bhp & O° STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 0-488 Petitioner, vs. Case Nos. 2010006599 2010006601 OAKBRIDGE HEALTH CARE ASSOCIATES, LLC d/b/a OAKBRIDGE HEALTHCARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Agency” or “Petitioner”), by and through the undersigned counsel, and files this Administrative Complaint against OAKBRIDGE HEALTH CARE ASSOCIATES, LLC. d/b/a OAKBRIDGE HEALTHCARE CENTER, (hereinafter “Respondent”), pursuant to §§ 120.569 and 120.57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing June 4, 2010 and ending June 28, 2010, and impose an administrative fine in the amount of ten thousand dollars ($10,000.00) and an imposition of a six (6) month survey cycle fee of six thousand dollars ($6,000.00) for a total of sixteen thousand dollars ($16,000.00), based upon Respondent being cited for one (1) isolated State Class I deficiency, pursuant to § 400.121, Fla. Stat. (2009). with rules as adopted by the agency.” See § 400.022(1)(1), Fla. Stat. (2009). 8. That Florida law, within the Nurse Practice Act of Chapter 464, defines “Practice of professional nursing” to mean: - “__. the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (a) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. (b) The administration of medications and treatments as prescribed or ~ authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments. (c) The supervision and teaching of other personnel in the theory and performance of any of the acts described in this subsection. A professional nurse is responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing.” See § 464.003(20), Fla. Stat. (2009). 9. That pursuant to Florida law, an intentional or negligent act materially affecting the health or safety of residents of the facility shall be grounds for action by the agency against a licensee. See § 400.102(1), Florida Statutes (2009). 10. That on or about 06/04/ 10, the Agency completed a Complaint Investigation (CCR No. 2010005148) of Respondent’s facility. 11. That based on interview, record review, and policy review, the Respondent failed or refused to provide adequate and appropriate health care and protective and supportive services where the Respondent failed to perform CPR to a resident, Resident No. 4 (hereafter “R4”), who required CPR and was not subject to a valid DNR order. The Respondent did not implement Respondent’s policies and procedures for emergency care. 12. That during an interview with the Respondent’s Administrator on 06/03/10 at 1:04 p.m., it was revealed that he was informed of an incident surrounding R4 around 2:00 or 3:00 a.m. Page 3 of 14 9) Document incident, notification of 911, CPR _ initiation, and resident/patient disposition. 15. That a telephone interview on 06/03/10 at 4:27 p.m. with the registered nurse (hereafter “RN”) who worked on the 11:00 p.n. - 7:00 a.m. shift on 05/06/10 - 05/07/10 revealed: a. She had observed R4 several times in the late night hour of 05/06/10 and early. morning hour of 05/07/10. b. The RN indicated the resident was in his/her usual position on the right side of the bed on his/her back. c. The RN stated that the resident rarely moved, as s/he was very weak. At approximately 1:10 am. on 05/07/10, the RN stated she walked by the resident’s room and saw him/her laying on the floor, on his/her left side ina fetal position with the wheelchair next to him/her. d. The resident’s oxygen tubing was off his/her face and wrapped around his/her hands. The bathroom door was wide open making it appear as though s/he was trying to get to the bathroom. The resident had no pulse and no respirations. The RN stated she called for a certified nursing assistant (hereafter “CNA”) and went to check the resident’s chart for do not resuscitate (hereafter “DNR”) orders. The RN indicated she saw the yellow DNR form in the resident’s record. The RN thought the form was a valid DNR order and did not administer CPR or call 911. The RN stated she went back to the resident’s room to try to figure out what happened, as she had just seen the resident about twenty (20) minutes earlier and s/he showed no abnormal signs of distress. The RN placed the resident back in bed with the assistance of two nursing assistants. The RN stated she then proceeded to contact the resident's doctor and left a message with the answering service and called the resident’s Page 5 of 14 That continued review of the clinical record revealed a Social/Psychosocial Data Collection and Evaluation form, dated 04/22/010, and signed by the facility’s social service assistant. This form documented this resident to have no advanced directives in place to include do not resuscitate, health care surrogate, living will , durable power of attorney, certification of terminal/end stage condition, certificate of incapacity, legal guardian, or health care proxy. In addition, the evaluation noted the patient lived with the daughter prior to hospitalization and the current plan was for the resident to continue to receive therapy with the goal of returning to home. In addition, social service progress notes, dated 05/04/10, stated daughter plans to take patient home on 05/07/2010, per patient request. Patient and daughter request care at home with hospice. Social services to make referral and assist with this patient initiated discharge. R4’s physician also noted in the clinical record on 05/06/10 at 8:00 p.m. plan is to go home in the morning with hospice. Continued review of the record revealed a yellow State of Florida Do Not Resuscitate Order form, dated 05/07/10, signed by the resident’s family member who was checked as surrogate. The form was not signed by the resident’s physician and no telephone orders for do not resuscitate were located in the record. The resident’s clinical record did not include documentation to validate the family member’s legal capacity to sign this document on the resident’s behalf. This was the only advanced directive document found in the resident’s clinical Page-7 of 14 22. That further investigation and interview with the resident’s physician on 06/03/10 at 12:08 p.m. revealed he was very familiar with this resident, as he had treated hinvher in the hospital prior to admission in the Respondent’s facility. According to the physician, the resident had severe lung problems, congestive heart failure (hereafter “CHF”), was weak, and depressed. a. The physician said he had spoken to the resident’s family member about the resident’s poor prognosis but encouraged the resident and family to transfer to arehab facility for strengthening prior to returning back home. The physician indicated that the resident was very depressed but remained focused on one thing and that was to go home. The physician stated that the resident did finally agree to temporary rehab placement prior to returning home. Once admitted to the rehab, the resident did not make any progress from a medical standpoint and after a few weeks the physician spoke with the family member again. At that time, the family member indicated the resident's wishes were to go home and die at home, whether it is in a few weeks or in a few months. The physician indicated that he met with the resident to discuss his/her condition ~ of two organ failure and depression. Although the resident had a flat affect, s/he was alert and did comprehend the severity of his/her condition. The physician stated that he never discussed hospice or do not resuscitate orders with the patient. The physician stated he was unaware of the do not resuscitate order form being signed by the resident’s family member prior to the incident on 05/07/10 in which the resident was found without pulse or respirations. Page 9 of 14 resident with the Agency surveyor at that time. 25, That further interview with the Administrator on 06/03/10 at 1:04 p.m. revealed the Respondent immediately became aware of their error upon investigation and a four (4) point corrective process was instituted on 05/07/10, the date of the incident. 26. A review of the four (4) point process revealed the following: a. Physician and family notified. All appropriate personnel came into the facility to initiate investigation. b. Facility wide audit done 05/07/10 by Social Services Director to ensure: i. DNR signed by appropriate person and medical doctor. If signed by family, documentation present of health care surrogate, health care proxy, or power of attorney in place. ii. Ensure medical doctor signed DNR iii. Ensure telephone order for DNR in place. c. Social Services Director provided education to nurses beginning on 5/7/10 and prior to the start of shift for each nurse thereafter. Nurses were re-educated on DNR and advanced directive process. 24 hour report will be utilized as its intended to alert either staff and management of any changes. d. Will monitor through Quality Assurance (hereafter “QA”) process by Executive Director and QA committee. 27. A teview of the Respondent’s audit completed 05/07/10 revealed the Respondent completed an-house review of all residents to ensure that wishes related to resuscitation are clearly denoted and consistent with the expressed wishes of the resident and/or responsible family member. This was validated through review of audit records and comparison of sampled residents. The Respondent began in-service training on advanced directives and DNR orders on the day of the incident. The Respondent developed a system to ensure all licensed and registered nurses received the training on the revised process for receiving and acting in accordance with advanced directives and DNR orders prior to working their next shift. This was validated through in-service records and random interviews of nurses on 05/26/10 and 06/03/10. Based on the Respondent’s systems process, the IJ was abated on 05/08/10. 28. That the above reflect, inter alia, that Respondent failed or refused to provide adequate Page 11.of 14 Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Florida Statutes (2009). WHEREFORE, the Agency intends to assign a.conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2009) commencing June 4, 2010 and ending June 28, 2010. * Respectfully submitted this 3e “day of September, 2010. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION The Sebring Building 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1942 DISPLAY OF LICENSE Pursuant to § 400.23(7)(d), Fla. Stat. (2009), Respondent shall post the most current license in a prominent place and a list of the deficiencies of the facility shall be posted in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to that facility. Licensees receiving a conditional licensure status for a facility shall prepare, within ten (10) working days after receiving notice of deficiencies, a plan for correction of all deficiencies and shall submit the plan to the agency for approval. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of . Rights. All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 412-3630. Page 13 of 14 STATE OF FLORIDA AGENCY FOR HEALTH CARE/ADMINISTRATION RE: Oakbridge Health Care Associates, LUMOLT 29 PHL: CASE NO. 2010006599 d/b/a Oakbridge Healthcare Center 93 2010006601 for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. | understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2)_ 1 admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)___—iI dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be ELIZABETH DUDEK GOVERNOR es - - INTERIM- SECRETARY —_—______ September 16, 2010 OAKBRIDGE HEALTHCARE CENTER 3110 OAKBRIDGE BLVD E ‘LAKELAND, FL 33803 Dear Administrator: The attached license with Certificate #16438 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on 4 Copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued to reflect a status change to Conditional. Sincerely, Thea Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 OA COMPARE MARE Visit AHCA online at Health Care in the Sunshine ahca.myflorida.com ‘www. Floridacomparecare.Jov FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ELIZABETH DUDEK INTERINTSECRETARY——— GOVERNOR September 16, 2010 OAKBRIDGE HEALTHCARE CENTER 3110 OAKBRIDGE BLVD E LAKELAND, FL 33803 Dear Administrator: The attached license with Certificate #16439 is being issued for the operation of your facility. Please review it thoroughly to ensure that all information is correct and consistent with your records. If errors or omissions are noted, please make corrections on a copy and mail to: Agency for Health Care Administration Long Term Care Section, Mail Stop #33 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Issued for a status change to Standard. Sincerely, oot of. Meno — Agency for Health Care Administration Division of Health Quality Assurance Enclosure ° cc: Medicaid Contract Management LORIDA GoM PARE GARE Visit AHCA online at Health Care In the Sunshine ahca.myflorida.com 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 es, _ff wwaticidatomparecare.goy Sor THIS SECTION ® Complete items 1, z, and 3. Also complete item 4.{f Restricted Delivery is desired. ® Print your name and address on the reverse so that we can return the card to you. ® Attach this card to the back of the mailplece, or on the front if space permits. © 1. Article Addressed to; if YES, enter delivery address below: C1] No Alexandra J. Kusmierz, ot Administrator Dakbridge Healthcare Center 3110 Oakbridge Bivd., E. Lakeland, Florida 33803 3.,, Service Type... ; “1D. Certified Met (1 Express Mail Ol Registered Cl Return Receipt for Merchandise D insured Mail = 1 G.0.D. . 2. Aricenumoer =. 7008 O500 OOOL 350 8773 {Transfer from service earoy br PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 10-009958