STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. , Case Nos. 2010012163 (Fine) 2010012165 (Cond.) M-K OF FERNANDINA BEACH, L. L. C., d/b/a QUALITY HEALTH OF FERNANDINA BEACH, 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 M-K Fernandina Beach, L. L. C., d/b/a Quality Health of Fernandina Beach (hereinafter “Respondent”), pursuant to §§120,569 and 120.57 Florida Statutes (2010), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $5,000.00 upon Respondent, ‘pursuant to §§ 400.022, 400.102 and 400.23(8), Florida Statutes (2010). The imposition of this fine is based on two (2) Class II deficiencies. The Agency also intends to impose a Conditional rating effective November 3, 2010 pursuant to §400.23(7), Florida Statutes (2010). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2010). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. Filed January 5, 2011 4:21 PM Division of Administrative Hearings PARTIES 3. . The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing ‘skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code, 4. Respondent operates a 120-bed nursing home, located at 1 625 Lime Street; Fernandina Beach, Florida 32034, and is licensed as a nursing facility license number 1457096. 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 IJ (Tag N201) RESPONDENT’S FACILITY FAILED TO MEET PROFESSIONAL STANDARDS OF QUALITY CARE §400.022(1)(), Florida Statutes (2010) ISOLATED CLASS I DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to §400.022(1)(1), Florida Statutes (2010), Florida law states, 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 2 recognized practice standards within the community, and with rules as adopted by the agency. 8. That an unannounced complaint investigation CCR# 2010011158 of Respondent’s facility was conducted on November 3, 2010. 9. That based on staff interviews, review of three resident records and resident interviews the facility failed to meet professional standards of quality care for providing adequate safety measures for one of three residents reviewed (#1) that resulted in actual harm to the resident, by the resident falling and having a fractured arm. . | 10. Professional Standard of Care is defined in Chapter 766,102 as "the prevailing professional standard of care for a given health care provider shall be that level of care, skill and — treatment which in light of all relevant surrounding circumstances is recognized as acceptable, and appropriate by reasonably prudent similar health care providers." 11. The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as the "performance of those acts requiring substantial specialized knowledge, judgement and nursing skill based on applied principles of psychological, biological, physical and social sciences which shall include, but not limited to: the administration of treatments and medications as prescribed or authorized by a duly authorized practitioner “practice of practical nursing" as the performance of selected acts, including the administration of treatments and medications in the care of the ill, injured or informed and the promotion of wellness, maintenance of health and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. 12. That Resident #1 had a fall that occurred on 9/19/10 (a Sunday) at 7:45AM as nursing. staff were transferring the resident from the bed to wheelchair using a sit to stand lift resulting in actual harm to the resident when the plan of care was not followed. The resident sustained a fracture of the left arm identified by x-ray on 9/19/10. The facility failed to ensure that the physician was notified in a timely manner, thus causing the resident not to be sent out to the hospital until the next day. 13. Per the resident's medical record, Resident #1 was admitted to the facility on 3/8/10 with diagnoses of stroke with left sided paralysis, GERD, hypertension, muscle weakness and cardiovascular disease. . 14. The Minimum Data Set (MDS) of’ 9/9/10 noted that the resident's cognitive status was alert and oriented times thrée, periodic confusion and forgetfulness at times. The resident needed assistance with all activities of daily living. It noted one person support for bed mobility and extensive assistance of two person plus for transfers. 15. The resident was identified as a fall risk on admission, and again on 6/11/10. The facility had a care plan from 3/17/10, with updates on 6/14/10 and 9/13/10 for fall risk due to hemiparesis/fall history, and assist of 2 for transfers with sit to stand lift. 16, Per the medical record, the resident had a fall that occurred on 9/19/ 10 at 7:45AM as nursing staff were transferring the resident from the bed to wheelchair using a sit to stand lift. The resident's left arm slipped out of the sling and the resident was unable to be transferred. The resident was assisted back to bed. The nurse was notified, and an assessment of the injury was done after the fall. 17. On 11/3/10 at 1:20PM during an interview with the nurse who was working with Resident #1 that day (9/19/10), the nurse stated she was informed by the CNA staff on 9/19/10 of a fall during transfer using the sit to stand lift when the resident's arm fell out of the sling resulting in a fall to the floor with a shoulder injury. The nurse recalled asking the resident if family needed to be informed and the resident requested no family be contacted at that time. 18. During an interview with the resident on 11/3/10 at 12:40pm, the resident stated that there was just one aide assisting with the sit to stand, and that after the fall, the resident requested CNA #1 to get CNA #2 to assist with getting the resident back to bed. 19. The nurse stated the MD made rounds at the facility before lunch and at that time was informed of the fall with orders received for X-ray in the morning. The nurse had already written the verbal order for the X-ray and the physician was agreeable to same. 20. There was no additional documentation in the medical record regarding follow up care or pain management on 9/19/10 after Spm, when the nurse noted the X-ray report was emailed to the physician. 21. Per the nursing note for 9/19/10 at 7:45am, the resident complained of left shoulder discomfort. The physician was notified during rounds prior to lunch, and an order received for an x-ray to be taken of the left arm The resident had an x-ray done by a mobile x-ray company completed on 9/19/10, Per the nursing notes it states that the mobile x-ray company was at the facility at 12:30pm; however, there was a fax in the medical record that showed the facility received the report at 9:52am mountain standard time (11:52am eastern time) showing a surgical neck fracture left shoulder in good position. The nurse did not notify the physician until Spm when she emailed the results to the physician on 9/19/10 (a Sunday). 22. Review of the resident's medication administration record showed that the only pain medication provided to the resident was two Tylenol at 9pm on 9/19/10, although the fall occurred at 7:45am, There was no documentation in the medical record as to the effect. There was an order to rate the level of pain on a scale of 0-10 during each medication pass and document any intervention. Review of this documentation showed on 9/19/10 and at 9am on 9/20/10, staff had filled in with a 0 (zeto), representing no pain. 23. However, on 9/20/10, nursing documentation at 10:55am noted vital signs and that the resident was going to the hospital for evaluation regarding swelling and pain noted to the left | shoulder. The notes indicated that the resident was given pain medication at that time. The resident returned to the facility at 2:50pm on 9/20/10. 24, That the Agency provided a mandatory correction date of December 3, 2010. "25. — The above constitutes a violation of §400.022(1), Florida Statutes (2010), and constitutes an isolated class II deficiency pursuant to section 400.23(8)(b), Florida Statutes (2010). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida. COUNT I (Tag N216) RESPONDENT’S FACILITY FAILED TO PREVENT AN ACCIDENT CAUSING ACTUAL HARM §400.102(1), Florida Statutes (2010) ISOLATED CLASS I DEFICIENCY 26. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 27. That pursuant to §400.102(1), Florida Statutes (2010), Florida law states: In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility; 28. That an unannounced complaint investigation CCR# 2010011158 of Respondent’s facility was conducted on November 3, 2010. 29 That based on staff interviews, record review and resident interview for one of three residents reviewed (Resident #1), the facility failed to ensure that adequate safety measures were put into use to prevent an accident thus allowing the resident to fall causing actual harm resulting in a fractured arm. The facility had a care plan in place from 3/17/10 to 9/21/10 that stated to use a 2 person assist to transfer resident using the sit to stand lift. 30. Resident #1 was admitted to the facility on 3/8/10 with diagnoses of stroke with left sided paralysis, GERD, hypertension, muscle weakness and cardiovascular disease. 31. The MDS (Minimum Data Set) of 9/9/10 documented that the resident's cognitive status alert and oriented times three, periodic confusion and forgetfulness at times. The resident needed assistance with all activities of daily living. It noted one person support for bed mobility and extensive assistance of two person plus for transfers. 32. The resident was identified as a fall risk on admission, and again on 6/11/10, The facility had a care plan for fall risk due to hemiparesis/fall history, and assist of 2 for transfers with hoyer lift. 33. The resident had a fall which occurred on 9/19/10 (a Sunday) at 7:45AM as nursing staff were transferring the resident from the bed to wheelchair using a sit to stand lift. The resident's left arm slipped out of the sling and the resident was unable to be transferred. The resident was assisted back to bed, The nurse was notified, and an assessment of the injury was done after the fall. . 34, Per the nursing note on 9/19/10 at 7:45am, the resident complained of left shoulder discomfort after being assisted back to bed. The physician was notified and an order received for an x-ray to be taken of the left arm The resident had an x-ray of the arm and shoulder done with a mobile x-ray company that was completed on 9/19/10, Per the nursing notes it stated that the mobile x-ray was there at 12:30pm; however, there was a fax in the medical record that showed the facility received the faxed x-ray report at 9:52am mountain standard time (11:52am eastern time) showing a surgical neck fracture left shoulder in good position. Per nursing documentation on 9/19/10 (a Sunday) at Spm, the nurse notified the physician of the fracture by emailing the x- ray results to the physician, This caused a delay in the resident receiving further care for the fracture. 35. On 11/3/10 at 1:20PM during an interview with the nurse who was working with Resident #1 that day, the nurse stated she was informed by the CNA staff on 9/19/10 of a fall during transfer using the sit to stand lift when the resident's arm fell out of the sling resulting . in a fall to the floor with a shoulder injury. The nurse recalled asking the resident if family needed to be informed and the resident requested no family be contacted at that time. 36, The nurse stated the MD had rounded at the facility before lunch and at that time was informed of the fall with orders received for x-ray in the morning. The nurse had already written the verbal order for the x-ray and the physician was agreeable to same. 37. There was no additional documentation in the medical record regarding follow up care or’ ‘pain management on 9/19/10 after 5pm, when the nurse noted the x-ray report was emailed to the physician. 38. Review of the resident's medication administration record showed that the only pain medication provided to the resident was two Tylenol at 9pm on 9/19/10, although the fall occurred at 7:45am. There was no documentation in the medical record as to the effect. There was an order to rate the level of pain on a scale of 0-10 during each medication pass and document any intervention, Review of this documentation showed on 9/19/10 and at 9am on 9/20/10, staff had filled in with a 0 (zero), representing no pain. 39, However, on 9/20/10, nursing documentation at 10:55am noted vital signs and that the resident was going to the hospital for evaluation regarding swelling and pain noted to the left shoulder. The notes indicated that the resident was given hydro codon for pain at that time. The resident returned to the facility at 2:50pm on 9/20/10, 40. During an interview with the resident on 11/3/10 at 12:40pm, the resident stated that there was just one aide assisting with the sit to stand, and that after the fall, the resident requested CNA #1 to get CNA #2 to assist with getting the resident back to bed. 41. Review of the resident's care plan for 3/17/10, with updates on 6/14/10 and 9/13/ 10 notes 2 person assist for transfers using sit to stand lift. 42. The information obtained from required reports to the state and to CMS regarding the circumstances stated CNA #1 was attempting to transfer the resident from the bed to the Hoyer Lift without using the two person assist which is the facility policy for mechanical lift transfers. During this process, the resident slid off the bed onto the floor and as a result suffered a fracture of the surgical neck of the humerus, 43. The analysis or apparent cause of this incident stated that it was the facility's finding that the resident fell and fractured the left humerus because the transfer lacked adequate supervision and CNA #1 did not follow the facility protocol of using two assistants for all Mechanical Lift transfers. 44.. During the facility investigation, the assistant director of nursing wrote a statement on 9/20/10, that was not timed that she had interviewed the resident, and it was stated that there was only one CNA in the room when the incident occurred. 45. The Agency provided a mandatory correction date of December 3, 2010. .46. The above constitutes a violation of §400.102(1), Florida Statutes (2010), and constitutes an isolated class II deficiency pursuant to section 400,23(8)(b), Florida Statutes (2010). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida. COUNT I 47. The Agency re-alleges and incorporates paragraph one (1) through five (5) and Count I and Count IJ of this Complaint as if fully set forth herein. 48. Based upon Respondent’s cited two State Class II deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Florida Statutes (2010). 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 (2010) commencing November 3, 2010. CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I through II; (B) Recommend administrative fines against Respondent in the amount of $5,000 for Count I and TI; (C) Impose a conditional license commencing November 3, 2010. (D) Assess attorney’s fees and costs; and (E) Grant all other general and equitable relief allowed by law. Respondent is notified that it has a right to request an administrative hearing pursuant.to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the 10 attached Election of Rights form. All requests for hearing shall be made to the attention of Richard Shoop, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, (850) 922-5873. If you want to hire an attorney, you have the right to be represented by an attorney in this matter. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted this Zz day of December, 2010 D. Carlton Enfinger, II Fla. Bar. No. 793450 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 (850) 412-3640 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7001 0360 0003 3808 3550 to Facility Administrator Stephen Jordan, Quality Health of Fernandina Beach, 1625 Lime Street, Fernandina Beach, Florida 32034 and via U.S. Mail to Registered Agent C T Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on Decembered , 2010. Mb D. Carlton Enfing Copy furnished to: Rob Dickson, FOM 11 USPS - Track & Confirm Page 1 of 1 UNITED STATES WE POSTAL SERVICEe Home | Help | Sign In Track & Confirm FAQs Track & Confirm Search Results Label/Receipt Number: 7001 0360 0003 3808 3550 caoxtamienennaeeianin mite Service(s): Certified Mail™ Track & Confinn Status: Delivered Enter Label/Recelpt Number. Your item was delivered at 2:50 pm on December 06, 2010 in seve . . . i FERNANDINA BEACH, FL 32034. (@o>* wee Notification Options Track & Confirm by email Get current event information or updates for your item sent to you or others by email. { Go>) : Peed bc peredians lange ihenanens, Copyright® 2010 USPS. All Rights Reserved. No FEAR ActEEO Data FOIA a E Spo aaday Ree) Plog nategy tig hy http://trkenfim1.smi.usps.com/PTSInternetW eb/InterLabelInquiry.do 12/07/2010 3608 3550 Postage Ceitified Fee Postmark Return Receipt Fee Here (Endorsement Required) Restricted Delivery Fee (Endorsement Required) Total Postage & Fees 7001 0360 o003 SENDER: COMPLETE THIS SECTION ™ Complete items 1, 2, and 3, Also complete item 4 If 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 malipiece, or on the front If space permits, 1. Article Addressed to: B. Recelved by ( Printed Nama D Nevy boy woWd-¢ | D. Is delivery address different from Item 12 LI Yes 'f YES, enter delivery address below: [No 1 , 6 Type Neack &¥ te Certified Mall [1 Express Mall C1 Registered O Return Recelpt for Merchandise [ QO tnsured Matt =F. 0.0.D, 4, Restricted Detlvery? (Extra Fea) 7001 0360 goo3 34048 3550 PS Form 381 102595-02- February 2004 Domestic Return Recelpt FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION CHARLIE CRIST GOVERNOR November 18, 2010 QUALITY HEALTH OF FERNANDINA BEACH 1625 LIME STREET FERNANDINA BEACH, FL 32034 Dear Administrator: ELIZABETH DUDEK INTERIM SECRETARY The attached license with Certificate #16544 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 6r 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 status change to Conditional. Sincerely, Jusbathorgpoen Tracey Weatherspoon Agency for Health Care Administration Division of Health Quality Assurance Enclosure ce: Medicaid Contract Management FLO RIDA COMPARE DARE Health Care in the Sunshine 2727 Mahan Drive, MS#33 Tallahassee, Florida 32308 # www. FloridaCompareCare.gov Visit AHCA online at ahca.myflorida.com CERTIFICATE #: 165 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF HEALTH QUALITY ASSURANCE NURSING HOME CONDITIONAL This is to confirm that MK OF FERNANDINA BEACH,L.L.C. has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following: QUALITY HEALTH OF FERNANDINA BEACH 1625 LIME STREET FERNANDINA BEACH, FL 32034 TOTAL: 120 BEDS STATUS CHANGE EFFECTIVE DATE: 11/03/2010 EXPIRATION DATE: 07/31/2011

Docket for Case No: 11-000022