reflect knowledge of the significant weight loss and to initiate new interventions to prevent further weight loss. 153. That an interview with the dietitian at 3 PM on 4/16/10 revealed that she was not responsible to develop care plans on the residents. Residemt #135 154. That on 4/14/10 at 8:40 am Resident #135 was observed in room, just finishing their breakfast. The resident stated that they had 4 pes toast, scrambled eggs and grits; 1 carton whole milk, 40z orange juice and a cup of coffee. The resident ate 100%. 155. That on 4/ 14) 10 at 12:45 PM the résident was observed having lunch in their room, 1 piece of country fried steak, succotash, mashed potatoes and apple slices. The resident had a cup of water, a cup of iced tea and a cup of black coffee. The resident ate 100%. 156. That the initial MDS dated 12/17/09 coded resident section K2 with a height of 60 inches and a weight of 197 Ibs. Section K3 did not code resident with any significant weight loss. K5c coded received mechanically altered diet and section K5e noted a therapeutic diet. 157. That a quarterly MDS assessment dated 3/16/2010 coded the resident in Section K2 with a height of 60 inches and a weight of 180 lbs which was a 8.5% weight loss in 3 months. Review of the monthly weights revealed: 1/10 - 184.8 Ibs 2/10 - 186.2 lbs 3/10 - 180.4 Ibs and 4/10 - resident refused to be weighed. 158. That on 4/9/10 the physician discontinued mechanical diet and instituted regular consistency diet with NCS and NAS diet. 159. That a review of the care plans revealed that the plans of care for Resident #135, that were written 12/24/09, had not been updated to reflect the steady weight loss that resident had incurred. There was no new intervention to address the resident's weight loss or to address it for intended weight loss. 34 160. That the current care plan dated 12/24/09 revealed the problem, the resident received a Mechanical altered diet with no gravy or fried foods. ° Goal: will maintain present weight +/- 3% thru next review. o Approach: o Provide diet per MD orders; © Provide snack that complies with diet restrictions; e Monitor weight at least monthly; ° Notify MD and dietitian if significant weight loss or gain is noted; ° Assist with meals as needed; ° Monitor labs, report abnormal to MD/RD; and © Plate guard for all meals. This was not observed on any days of the survey. 161, That the Agency provided the Respondent with a mandatory correction date of May 5, 2010. 162, That a Class I deficiency is a deficiency that the agency determines 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. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class 1 deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency. 163. That Respondent had been cited for two (2) Class I deficiencies following an 35 unannounced complaint survey CCR #20100001200 on February 5, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $25,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2009). COUNT V (Tag N201) 164. The Agency re-alleges and incorporates paragraphs one (1) through five (5) of this Complaint as if fully set forth herein. 165. Pursuant to §400.022(1)(), Florida Statutes (2009), Florida law provides the following: 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: (1) 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. 166. That based on observations, record review, resident and staff interviews, the facility neglected to provide care and services to residents identified as "at risk for falls" and injury, develop successful interventions to prevent occurrence and reoccurrence of the falls and to adequately monitor the residents who were at high risk for falls by implementing the written policy and procedures for assessing for falls and their causes for 5 of 7 sampled residents, Residents #74, #76, #45, #96 and #125, who fell at least once, if not repeatedly, in the facility. 36 Resident #76 fell and broke their hip and the facility failed to provide appropriate emergency services. 167. That this situation which placed the health and safety of the residents at risk for falling has occurred in the past, is occurring in the present and is likely to occur in the very near future as a result of the jeopardy situation. Resident # 74 168. That during the initial tour of the facility on 4/12/10 at 10 am, Resident #74, a 76 year old weighing 79.8 Ibs, was observed self propelling their wheelchair along the South wing hallway with a visible bruised upper cheek and nose. 169. That an interview with a staff member on 4/12/10 at 10:05 am revealed that the resident had fallen over the weekend but staff did not have any further details. 170. That Resident #74 was observed on 4/13/10 in the hallway with the bruise more pronounced on both cheeks, forehead and nose, revealing larger bruised areas from the day before. 171. That observations on 4/14/10 revealed the following: a. At 9:30 am the resident was not observed in their room. The resident's bed was observed at the lowest height and there were 2 full side rails present which were not raised. b. At 9:35 am a CNA assigned to the resident was interviewed and revealed that the resident had fallen over the weekend from their bed. She stated that Resident #74 always crawled out of bed at night and had fallen numerous times and enumerated the resident's behavior to include aggressiveness, and scratching staff. When asked how often did the resident exhibit such behavior, the staff stated that it was not daily but the resident did exhibit the behavior sometimes, other times the resident was pleasant. The staff identified the resident as one that needed total 37 care. The staff added that the resident was "all over the facility". The staff also stated that the resident would crawl out of their waist restraint at times. At 9:40 am the resident was observed in the hallway, self-propelling their wheelchair, with a blue waist restraint tied to the back of the chair. . At 9:40 am in Resident #74's room the CNA showed the surveyor how the resident fell out of bed. The mattress was observed to be shorter than the bed but a filler pad was in place. There was no bed alarm observed on the bed at that time. When asked whether the resident had a bed alarm, the staff said that the resident used to have one but the resident would turn off the device and/or take the device off such that the device would not alarm. The staff confirmed at that time that the resident never had mats at bedside. . At 9:45 am the MDS coordinator was interviewed at the South wing nurses station regarding what kind of system was in place to prevent falls and injury for Resident #74, The MDS coordinator picked up Resident #74's medical chart and reviewed the "Falls" care plan. The staff revealed that the resident had a bed alarm instituted on 3/11/10 and a soft waist belt restraint on 3/19/10. She said that resident "always crawled over the bed side rails at night". She was asked why resident needed 2 full side rails when she had the behavior of crawling over the bed rails. She did not respond, Observation with the staff in the resident's room at that time did not reveal the presence of a bed alarm. The staff could not find the alarm. Further interview with the MDS coordinator at this time concerning the most recent fall per the CNA interview and observation of the resident on 4/12/10, the MDS coordinator said that the resident fell on March 19, 2010. When asked if staff was aware that resident had fallen again over this past weekend, the staff said that she was not aware of it. . Areview of the nurses notes dated 4/11/10 at 11:15 PM confirmed that resident fell forward in their wheelchair in the main dining room and had a bruised forehead and a crooked nose, bleeding from the left nostril. The notes also noted that the Physician was called and an order to transfer to a local hospital was received. Family was notified by phone (answering machine). 38 h. A request was made for the corresponding incident report. The MDS coordinator said that the Risk manager kept incident reports. i. At 9:50 am an interview with the Risk manager at the South Hall nurses station revealed that staff was not aware of the 4/11/10 fall until the surveyor asked to see the incident report. The staff revealed that an adverse incident report had not been filed. The staff denied any information from nursing staff about the incident, yet she was able to produce the incident report filed in her mail box from the 3-11 PM nurse after the incident. The risk manager said that she relied on staff reporting any adverse events to her. The staff said that the facility did not have a morning meeting where care issues were discussed. The facility did have a QCI meeting which was held on Wednesdays. 172. That observations in the main dining room was conducted on Monday, 4/12/10 between 11:30 am and 12:30 PM when Resident #74 was eating lunch. Facility staff were present including restorative aides, direct care staff and facility management team. Resident #74 was in full view of all residents and staff present in the dining room at that time. However the staff did not recognize the Caucasian resident with a blue/black bruised face while she was eating. 173. That a review of the incident report completed by the nurse on duty revealed that a CNA going to the "time clock" witnessed the fall. The report revealed that the resident flipped over in the main dining room onto their face while restrained in wheelchair. Crooked bloody nose and bruise to fore head were sustained as documented on the "diagram location of injury". The report further stated that the staff asked the resident what happened and the resident indicated that they were trying to "get up from the wheelchair". 174. That Resident #74 was first admitted to the facility on 3/15/2007 with diagnoses of: UTI; Sepsis; Dementia; Depression; and Hypokalemia. A review of the most recent annual MDS assessment dated 2/3/10 coded Resident #74, under section G5b and G5d, as using a 39 wheelchair as a primary mode of locomotion and self-wheeled. Section J4a and J4b coded the resident as having a history of falls, within past 30 days and also within past 31-180 days. The RAP (Resident Assessment Protocol) summary dated 2/5/10 noted that the resident "triggered for falls". The RAP Falls decision summary noted: “Resident at risk for falls, has a history of falls and has impaired safety awareness along with cognition, resident is in a wheelchair at this time, receives daily psych meds, is not displaying any drug related side effects but remains at risk, will proceed to care plan". A review of the facility's form titled Fall Risk Assessment dated 1/27/10 noted the resident scored 16. A total score of 10 or above placed the resident at a "High Risk" for ’ falls. 175. That the facility did have a plan of care dated 2/9/10 identifying that the resident was at risk for falls related to unsteady gait, impaired bed mobility, and cognition, use of psychoactive medications and attempts to transfer from chair to bed and bed to chair with supervision. A review of the Incident Reports for Resident #74 supplied by the Risk manager revealed that the resident had reported falls as follows: a. On 2/23/10 at 9:30 PM the resident was "found sitting on. the floor beside bed, attempting to transfer without assistance. CNA assisting another resident. (Prevention: remind the resident to ask for help.) Investigation report dated for 2/23/10, risk mgr signed (no injury)". According to the Incident Log for February 2010, this fall was unwitnessed. b. On 3/1/10 at 10 PM the resident was "found sitting on the floor beside bed, attempting to transfer without assistance. CNA assisting a resident in rm 123. (Prevention: constantly remind her to call for assistance when she needs to transfer) Investigation report dated for 3/1/10, signed by risk manager (no injury)". According to the Incident Log for March 2010, this fall was unwitnessed. c. On 3/4/10 at 7 PM the resident "fell from shower chair while getting bath, resident being physically aggressive. Laceration above the left eye (have 2 CNA assist with 40 bath when resident is aggressive) Investigation report dated for 3/4/10, signed by risk manager (no adverse incident report filed)(first aid applied at NH)". According to the Incident Log for March 2010, this fall was unwitnessed. . On 3/8/10 at 11 PM observed "resident sitting on the floor beside their wheelchair (w/c) by the bedside. SWB (soft waist belt) not on at time of fall. CNA assisting other residents, nurse in station charting. (Prevention: will discuss in CQ] Investigation report dated for 3/8/10, signed by risk manager". According to the Incident Log for March 2010, this fall was unwitnessed. e. There-was no evidence that this fall was discussed in the next CQI meeting which according to facility staff would have taken place on Wednesday, March 10, 2010. On 3/10/10 at 9 PM the “resident walked from bed w/o assistance and fell at door, on ground in supine position. CNA assisting other residents. injury: edema on the back of the bed. (Prevention: will put bed alarm on resident while she is in bed, soft waist belt (SWB) was on while in wheelchair. SWB not on at time of fall. Investigation report dated for 3/10/10, signed by risk manager (first aid only, ice applied to raised area)". According to the Incident Log for March 2010, this fall was unwitnessed. . On 3/11/10 at 12:40 am - "Resident lying on floor beside clothes hamper, lying on back with knees drawn up, noted laceration to right temple. Soft waist belt (SWB ) was not on at the time of fall. (Bed alarm ordered and placed on bed this morning). Investigation report dated for 3/11/10, signed by risk manager". According to the Incident Log for March 2010, this fall was unwitnessed. . On 3/19/10 at at 11:10 PM - "Resident was found on the floor in front of wheelchair at South 2 Nursing station. Resident was not interviewable due to confusion. Fall occurred during the change of shift. Nose fractured per CT scan. "Possible cause: Resident is very weak and possibly attempted to stand up un- assisted. Injury: bruising to face". (Prevention: SWB while up in w/c, bed alarm when resident is in bed.) Investigation report dated for 3/19/10, signed by risk manager (ice applied, resident sent to hospital) (resident actually fell on the 18")". According to the Incident Log for March 2010, this fall was unwitnessed. 41 k. On 4/11/10 "the resident flipped over in wheel chair on face while restrained in wheelchair ‘in dining room. (Witnessed by) CNA going to time clock. 1. Injury: bloody nose, bruise to forehead and crooked nose", 176. That despite all these documented falls and the 3/19/10 trip to the hospital, a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. The facility did not have any system in place to adequately care for this resident and to prevent further falls until the survey team identified on-going immediate jeopardy on 4/ 14/10. The facility instituted a One on One staff monitoring for Resident #74 at 4:30 PM on 4/14/10. The One on Oné monitoring was due to the survey team identifying the immediate jeopardy situations in regards to this resident having repeated falls without reassessing the resident's condition post falls. 177. That a review of the Adverse incident log book revealed that there was not a single adverse investigation filed with the State of Florida on Resident #74. Per facility policy, neurological assessments are completed for 72 hrs after each fall. Review of the neurological flow sheets revealed completed for the following dates only: 3/4/10, 3/5/10, 3/10/10, 3/11/10, 3/12/10 and 3/19/10. 178. That Immediate Jeopardy was identified on 4/14/10 when it was revealed that Resident #74 fell on 3/4/10 from a shower chair while being bathed by facility staff and received a laceration: above his/her left eye. The resident fell 4 more times during the same month and sustained injuries to the head, the face and the nose. The facility failed to provide necessary care and services to avoid physical harm. The immediate jeopardy is ongoing due to the most recent fall on Sunday, 4/11/10 when the resident sustained a broken nose. 42 Resident #76 179. That a record review of the medical record for Resident #76 on 4/13/10 at 2:08 PM revealed that he/she had a history of glancoma, Alzheimer's disease, seizure disorder, anxiety syndrome, psychosis and falls. The resident was disoriented to place and time and ambulated throughout the facility at will. The resident was globally confused with poverty of speech. On 2/24/10 at 5:30 PM the resident “tripped and fell" in the reception area with no injuries related to the fall. 180. That a review of the nurse's notes dated 2/27/10 at 12:50 PM revealed that on 2/27/10 at 9:15 am, another resident had their legs out and Resident #76 "tripped" over their legs and fell with no injuries. On 2/27/10 at 11:00 am, the resident was ambulating down the hallway when another resident was being placed into a wheelchair. Resident #76 was trying to move out of the way; took a wrong turn and fell with no injuries reported. The nurses notes of 3/2/10 stated that the resident was not in pain. However, there were no notes until 3/13/10 at 4 PM when the resident was noted as limping and an X-ray was ordered. 181. .That an interview with the staff nurse on 4/13/10 at 1:58 PM revealed that the resident had numerous falls. She stated that the resident had three falls without injury and that the resident was now on.a soft belt restraint. She stated that the Certified Nursing Assistant (CNA) rounded every 2-3 hours to make sure of the location of the resident. 182. That an interview with the CNA on 4/15/10 at 8:01 am revealed that the resident constantly walked back and forth; that he/she will walk over anything since they did not have any safety awareness. 43 183. That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 184. That on 3/13/10 at 4:00 PM, the staff nurse documented that the resident was ambulating in the hallways and was limping. The staff nurse documented that "this time complains of (the resident's) leg but cannot identify which leg." X-Rays of the left hip was done and at 7:30 PM on 3/13/10 it showed a "unilateral osteoporotic subtle almost invisible impacted fracture of the femoral neck with no dislocation to the joint". At 7:30 PM the physician was called and the nurse received orders to send the resident to the emergency room. The resident was sent to the emergency room (ER) by stretcher ambulance service. The resident's power of attorney was notified on 3/13/10 and she refused to have the resident seen in the emergency room (ER) without her presence and demanded that the resident be returned to the facility. The transporting vehicle turned around and brought the resident back to the facility. This procedure was not in keeping with the physician's order to send the resident for emergency treatment. The POA informed the facility that she would come to the facility the next day (3/14/10) to take the resident to the doctor. 185 That a review of the resident's clinical record, including the social worker's progress notes, did not reveal any documentation of education by the facility staff that indicated they addressed the concerns with the resident and/or the power of attorney regarding the immediate need for an evaluation at the emergency room (ER). The resident remained in the facility on 3/14/10 without being evaluated for the left hip fracture. 44 186. That the power of attorney (POA) did return to the facility on 3/15/10 and took the resident for medical services. However, there was no doctor's order at that time. The resident was admitted to a local hospital on 3/15/10 due to the hip fracture. 187. That an interview with the power of attorney (POA) on 4/15/10 at 7:55 PM revealed that she was aware of the left hip fracture and she refused to have the resident seen in the ER because the resident could not speak for herself and that she wanted to be there with the resident. 188. That an interview with the Medical Director on 4/15/10 at 2:48 PM revealed that he wrote an order for the resident to go to the emergency room and that the niece should not have interfered with what they wanted to do. The medical director stated that they only knew when the resident returned to the facility. Residemt #45 189. Thata review of Resident #45's medical record revealed a nurse's note dated 4/1/2010 at 12:30 PM which read "writer was notified that pt (resident) was playing around in dining room lost (their) balance and fell over a chair and tried to grab ahold of another resident and pulled (another resident) down with (him/her). Slight bruising and swelling noted to right middle finger, Tylenol given for pain. meds effective 30 min past admin, res (resident) able to bend and move finger." A nurse's noted written on 4/1/2010 at 1:30 PM read" Critical Phenobarbital level of 50.2, called Advanced Registered Nurse Practitioner (ARNP) order to hold Phenobarbital for two days then resume and report lab in two weeks, " A therapeutic anticonvulsant level of phenobarbital in serum is 10 to 25 ug/mL. 45 190. That a review of adverse reactions for Phenobarbital users includes unsteady gait, slurred speech, fainting, drowsiness, dizziness, restless muscle movement, excitement, irritability, aggression and confusion especially in the elderly. 191. That a review of the Risk Manager's investigation report for the 4/1/2010 fall, she wrote the possible cause of the fall was that the resident was playing around in the dining room when he/she tripped and fell. She lists actions to be taken as "remind the resident to be careful in the dining room, keep hallways and dining room clear and clutter free". The facility had repeatedly assessed the resident as alert with confusion in the medical record, so that the interventions were inappropriate for this resident. They also did not place appropriate intervention on the resident's care plan to implemented. 192. That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was ° performed and no revision to the resident's fall care plan were made to prevent further falls. 193. That a nurse’s note on 4/14/2010 at 2:00 PM read "pt complained of left hand pain. swollen. pt stated "I fell yesterday" pt Stated (he/she) had pain in left hand. Pt noted to have swelling in left forearm also. Dr order for x-ray. risk manager informed. Tylenol given for pain. pt has confusion and oriented X 1. No signs or symptoms of change in mental status. Pt states (he/she) doesn't know what time, but that (he/she) fell in the dining room. "Resident sent to hospital on 4/15/2010 at 9:45 am. A nurse's note written on 4/15/10 read "called for update, resident admitted with left radial fx and phenobarbital intoxication. " 194, That on 4/14/2010 at 12:59 PM an interview was conducted with the MDS Coordinator. She stated that she only makes care plan changes at time of quarterly review and that 46 the nurses and unit managers were responsible for making changes at all other times. She stated that the Risk Manager was in charge of coming up with new intervention in a fall situation. 195. That on 4/16/2010 at 11:15 am an interview was conducted with the Risk Manager. She agreed that she should have considered the resident's high phenobarbital level reported on 4/1/2010, which can cause slowing of body systems, as a possible cause of the resident's fall and not just that the resident's "fooling around" caused it. She stated she should have taken further action to prevent the resident from falling again until their phenobarbital level was back within normal range. Resident #96 196. That a review of Resident #96's medical record revealed he/she has dementia, glaucoma, was legally blind, and had an extensive history of falls. The resident had had ten falls since December of 2008, two of them with injury. 197. That on 12/12/09 at 6:30 am a nurse's note was written that read "wallcing in hall and heard housekeeper say the resident was on the floor, small laceration on forehead area was cleansed with normal Saline and applied triple antibiotic ointment and bandage. " 198. That on 4/15/2010 at 10:25 am, an interview was conducted with the Risk Manager. She stated the facility had no reports for a incident on 12/12/09 for Resident #96. She stated the facility only had one for 11/12/09, that was for a finding of old bruising. She looked through her log during the interview and stated that it would be listed there if an investigation was done, she stated that no one must have filled out an incident report. 199. That on 4/14/2010 at 1:20 PM an interview was conducted with the Risk Manager when she stated they had "exhausted interventions" for this resident in regards to preventing future falls. However there was no evidence that the facility had tried some of the latest 47 equipment that may have prevented the resident from falling or alerted the staff to the possibility that the resident was in the process of falling. 200. That a record review revealed a nurse's note written 1/28/10 that read "resident found on floor next to bed, unaware of how it happened. Abrasions to RLE (right lower extremities) no other injuries noted." A review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 201. That during multiple observations of the the resident's room during the survey revealed the resident's door was closed and his/her curtain was pulled which would prevent the staff from observing the resident. 202. That on 4/15/2010 at 12:23 PM, in an interview with the Resident 's LPN (Licensed Practical Nurse), she stated that the resident 's door was always closed because his/her roommate closed the door. She agreed that she would not be able to hear the newly placed pressure released bed alarm with the door closed. She said they will just open the door. 203. That on 4/15/2010 at 1:28 PM, an interview was conducted with the MDS coordinator, with the Risk Manager present. She stated that the resident was never evaluated for a One on One monitoring for falls, they only assessed behavior residents for One on One monitoring. | Resident #125 204. That Resident #125 was admitted into the facility on 1/23/2009 with multiple diagnoses which included Dementia. ‘The resident was also noted on the current MDS as "at risk for falls". 48 205. That clinical record review revealed that the resident was placed on One on One Monitoring on January 25, 2009. A review of the facility's current Nursing Policy and Guidelines for One on One monitoring with an effective date of 3/21/1020 (revised) revealed that the purpose of the monitoring was "to reduce the episodes of physical aggression and provide quick intervention", revealing that the nursing staff were to continuously monitor the residents for "narticular behaviors". There was no evidence that the facility had a Nursing Policy and Guidelines for One on One monitoring for residents at risk for falls and falling. 205. That a review of the clinical record revealed a plan of care for Resident #125 dated 2/04/2010 which revealed behaviors such as delusions, pacing, elopement, verbal abuse of staff and residents, agitation and talking to him/herself. The approaches included One on One with a staff member and to redirect the resident from exit doors. 206. That a review of the facility's incident/accident report dated 3/23/2010 revealed that the facility failed to monitor Resident #125 during the nursing assistant's break. Resident #125 was left unattended on 3/23/2010 at 6:55 am. Resident #125 was found on the floor upon the nursing assistant's return to the resident's room. A review of the Incident Log Sheet for March 2010 did not reveal that this was a "witnessed fall”. 207. That an interview with the charge nurse for the 200 hall on 4/13/2010 at 2:23 PM revealed that Resident #125 was on One on One monitoring for elopement precautions, not behavior precautions. 208. That an interview with the facility risk manager on 4/15/2010 at 2:00 PM revealed that there was no adverse incident report completed on 3/23/2010 after Resident #125's fall because the resident was not injured in the fall. 209. That a review of the resident's record revealed that no post fall 49 evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 210. That a review of the facility's form titled "Assessing Falls and Their Causes" which was currently in use by the facility noted the purpose of this form was "to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall". The form identifies "General Guidelines", Equipment and Supplies", "Resident's Rights Protocol", "Infection Control Protocol and Safety" and "Steps in the Procedure - After a Fall". The steps outline what the facility would do "After a Fall", defines "Details of Falls", identifies "Cause of a Fall or Fall Risk ", “Performing a Post-Fall Evaluation" and "Identifying Complications of Falls". The form also instructs staff as to what to document and how to report. 211. That a review of the General Guidelines revealed: #1 Falls are a leading cause of morbidity and mortality among the elderly in nursing homes; #4 Falling can point to underlying clinical conditions and functional decline, medication side effects, and/or environmental risk factors; and #5 Residents must be assessed for potential causes of falls immediately. 212. A review of the Steps in the Procedure - After a Fall: a. If aresident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine, and extremities. b. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. c. (e.) Nursing staff will observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. d. (£.) Documentation will include at least statements about observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility. Tt will note the presence or absence of significant findings. 50 213. That a review of the section of the form subtitled "Performing a Post-Fall Evaluation" revealed the following instructions as to what the facility staff should do after a resident fell: a. After a first fall, a nurse and/or physical therapist will watch the resident rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results of this effort. b. Ifthe individual has no difficulty or unsteadiness, no further evaluation is needed at that time. c. Ifthe individual has difficulty or is unsteady in performing this test, additional evaluation may be initiated as warranted. 214. That a review of the section of the form subtitled "Identifying Complications of Falls" revealed the following instructions as to what the facility staff should do after a resident fell: a. Staff, with the attending physician's input, will define the complications of a fall such as bruising, fracture, or increased fear of walking. b. Additional, the staff and physician will identify significant potential complications of falling for each resident at risk for falling; (e.g. fracture in someone with osteoporosis or bleeding in someone receiving anticoagulation). 215. That the Agency provided the Respondent with a mandatory correction date of May 5, 2010. 216. That a Class I deficiency is a deficiency that ‘the agency determines 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. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required 51 for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class 1 or class Il deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency. 217. That Respondent had been cited for two (2) Class I deficiencies following an unannounced complaint survey CCR #20100001200 on February 5, 2010. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $25,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400.23 (8)(a), Florida Statutes (2009). COUNT VI (Tag N906) 218. The Agency re-alleges and incorporates paragraphs one (1) through five (5) of this Complaint as if fully set forth herein. 219. Pursuant to §400.147(1)(e), Florida Statutes (2009), Florida law provides the following: Every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: (e) The development of appropriate measures to minimize the risk of adverse incidents to residents, including, but not limited. to, education and training in.risk management and risk prevention for all non-physician personnel, as follows: 52 1. Such education and training of all non-physician personnel must be part of their initial orientation; and . 2. At least 1 hour of such education and training must be provided annually for all non-physician personnel of the licensed facility working in clinical areas and providing resident care. 220. That based upon record review, interview, observation, and a review of the facility's Continuous Quality Improvement (CQD meeting roster, the facility failed to identify and or recognize quality of life and quality of care deficient practices taking place in the facility and they failed to develop and implement plans of action to correct these deficient practices. This placed. all residents at risk for abuse and/or neglect and created a situation that is likely to result in serious injury, harm, impairment, or death requiring immediate corrective action on the part of the facility. 221. That the facility neglected to provide care and services to residents identified as “at tisk for falls" and injury, develop successful interventions to prevent occurrence and reoccurrence of neglect and to adequately monitor the residents who were at high risk for falls by implementing the written policy and procedures for assessing for falls and their causes for 5 of 7 sampled residents, Residents #74, #76, #45, #96 and #125, who fell at least once, if not repeatedly, in the facility. Resident #76 fell and broke their hip and the facility failed to provide appropriate emergency services. | Residemt #74 222. That during the initial tour of the facility on 4/12/10 at 10 am, Resident #74, a 76 year old weighing 79.8 Ibs, was observed self propelling their wheelchair along the South wing hallway with a visible bruised upper cheek and nose. 53 223, That an interview with a staff member on 4/12/10 at 19:05 am revealed that the resident had fallen over the weekend but staff did not have any further details. 224, That Resident #74 was observed on 4/13/10 in the hallway with the bruise more pronounced on both cheeks, forehead and nose, revealing larger bruised areas from the day before. 225. That observations on 4/14/10 revealed the following: a, At 9:30 am the resident was not observed in their room. The resident's bed was observed at the lowest height and there were 2 full side rails present which were ~ not raised. b. At 9:35 am a CNA assigned to the resident was interviewed and revealed that the resident had fallen over the weekend from their bed. She stated that Resident #74 always crawled out of bed at night and had fallen numerous times and enumerated the resident's behavior to include aggressiveness, and scratching staff. When asked how often did the resident exhibit such behavior, the staff stated that it was not daily but the resident did exhibit the behavior sometimes, other times the resident was pleasant. The staff identified the resident as one that needed total care. The staff added that the resident was "all over the facility". The staff also stated that the resident would crawl out of their waist restraint at times. c. At 9:40 am the resident was observed in the hallway, self-propelling their -wheelchair, with a blue waist restraint tied to the back of the chair. d. At 9:40 am in Resident #74's room the CNA showed the surveyor how the resident fell out of bed. The mattress was observed to be shorter than the bed but a filler pad was in place. There was no bed alarm observed on the bed at that time. When asked whether the resident had a bed alarm, the staff said that the resident used to have one but the resident would turn off the device and/or take the device off such that the device would not alarm. The staff confirmed at that time that the’ resident never had mats at bedside. 54 e. At 9:45 am the MDS coordinator was interviewed at the South wing nurses ) station regarding what kind of system was in place to prevent falls and injury for Resident #74. The MDS coordinator picked up Resident #74's medical chart and reviewed the "Falls" care plan. The staff revealed that the resident had a bed alarm instituted on 3/11/10 and a soft waist belt restraint on 3/19/10. She said that resident "always crawled over the bed side rails at night". She was asked why resident needed 2 full side rails when she had the behavior of crawling over the bed rails. She did not respond, Observation with the staff in the resident's room at that time did not reveal the presence of a bed alarm. The staff could not find the alarm. Further interview with the MDS coordinator at this time concerning the most recent fall per the CNA interview and observation of the resident on 4/12/10, the MDS coordinator said that the resident fell on March 19, 2010. When asked if staff was aware that resident had fallen again over this past weekend, the staff said that she was not aware of it. A review of the nurses notes dated 4/11/10 at 11:15 PM confirmed that resident fell forward in their wheelchair in the main dining room and had a bruised forehead and a crooked nose, bleeding from the left nostril. The notes also noted that the Physician was called and an order to transfer to a local hospital was received, Family was notified by phone (answering machine), A request was made for the corresponding incident report. The MDS coordinator said that the Risk manager kept incident reports. f. At 9:50 am an interview with the Risk manager at the South Hall nurses station revealed that staff was not aware of the 4/11/10 fall until the surveyor asked to see the incident report. The staff revealed that an adverse incident report had not been filed. The staff denied any information from nursing staff about the incident, yet 55 she was able to produce the incident report filed in her mail box from the 3-11 PM nurse after the incident. The risk manager said that she relied on staff reporting any adverse events to her. The staff said that the facility did not have a morning meeting where care issues were discussed. The facility did have a QCI meeting which was held on Wednesdays. 226. That observations in the main dining room was conducted on Monday, 4/12/10 between 11:30 am and 12:30 PM when Resident #74 was eating lunch. Facility staff were present including restorative aides, direct care staff and facility management team. Resident #74 was in full view of all residents and staff present in.the dining room at that time. However the staff did not recognize the Caucasian resident with a blue/black bruised face while she was eating. 227. That a review of the incident report completed by the nurse on duty revealed that a CNA going to the "time clock" witnessed the fall. The report revealed that the resident flipped over in the main dining room onto their face while restrained in wheelchair, Crooked bloody nose and bruise to fore head were sustained as documented on the "diagram location of injury". The report further stated that the staff asked the resident what happened and the resident indicated that they were trying to "get up from the wheelchair". 228. That Resident #74 was first admitted to the facility on 3/15/2007 with diagnoses of: UTI; Sepsis; Dementia; Depression; and Hypokalemia. A review of the most recent annual MDS assessment dated 2/3/10 coded Resident #74, under section G5b and G5d, as using a wheelchair as a primary mode of locomotion and self wheeled. Section J4a and J4b coded the resident as having a history of falls, within past 30 days and also within past 31-180 days. The RAP (Resident Assessment Protocol) summary dated 2/5/10 noted that the resident "triggered for falls". The RAP Falls decision summary noted: "Resident at risk for falls, has a history of falls and has impaired safety awareness along with cognition, resident is in a wheelchair at this time, 56 receives daily psych meds, is not displaying any drug related side effects but remains at risk, will proceed to care plan". A review of the facility's form titled Fall Risk Assessment dated 1/27/10 noted the resident scored 16. A total score of 10 or above placed the resident at a "High Risk" for falls. 229. That the facility did have a plan of care dated 2/9/10 identifying that the resident was at risk for falls related to unsteady gait, impaired bed mobility, and cognition, use of psychoactive medications and attempts to transfer from chair to bed and bed to chair with supervision. A review of the Incident Reports for Resident #74 supplied by the Risk manager revealed that the resident had reported falls as follows: a. On 2/23/10 at 9:30 PM the resident was "found sitting on the floor beside bed, attempting to transfer without assistance. CNA assisting another resident. (Prevention: remind the resident to ask for help.) Investigation report dated for 2/23/10, risk mgr signed (no injury)". According to the Incident Log for February 2010, this fall was unwitnessed. b. On 3/1/10 at 10 PM the resident was "found sitting on the floor beside bed, attempting to transfer without assistance. CNA assisting a resident in rm 123, (Prevention: constantly remind her to call for assistance when she needs to transfer) Investigation report dated for 3/1/10, signed by risk manager (no injury)". According to the Incident Log for March 2010, this fall was unwitnessed. c. On 3/4/10 at 7 PM the resident "fell from shower chair while getting bath, resident being physically aggressive. Laceration above the left eye (have 2 CNA assist with bath when resident is aggressive) Investigation report dated for 3/4/10, signed by risk manager (no adverse incident report 57 filed)(first aid applied at NH)". According to the Incident Log for March 2010, this fall was unwitnessed. d. On 3/8/10 at 11 PM observed "resident sitting on the floor beside their wheelchair (w/c) by the bedside. SWB (soft waist belt) not on at time of fall. CNA assisting other residents, nurse in station charting. (Prevention: will discuss in CQD) Investigation report dated for 3/8/10, signed by risk manager". According to the Incident Log for March 2010, this fall was unwitnessed, There was no evidence that this fall was discussed in the next CQI meeting which according to facility staff would have taken place on Wednesday, March 10, 2010. e. On 3/10/10 at 9 PM the "resident walked from bed w/o assistance and fell at door, on ground in supine position. CNA assisting other residents. injury: edema on the back. of the bed, (Prevention: will put bed alarm on resident while she is in bed, soft waist belt (SWB) was on while in wheelchair. SWB not on at time of fall. Investigation report dated for 3/10/10, signed by risk manager (first aid only, ice applied to raised area)". According to the Incident Log for March 2010, this fall was unwitnessed, f. On 3/11/10 at 12:40 am - "Resident lying on floor beside clothes hamper, lying on back with knees drawn up, noted laceration to right temple. Soft waist belt (SWB ) was not on at the time of fall. (Bed alarm ordered and placed on bed this morning). Investigation report dated for 3/11/10, signed by risk manager". According to the Incident Log for March 2010, this fall was unwitnessed. g. On 3/19/10 at at 11:10 PM - "Resident was found on the floor in front of wheelchair at South 2 Nursing station. Resident was not interviewable due 58 to confusion. Fall occurred during the change of shift. Nose fractured per CT scan. "Possible cause: Resident is very weak and possibly attempted to stand up un-assisted. Injury: bruising to face". (Prevention: SWB while up in w/c, bed alarm when resident is in bed.) Investigation report dated for 3/19/10, signed by risk manager (ice applied, resident sent to hospital) (resident actually fell on the 18")", . According to the Incident Log for March 2010, this fall was unwitnessed. h. On 4/11/10 "the resident flipped over in wheel chair on face while restrained in wheelchair in dining room. (Witnessed by) CNA going to time clock. Injury: bloody nose, bruise to forehead and crooked nose". 230. That despite all these documented falls and the 3/19/10 trip to the hospital, a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. The facility did not have any system in place to adequately care for this resident and to prevent further falls until the survey team identified on-going immediate jeopardy on 4/14/10. The facility instituted a One on One staff monitoring for Resident #74 at 4:30 PM on 4/14/10. The One on One monitoring was due to the survey team identifying the immediate jeopardy situations in regards to this resident having repeated falls without reassessing the resident's condition post falls. 231. That a review of the Adverse incident log book revealed that there was not a single adverse investigation filed with the State of Florida on Resident #74. Per facility policy, neurological assessments are completed for 72 hrs after each fall. Review of the neurological flow 59 sheets revealed completed for the following dates only: 3/4/10, 3/5/10, 3/10/10, 3/11/10, 3/12/10 and 3/19/10, | _ 232. That Immediate Jeopardy was identified on 4/14/10 when it -was revealed that Resident #74 fell on 3/4/10 from a shower chair while being bathed by facility staff and received a laceration above his/her left eye. The resident fell 4 more times during the same month and sustained injuries to the head, the face and the nose. The facility failed to provide necessary care and services to avoid physical harm. The immediate jeopardy is ongoing due to the most recent fall on Sunday, 4/11/10 when the resident sustained a broken nose. Resident #76 234. That arecord review of the medical record for Resident #76 on 4/13/10 at 2:08 PM revealed that he/she had a history of glaucoma, Alzheimer's disease, seizure disorder, anxiety syndrome, psychosis and falls. The resident was disoriented to place and time and ambulated throughout the facility at will. The resident was globally confused with poverty of speech. On 2/24/10 at 5:30 PM the resident "tripped and fell" in the reception area with no injuries related to the fall. 235. That a review of the nurse's notes dated 2/27/10 at 12:50 PM revealed that on 2/27/10 at 9:15 am, another resident had their legs out and Resident #76 "tripped" over their legs | and fell with no injuries. On 2/27/10 at 11:00 am, the resident was ambulating down the hallway when. another resident was being placed into a wheelchair. Resident #76 was trying to move out of the way; took a wrong turn and fell with no injuries reported. The nurses notes of 3/2/10 stated that the resident was not in pain. However, there were no notes until 3/13/10 at 4 PM when the resident was noted as limping and an X-ray was ordered. 60 236. That an interview with the staff nurse on 4/13/10 at 1:58 PM revealed that the resident had numerous falls. She stated that the resident had three falls without injury and that the resident was now on a soft belt restraint. She stated that the Certified Nursing Assistant (CNA) rounded every 2-3 hours to make sure of the location of the resident. 237. That an interview with the CNA on 4/15/10 at 8:01 am revealed that the resident constantly walked back and forth; that he/she will walk over anything since they did not have any safety awareness. . 238. That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to. prevent further falls. 239. That on 3/13/10 at 4:00 PM, the staff nurse documented that the resident was ambulating in the hallways and was limping. The staff nurse documented that "this time ° complains of (the resident's) leg but cannot identify which leg." X-Rays of the left hip was done and at 7:30 PM on 3/13/10 it showed a "unilateral osteoporotic subtle almost invisible impacted fracture of the femoral neck with no dislocation to the joint". At 7:30 PM the physician was called and the nurse received orders to send the resident to the emergency room. The resident was sent to the emergency room (ER) by stretcher ambulance service. The resident's power of attorney was notified on 3/13/10 and she refused to have the resident seen in the emergency room (ER) without her presence and demanded that the resident be returned to the facility. The transporting vehicle turned around and brought the resident back to the facility. This procedure was not in keeping with the physician's order to send the resident for emergency treatment. The POA informed the facility that she would come to the facility the next day (3/14/10) to take the resident to the doctor. 61 240. That a review of the resident's clinical record, including the social worker's progress notes, did not reveal any documentation of education by the facility staff that indicated they addressed the concerns with the resident and/or the power of attorney regarding the immediate need for an evaluation at the emergency room (ER). The resident remained in the facility on 3/14/10 without being evaluated for the left hip fracture. 241. That the power of attorney (POA) did return to the facility on 3/15/10 and took the resident for medical services. However, there was no doctor's order at that time. The resident was admitted to a local hospital on 3/15/10 due to the hip fracture. 242. That an interview with the power of attorney (POA) on 4/15/10 at 7:55 PM revealed that she was aware of the left hip fracture and she refused to have the resident seen in the ER because the resident could not speak for herself and that she wanted to be there with the resident. 243, Interview with the Medical Director on 4/15/10 at 2:48 PM revealed that he wrote an order for the resident to go to the emergency room and that the niece should not have interfered with what they wanted to do. The medical director stated that they only knew when the resident returned to the facility. Resident #45 244, That a review of Resident #45's medical record revealed a nurse's note dated 4/1/2010 at 12:30 PM which read "writer was notified that pt (resident) was playing around in dining room Jost (their) balance and fell over a chair and tried to grab ahold of another resident and pulled (another resident) down with (him/her). Slight bruising and swelling noted to right middle finger, Tylenol given for pain. meds effective 30 min past admin, res (resident) able to bend and move finger." A nurse 's noted written on 4/1/2010 at 1:30 PM read" Critical 62 Phenobarbital level of 50.2, called Advanced Registered Nurse Practitioner (ARNP) order to hold Phenobarbital for two days then resume and report lab in two weeks." A therapeutic anticonvulsant level of Phenobarbital in serum is 10 to 25 g/mL. 245. That a review of adverse reactions for Phenobarbital users includes unsteady gait, slurred speech, fainting, drowsiness, dizziness, restless muscle movement, excitement, irritability, aggression and confusion especially in the elderly. 246. That a review of the Risk Manager's investigation report for the 4/1/2010 fall, she wrote the possible cause of the fall was that the resident was playing around in the dining room when he/she tripped and fell. She lists actions to be taken as "remind the resident to be careful in the dining room, keep hallways and dining room clear and clutter free". The facility had repeatedly assessed the resident as alert with confusion in the medical record, so that the interventions were inappropriate for this resident. They also did not place appropriate intervention on the resident's care plan to implemented. . 247, That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - "Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 248, That a nurse’s note on 4/14/2010 at 2:00 PM read "pt complained of left hand pain. swollen. pt stated "I fell yesterday" pt Stated (he/she) had pain in left hand. Pt noted to have swelling in left forearm also. Dr order for x-ray. risk manager informed. Tylenol given for pain. pt has confusion and oriented X 1. No signs or symptoms of change in mental status, Pt states (he/she) doesn't know what time, but that (he/she) fell in the dining room. "Resident sent to hospital on 4/15/2010 at 9:45 am. A nurse's note written on 4/15/10 read "called for update, resident admitted with left radial fx and phenobarbital intoxication. " 63 249, That on 4/14/2010 at 12:59 PM an interview was conducted with the MDS Coordinator. She stated that she only makes care plan changes at time of quarterly review and that the nurses and unit managers were responsible for making changes at all other times. She stated that the Risk Manager was in charge of coming up with new intervention in a fall situation. 250. That on 4/16/2010 at 11:15 am an interview was conducted with the Risk Manager. She agreed that she should have considered the resident's high phenobarbital level reported on 4/1/2010, which can cause slowing of body systems, as a possible cause of the resident's fall and not just that the resident's "fooling around" caused it. She stated she should have taken further action to prevent the resident from falling again until their phenobarbital level was back within normal range. Resident #96 251. That areview of Resident #96's medical record revealed he/she has dementia, glaucoma, was legally blind, and had an extensive history of falls. The resident had had ten falls since December of 2008, two of them with injury. 252. That on 12/12/09 at 6:30 am a nurse's note was written that read "walking in hall and heard housekeeper say the resident was on the floor, small laceration on forehead area was cleansed with normal Saline and applied triple antibiotic ointment and bandage. " 253. That on 4/15/2010 at 10:25 am, an interview was conducted with the Risk Manager. She stated the facility had no reports for a incident on 12/12/09 for Resident #96. She stated the facility only had one for 11/12/09, that was for a finding of old bruising. She looked through her log during the interview and stated that it would be listed there if an investigation was done, she stated that no one must have filled out an incident report. 64 254. That on 4/14/2010 at 1:20 PM an interview was conducted with the Risk Manager when she stated they had "exhausted interventions" for this resident in regards to preventing future falls. However there was no evidence that the facility had tried some of the latest equipment that may have prevented the resident from falling or alerted the staff to the possibility that the resident was in the process of falling. 255. That arecord review revealed a nurse's note written 1/28/10 that read "resident found on floor next to bed, unaware of how it happened. Abrasions to RLE (ight lower extremities) no other injuries noted," A review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 256. That during multiple observations of the the resident ' s room during the survey revealed the resident's door was closed and his/her curtain was pulled which would prevent the staff from observing the resident. 257. That on 4/15/2010 at 12:23 PM, in an interview with the Resident 's LPN (Licensed Practical Nurse), she stated that the resident 's door was always closed because his/her roommate closed the door. She agreed that she would not be able to hear the newly placed pressure released bed alarm with the door closed. She said they will just open the door. 258. That on 4/15/2010 at 1:28 PM, an interview was conducted with the MDS coordinator, with the Risk Manager present. She stated that the resident was never evaluated for a One on One monitoring for falls, they only assessed behavior residents for One on One monitoring. 65 Resident #125 259, That Resident #125 was admitted into the facility on 1/23/2009 with multiple diagnoses which included Dementia. The resident was also noted on the current MDS as "at risk for falls". 260. That clinical record review revealed that the resident was placed on One on One Monitoring on January 25, 2009. A review of the facility's current Nursing Policy and Guidelines for One on One monitoring with an effective date of 3/21/1020 (revised) revealed that the purpose of the monitoring was "to reduce the episodes of physical aggression and provide quick intervention", revealing that the nursing staff were to continuously monitor the residents for “particular behaviors". There was no evidence that the facility had a Nursing Policy and Guidelines for One on One monitoring for residents at risk for falls and falling. 261. That a review of the clinical record revealed a plan of care for Resident #125 dated 2/04/2010 which revealed behaviors such as delusions, pacing, elopement, verbal abuse of staff and residents, agitation and talking to him/herself. The approaches included One on One with a staff member and to redirect the resident from exit doors. 262, That a review of the facility's incident/accident report dated 3/23/2010 revealed that the facility failed to monitor Resident #125 during the nursing assistant's break. Resident #125 was left unattended on 3/23/2010 at 6:55 am. Resident #125 was found on the floor upon the nursing assistant's return to the resident's room. A review of the Incident Log Sheet for March 2010 did not reveal that this was a “witnessed fall". 263. That an interview with the charge nurse for the 200 hall on 4/13/2010 at 2:23 PM . revealed that Resident #125 was on One on One monitoring for elopement precautions, not behavior precautions. 66 264. That an interview with the facility risk manager on 4/15/2010 at 2:00 PM revealed that there was no adverse incident report completed on 3/23/2010 after Resident #125's fall because the resident was not injured-in the fall. 265. That a review of the resident's record revealed that no post fall evaluation/assessment (per facility provided protocol - " Assessing Falls and Their Causes") was performed and no revision to the resident's fall care plan were made to prevent further falls. 266.