STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, :. vs. : Case Nos. 20110001473 . : "20110001475 BRIAR HILL, INC. d/b/a AUBURNDALE OAKS HEALTHCARE 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 Briar Hill, Inc. abla Auburndale Oaks Healthcare Center (hereinafter . “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2010), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from standard to conditional commencing January 28, 2011, to impose an administrative fine in the amount of twenty-five thousand dollars’ ($25,000.00), to impose a two (2) year survey cycle, and assess a survey fee of six thousand dollars ($6,000.00), based upon Respondent being cited for two (2) patterned State Class J deficiencies. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2010). Filed March 22, 2011 11:01 AM Division of Administrative Hearings 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207, 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 II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 7 | 4. Respondent operates a 120-bed nursing home, located at 919 Old Winter Haven Road, Auburndale, FL 33823 and is licensed as a skilled nursing facility license number 1 0860951. 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 "60° The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. , . , 7. That pursuant to Florida law, all physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift. Rule 59A-4.107(5), Florida Administrative Code. 8. That pursuant to Florida law, each facility shall adopt procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. Rule 59A-4.112(1), Florida Administrative Code. 9. That based upon the review of records, observation, and interview, Respondent failed to ensure that it followed physician's orders-and ensured the availability and administration of prescribed medications for eleven (11) of nineteen (19) sampled residents, the same being contrary to the mandates of law, 10.‘ That as a result of these findings, Immediate Jeopardy was identified on 1/19/2011 and is ongoing. 11. That Petitioner’s representative reviewed Respondent’s records related to resident number four (4) during the survey and noted as follows: ‘a. ~ The resident was admitted to the facility on December 22, 2009; b, Per the facility face sheet, the resident was eighty-six (86) years old with _tnultiple diagnoses including cardiac disease, peripheral vascular disease, a heart valve replacement and diabetes with neurological complications; c. The resident’s January 2011 physician orders reflected that three (3) types of ~ “insulin were ordered for the resident - Lantus Insulin, 25 units at bedtime, 9:00 p.m., Apidra Insulin, 18 units, twice daily at 7:00 a.m, and 4:30 p.m., and Novolog Regular Insulin; amount to be determined by sliding scale after blood glucose levels checked before meals and at bedtime; d. The resident’s January 2011 medication administration record documented that the resident did not receive Apidra Insulin from January 14, 2011 at 5:00 pan. through January 23, 2011 at 5:00 p.m. e. A total of nineteen (19) doses of prescribed Apidra were recorded as not given to the resident; f. The resident’s. January 2011 medication administration record documented two (2) blood glucose levels over 400 mg/DL — January 21, 2011 at 9:00 p.m. 3 the reading was four hundred forty-nine (449) and on January 23, 2011 at 4:30 p.m, the reading was four hundred thirty-six (436); g. ° Both values exceeded the upper limits of the sliding scale for regular insulin; h. Both readings occurred while the resident was not receiving prescribed Apidra; i, Absent from the records was any indication that the resident’s physician was notified on the nineteen (19) missed doses of Apidra or of the extreme high blood glucose levels suffered by the resident during this period. 12, That Petitioner’s representative interviewed resident number four (4) during the survey who indicated as follows; a. The resident confirmed that prescribed Apidra Insulin was not provided to the ' . 1 resident for multiple days; - b. The resident indicated that the nurse dropped the bottle and it was not replaced;.. c. The resident stated that.at least twice during this period, blood sugar readings were elevated:over 400 mg/DL. 13. That Respondent’s director of nursing indicated to Petitioner’s representative that she had no knowledge of the missed doses of insulin for resident number four (4) until the investigation of diabetic management revealed the details, the four (4) nutses involved received disciplinary action so far, and that it was unacceptable for professional nurses to fail to obtain the insulin and to not inform the physician of-the situation. 14. That-Petitioner’s representative interviewed the physician of resident number four (4) on January '25, 2011 who confirmed that he had not been informed of the multiple missed doses of Apidra Insulin for the resident and he had been in the facility several times during this time frame and had never been informed. 15. , That Petitioner’s representative reviewed Respondent’s records related to resident number two (2) during the survey and noted as follows: a. The resident was readmitted to the facility on January 16; 2011 with a diagnosis of sepsis; db. Per the face sheet, the resident was eighty-two (82) years old; c. Respondent’s nursing comprehensive admission data documented the resident was alert and vital signs were stable at the time-of admission, 1:15 p.m. and the resident had a nasogastric tube; d. Physician's orders, dated January 16; 2011 directed that the resident was to . receive tube feedings of Glucerna 1.2 at 55 cc per hour and Lantus insulin, 10 units, was ordered to be injected at 9:00 p.m. every night for diabetes; e. The resident was also ordered heart and respiratory medications; f. Physical and occupation therapy were ordered for increased mobility; 2g. A therapy evaluation, dated January 18, 2011, documented that the resident walked and transferred independently prior to the hospitalization; Nursing documentation contained five neurological assessments. that documented the resident was alert and oriented, with clear and appropriate speech Two (2) hours after admission, the resident pulled out the nasogastric ‘tube; Four (4) hours later the resident's blood sugar was documented in the nurse's notes as 85 mg/DL; Nursing notes document that the resident was sent to the hospital on January 17,2011 at 1:00 p.m. and returned at 5 :15 p.m. with a second nasogastric tube; . There! was located no documentation. regarding the feeding tube solution ~ infusing from-5:15'p.m. to 9:00 p.m. A note of 9:00 p.m. on January 17, 2011 documents that the resident pulled out the nasogastric tube a second time; Notes of January18, 2011 at 6:30 a.m. document that the resident was sent to the hospital for insertion of a PEG tube, a gastric tube used for long term tube feeding of residents; The resident returned to Respondent: facility at-10:40 p.m. on January 18, 2011; On. January 18, 2011 at noon, nurse number one (1) documented that the resident’s blood sugar was 418 mg/DL and insulin was given; nr oy a Documented at 2:00 p.m., the blood sugar. was 453 mg/D1 and the physician visited; The next entry, no time specified, stated the blood sugar was 348; Physician's orders revealed and untimed order that stated to increase the dose of Lantus insulin to 20 units nightly , starting January 20, 2011, and to give 10 units of regular insulin (circled R) by (intravenous) IV x 1; A peripheral IV was ordered to be inserted for access; The resident’s January medication administration record reflects that 10 units of Regular Insulin was recorded as given at 3:00 p.m. by nurse number one (1). 16. That Petitioner’s representative interviewed Respondent’s nurse number one (1) on January 25, 2011 at 9:45 a.m. who indicated as follows: a. She gave 1000 units of Regular insulin to resident number two (2) in error; She obtained a multi-dose bottle of insulin from the emergency drug kit that contained 10 milliliters of insulin with a concentration of 100 units per, milliliter; She realized her error immediately after giving the insulin dose and reported it © to the assistant director of nursing, nurse number seven (7), and the corporate registered nurse for quality assurance, nurse number two (2); She was upset, hysterical, and repeated that she gave 10 milliliters of insulin by IV; e, Norse number three (3), a licensed practical nurse, the "desk nurse", called the resident’s doctor to inform him and nurse number three (30 informed the physician of the volume but not the concentration of the insulin, thereby providing him with partial, inaccurate information of the situation; f Someone said it was 100 units, and that was the information that was provided to the physician. 17, That Petitioner’s representative interviewed Respondent’s director of nursing during the survey who indicated as follows: a. She was informed of the medication error with resident number tow (2) about ’ one hour after the event; db She thought one of the four nurses involved had clarified to the physician the exact dose of insulin given; — c Nurse number one 91) had not administered ten (10) units of insulin to - resident number two (2), but had in fact given one thousand (1000) units of insulin to the resident; d. Nurse number one (1) had obtained a ten (10) milliliter bottle of insulin from the emergency drug kit, picked up a ten (10) milliliter syringe and administered the entire bottle to the resident via intravenous push, 18. That Petitioner’s representative interviewed the physician of resident number two (2) on January 24, 2011 who indicated as follows: He. was informed that resident received a vial of insulin, equivalent to one . hundred (100) units; He ordered monitoring based on this information and the half life of intravenous insulin; ° ‘He was never notified of the actual dose administered, one thousand (1000) units of insulin, until January 20, 2011, after the resident's death He would have ordered her transferred to the hospital for more critical management if he had received accurate information regarding the overdose. 19. « That record’s further reflect the following: d. That, based on the inaccurate insulin over dosage information provided to the physician, the physician ordered blood glucose monitoring every thirty (30) minutes for four (4) hours; The resident wag found six (6) hours aftet the medication error, at 9:30 p.m. on January 19, 2011, without respirations and no audible heart rate; ~ Cardiopulmonary resuscitation was initiated and 911 was called; The resident was pronounced dead on January 19, 2011 at 10:00 p.m. 20. That the above reflect Respondent’s failure to ensure that all physician orders are followed as prescribed, and if not followed, the reason shall be recorded on the resident’s ‘medical record during that’shift and Respondent’s failure to ensure that procedures that assure the accurate acquiring, receiving, dispensing, and administering of.all drugs and biologicals, to meet the needs of each resident are implemented. 9 21... That: Petitioner’s representative reviewed Respondent’s records related to resident - number twelve (12) during the survey and noted as follows: The resident was eighty-four (84) years old and was admitted to the facility on December 30, 2005 and again on June 10, 2010; Admitting . diagnoses list ‘included: Cancer, hypertension, septicernia, . blindness and diabetes; The resident’s care plan, dated November 17, 2010, documented that the resident had diabetes with complications, Physician's ‘orders, ‘dated January 2011, included orders for blood glucose monitoring before meals and at bedtime, _ Insulin coverage was ordered based on the findings of the blood glucose values; The resident also received an oral medication for diabetic control, twice daily; The resident’s January 2011 medication administration record contained four. (4) instances of documentation of. blood sugar testing and insulin administration that were incomplete or inaccurate as follows: i. On January 10, 2010 at both 4:30 p.m. and 9:00 p.m., the documentation does not reveal the blood glucose values or the amount of insulin given; ii. .On January 20, 2011, at both 4:30 p.m. and 9:00 p.m., the, documentation does not reveal the blood glucose values or the amount of insulin given; The same nurse of Respondent initialed all four above identified areas of the - resident’s medication administration record. ‘22... That Petitioner’s representative interviewed Respondent’s director of nursing regarding resident number twelve. (12) during the survey who confirmed that: the documentation of diabetic management provided. by Respondent was inadequate and she would speak with the nurse, nurse number six (6), and later added that the nurse confirmed the incomplete documentation and the nurse was suspended, with probable termination after the investigation. 23: That. Petitioner’s representative reviewed Respondent’s records related to resident number fourteen (14) during the survey and noted as follows: a. Per the facility face sheet, resident number fourteen (14) was readmitted to the facility on September 11, 2010 after a hospitalization; ‘The resident was seventy-nine (79) years old and had numerous diagnoses listed on-the face sheet including: liver and kidney disease, hypertension, mental health disorders, and diabetes; Physician's orders for January 2011 revealed that the resident received the following: Novolog insulin 70/30 mix, 85 units every morning. Novolog ‘Insulin, 70/30 mix, 40 units at 5:00 p.m. daily, and blood glucose monitoring every four (4) hours with Novolog regular insulin coverage as needed per a sliding scale; The resident’s. January 2011 medication administration record reordered that on January 17, 2011 at 6:30 p.m. and 10:30 p.m. elevated blood glucose values of 355 mg/DL and 354 mg/DL respectively were recorded; however 11 ; } 4 H { i q there was.no documentation reflecting the administration of insulin in accord with the sliding scale prescribed based upon the glucose test results. 24." That Petitioner’s representative interviewed Respondent’s director of nursing regarding resident number fourteen (14) during the survey who confirmed that the documentation of diabetic management provided by Respondent was unacceptable, was completed by the same nurse, nurse number six (6), as noted regarding resident number twelve (12), and later indicated that the nurse was terminated. ‘25... That» Petitioner’s: representative xeviewed Respondent’s records related to resident number seventeen (17) during the:survey and noted as follows: Do a Per the facility face sheet, resident number seventeen (17) was ninety (90) years old with a diagnosis of muscle weakness, Alzheimer ' s, heart disease, hypertension, and diabetes at the time of admission, August 31, 2010; b. Physician's orders, dated’ January: 2011, ordered the following diabetic medications: Novolog Insulin 70/30 mix, 10 units every moming. Novolog Insulin 70/30 mix, 5 units at noon and 5:00 p.m. and blood glucose monitoring before meals and at bedtime with sliding scale coverage with Novolog Insulin; c, :. ‘The resident’s January 2011 medication administration record included the following: i. There was no documentation of the administration of prescribed sliding scale insulin coverage of Novolog Insulin, 70/30, 22 units at 06:00 a.m. on January 2, 2011; “ti. There was no documentation of the administration of prescribed sliding scale insulin coverage of Novolog Insulin, 10 units at 4:30 p.m. on January 3 and 21, 2011; jit. The documentation of blood glucose values of Janvary 9, 2011 at 4:30 p.m. was illegible and thus a determination of the application of the ‘prescribed insulin amount was not possible; iv. Blood glucose was recorded as 394 on January 23, 2011 at 4:30 p.m, however there was no documentation reflecting insulin given though, per the sliding scale, the resident was to receive eleven (11) units of insulin and the physician was to have been notified; Absent from the records was any indication that the resident’s physician had been notified as ordered based upon the above referenced January 23, 2011 ~ blood glucose level. 26, That Petitioner’s representative reviewed Respondent’s records related to resident number ten (10) during the survey and noted as follows: a. Per the facility face sheet, the resident was admitted to the facility on March 27, 2010 at 10:00 am. The resident was eighty-one (81) years old with diagnoses of: Coronary Atherosclerosis, Difficulty Walking, Muscle Weakness, Senile Dementia, Psychosis, Diabetes Mellitus, Hypothyroidism, and Chronic. Airway Obstruction; 13 ne eee nee Nurses notes, dated January 17, 2011 at 11:30 am., document the resident . was found to have a blood sugar of 490 mg/DL and the practitioner was called; Orders were received to give 10 units of Novolog insulin and repeat the blood sugar at 1:30.p.m. At 1:30 p.m. nurse's notes document the blood sugar was 582 and the ptactitioner was called; A second dose of Novolin Insulin, 10 units was ordered and the blood sugar to be repeated at 4:30 p.m. At 4:30 p.m. the blood sugar was recorded on the resident’s medication observation record as 402 mg/DL. Physician's orders, dated January 17, 2011, no time specified, reflect that the Advanced Registered Nurse Practitioner (ARNP) was called, was informed of ‘the resident's blood sugar of 402 mg/dl, and an order was received to give 10 units Novolog Insulin immediately (now) at 4:30 p.m. and to call the ARNP at 8:00-p.m. if the blood sugar was greater than 400; The resident’s medication administration record does not have the third dose . of Novolog Insulin, 10-units, transcribed as a "now" order; The 4:30 p.m. blood sugar of 402 mg/DL was documented in the sliding scale block a 4:30 p.m. with the 10 units of insulin written in the block below; The resident’s medication administration record showed the 4:30 blood sugar sliding scale upper limit was for 380 mg /DL, and to give 6 units of insulin The nurse documented 10 units of insulin in the sliding scale area indicating a routine dose of insulin, not an exception to the routine management. 27. That Petitioner’s representative reviewed Respondent’s: records related to resident number six (6) during the survey and noted as follows: Per the facility face sheet, the resident was admitted to the facility January 12, 2011 at 2:51 p.m. The resident was eighty-two (82) years old and had diagnoses of: Transient Ischemic Attacks (TIA); Altered Mental Status (AMS), Squamous Cell ‘Carcinoma of the tongue and mouth, Hemachromatosis, Diabetes Mellitus, Atrial Fibrillation and a history of Small Cell Lymphoma in 1994; Physician's orders dated January 12, 2011 directed insulin sliding scale for ~ Humalog Insulin for Diabetic Management and blood sugars were to be checked before meals.and at bedtime; The Insulin sliding scale was written as follows: 111-149-give 2 units, 150- 199-give 4 units, 200-249-give 7 units, 250-299-give 10 units, 300-349-give 12 units, and gréater 349-give 15 units; On January 13, 2011 at 6:00 p.m. there was no documentation of the blood sugar value or the Insulin coverage given, if needed. On January 22, 20100 at 6:00 a.m., the blood sugar was documented as 154° mg/DL, and the insulin coverage given was documented as 2 units of insulin though per the physician's order the resident should have received 4 units of insulin; Respondent’s nurse failed to follow the physician's orders for diabetic management; . On January 24, 2011 at 6:00 a.m., there was no documentation of the blood sugar value or the insulin coverage, if needed, for the resident. 28. That Petitioner's representative reviewed Respondent’s records related to resident number five (5) during the survey and noted as follows: Ay Per the facility face sheet, the resident was admitted to the facility January 11, 2011 at 7:30 p.m. _ The resident was seventy-four (74), years old. and had diagnoses of: Cardiovascular Accident (CVA), Atrial Fibrillation, Muscle Weakness, Late Effect Hemiplegia, Aphasia, Benign Hypertension, Depression, Diabetes, and Hyperlipidemia; Physician's order's dated January: 11, 2011 required testing of the blood sugar before meals and at bedtime and Novolog Insulin coverage , as needed, per an Insulin sliding scale; an The Insulin sliding scale for Insulin was as follows: 150-199 give 2 units, 200- 249 give 4 units, and the upper limit, greater than 400 mg/DL.., instructed the’ “nurse to call the médical doctor (M.D); The resident’s January medication administration record documented the “ blood sugar'on January 24, 2011 at 6:30 a.m. was documented as 173 mg/DL; Per the physician's sliding scale order the resident should have received 2 units of Novolog Insulin; ’ There was no documentation of the insulin administration for the resident on January 24, 2011 at 6:30 a.m. 29, That Petitioner's representative reviewed Respondent’s records related to resident number three (3) during the survey and noted as follows: Per the facility face sheet, the resident was admitted on December 20, 2007 and re-admitted on July 1, 2008 at 11:00 am. . The resident was ninety (90) years old and had diagnoses of: Renal Failure, Adjustment Disorder with Anxiety/Depression, Diabetes Mellitus 2, with Insulin sliding scale, Difficulty .Walking, Hypothyroidism, Hypertension, Cardiac disease, and Vascular Dementia; Physician's order's dated November 25, 2010 for December 2010included an order for blood glucose finger stick-testing twice daily, prior to meals, with sliding scale insulin coverage; 17 d. The physician's order stated: Novolog 100 units per milliliter dose per sliding " scale with the range prescribed 150-180;, give 2 units, 181-210; give 3 units, and 211-240 give 4 units, up to 8 units of Novolog Insulin for blood sugar values of 331-360 mg/DL. “. @ . The resident’s December 20120 medication administration record contained four (4) errors or omissions related to blood sugar results and Insulin coverage as follows; j. On December 26, 2010 at 6:00 a.m. there was no documentation of a blood sugar value and no documentation of Insulin coverage; ii, On December ‘15, 2010 at 4:30 p.m. there was no documentation of a blood sugar value and no documentation of Insulin coverage; iii, On December 16, 2010 at 4:30 p.m. there was no documentation of a blood sugar value and no documentation of Insulin coverage; iv. On December 28, 2010 at 6:00 a.m., the blood sugar was documented 158 but there was no documentation of the Insulin coverage; ' vy. Physician orders for insulin coverage stated that the resident should have been given two units of insulin. 30. :. That Petitioner’s representative interviewed :Respondent’s director of nursing regarding the above omissions who stated. "I could not find any insulin documented for those omissions." 31. That Petitioner’s representative reviewed Respondent’s records related to resident number eight (8) during the survey and noted as follows: 18 Per the facility face sheet, the resident was admitted to the facility April 9, 2010 at 1:30 p.m. The resident was fifty-one (51) years old with diagnoses of: Cellulitis of leg, Lymphedema, Muscle Weakness, Difficulty Walking, Diabetes Mellitus, Benign Hypertension, Atrial Fibrillation and Mental Retardation; Physician's orders for January 2011 required blood glucose finger stick before meals and at bedtime and for Novolog Insulin, 100 units per milliliter, for the insulin sliding scale as needed based on ‘the blood sugar results; The insulin coverage began at 150-180 mg/DL; give 2 units, up to 331-360 mg/DL; give 8 units; The resident’s January 2011 medication administration record teflected on January 25, 2011 at 6:30 a.m. the blood sugar is documented as 157; There was no documentation of insulin coverage provided; The physician’s order prescribed 2 units of insulin coverage; The order was not followed. That the above facts, individually and collectively, reflect Respondent’s failure to follow physician orders or document why such orders were not followed and reflect Respondent’s failure to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the-needs of each resident, said failures being contrary to the minimum requirements of law 19 ca emerrene a -33.. That on January 28, 2011 a limited moratorium was placed on the facility prohibiting the further admission of diabetic residents. 34, . That on January 28, 20100 at 4:00 p.m. Respondent’s administrator and director of nursing indicated that staff education and retraining was not complete at this time. 35. That the Agency determined that these failures relate to a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility and cited this deficient practice as an Patterned State Class I deficiency. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of twelve thousand five hundred dollars ($12,500.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2010). COUNTI | 36. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 37. — That pursuant to Florida law, all licensees of nursing homes’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 right to teceive 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. § 400.022(1)(), Fla. Stat. (2010). 20 Ree That based upon the review of records, interview, and observation, Respondent failed to assure the provision of adequate and appropriate health care and protective and support services consistent with the resident care plan and with established and recognized practice standards within the community in its facility-wide failure to ensure that resident’s suffering from diabetes receive care and services required including, but not limited to, inconsistent diabetic monitoring and medication, failure to identify and address diabetic needs, and the failure to appropriately contact resident physicians regarding diabetic management, the same being contrary to the requirements of law. 39. That initial comments to Petitioner’s representatives by Respondent’s director of nursing indicated that Réspondent’s census included thirty-two (32) diabetics in the population of one hundred (100) residents. 40. That on January 27, 2011, Respondent’s director of nursing indicated to Petitioner’s representatives that counting the diabetic residents that received oral medications, the total diabetics in the facility was forty-three (43) of the one hundred (100) resident census. 41. That Petitioner’s representative reviewed .Respondent’s records related to resident number two (2) during the survey and noted as follows: a, Per the face sheet, the resident was admitted to the facility from an acute care hospital where the resident was treated for sepsis; b. The resident was eighty-two (82) years old and was own responsible party at the time of admission; c. Respondent’s Nursing Comprehensive Admission Data sheet documented the resident to be alert, oriented to person, and with impaired cognition; 21 uncontrolled diabetes); The form documented the resident as totally dependent for nutrition and with a nasogastric tube in place; : Respondeiit’s plan for Rehabilitation, dated January 19, 2011, documented that the resident lived in the community with family and transferred and walked independently prior to the illness; Five (5) neurological nursing assessments, from January 16 through 19, 2011, documented the resident to be alert and oriented with clear appropriate speech; The resident’s history and physical, dated January 8, 2011, revealed that the resident was admitted to the hospital with a urinary tract infection, possible sepsis, uncontrolled diabetes and severe acidosis (a possible complication of The Laboratory data on page two (2) of the history noted that the resident's. blood glucose level was 549 mg/DL. Page three of the history recorded that the resident was receiving an Insulin Drip (intravenous) with consistent monitoring for further ketosis; Nurse's notes revealed that the resident was admitted to the facility at 3:00 p.m. on January 16, 2011 with a nasogastric tube, a Foley catheter, and was alert with mild confusion; At 5:00 p.m. January 16, 2011, the resident pulled the nasogastric tube out; 22 At 9:00 p.m. January 16, 2011, the resident’s blood sugar was recorded at 85 mg/DL; On January 17, 2011 at noon Respondent’s nurse wrote that the gastric tube _ Was out and the resident was transferred at 1:00 p.m. to the hospital for placement of a PEG tube, a tube placed directly through the abdominal wall - into the stomach for feeding; _- This note stated that the resident returned without the PEG tube, but with a second nasogastric tube at 5:15 p.m. The next note, at 9:00 p.m. stated that the resident pulled the second . nasogastric tube out; Absent from Respondent’s records was any indication that Respondent had weighed or implemented preventative measures to prevent the resident from removing the nasogastric tube a second time; Absent from Respondent’s records was any indication of the resident's source of nutrition on January 17, 2011; On January 18, 2011 at midnight, the resident’s blood sugar was 92 mg/DL; At 6:30 a.m. on January18, 2011, the resident was transferred to the hospital again for placement of a PEG tube; On January 18, 2011 at 10:40 p.m., the resident returned to the facility with a PEG tube; 23 bb. CG. dd. The next note, dated January 19, 2011 at 1200, no a.m. or p.m. specified, stated that the tube feeding was infusing and the blood sugar was 418 mg/DL; ' Insulin was given; A recheck at 2:00 p.m. stated the blood sugar was 453 mg/DL and the doctor visited; A physician telephone order, dated January 19, 2011, no time specified, stated to increase the Lantus insulin to 20 units nightly, starting on January 20, 2011, and to give 10 units of regular insulin by IV one time; The resident’s medication observation record “for January 19, 2011 documented that 10 units of Regular Insulin was recorded as given at 3:00 p.m. by Respondent’s nurse number one (1); ~ A nurse’s note dated January 19, 2011 at 5:55 pin, documented the resident was receiving tube feedings, oxygen at four liters, and the blood sugar was 102; The next recorded blood sugat was $7 at 6:25 p.m, and the nurse noted mouth ’ breathing at that time; ‘At 9:25 p,m. the recorded blood sugar was 87, BP 100/80, pulse 93, and respirations were 20; At. 9:30 p.m, it was noted: the resident's respirations had ceased, the resident did not respond to shaking, and no heart rate was heard, Cardiopulmonary resuscitation was initiated and 911 was called; 24 ee, At 10:00 p.m. on January 19, 2011 the resident was pronounced dead at the bedside. 42, That Petitioner’s representative interviewed Respondent’s director of nursing during the ‘survey regarding resident number two (2) and the director indicated as follows: Respondent’s nurse number one (1) did not give ten (10) units of insulin to the resident on January 19, 2011 at 3:00, but in fact gave one thousand (1,000) units of regular insulin; The nurse obtained a ten (10) milliliter bottle of insulin from the emergency drug kit, picked up a ten (10) milliliter syringe and administered the entire © bottle to the resident by intravenous push The nurse reported her error to three other nurses and nurse number three (3), the desk nurse, called the doctor; The physician requested clarification on the dose of the insulin error and was told "10 cc" but was not to either the amount in units or the concentration of one hundred (100) units per milliliter; Someone told nurse number three (3) that the dose equaled one hundred (100) units and that was reported to the physician; The physician then ordered blood sugar monitoring every thirty (30) minutes for four (4) hours; 25 nen nen g. At no time did any of the four nurses seek resources such as the pharmacy representative, the label of the insulin box, or a drug reference book to assist with calcification of the amount of insulin, in units, given to the resident; h. Invaddition, the initial trip to the hospital for ‘the PEG tube insertion, on Jamary 17, 2011, was a miscommunication as the hospital thought the resident had an existing PEG tube and that the catheter was being changed. 43. That Petitioner’s representative interviewed the physician for resident number two (2) on January 24, 2011 who indicated as follows: a. He. was never informed of the actual dose of insulin administered to the resident until after her death; b. Inthe past he. had difficulty finding a nurse in the facility with accurate . resident information. 44, That: Petitioner’s representative reviewed Respondent’s records related to resident -. number four (4) during the survey and noted as follows: a The resident was readmitted to the facility on December 22, 2009; b. Per the facility face sheet, the resident was eighty-six (86) years old with multiple diagnoses including: Heart disease; peripheral vascular disease, -.. obesity and diabetes; c. A physician order sheet for January 2011 directed that the resident receive three types of insulin daily and required Lantus insulin (long acting), 25 units at bedtime, Apidra, insulin glulisine, 18 units twice daily at 7:00 am and 4:30 26 p.m., and sliding scale regular insulin as needed per the blood glucose level monitoring before meals and at bedtime; The resident’s medication administration record (MAR) for January 2011, documented that nineteen (19) doses of Apidra Insulin were not given from January 14, 2011 at §:00 p.m. to January 23,2011 at 5:00 p.m. "The reverse of the medication administration record contained one entry, dated January 22, 2011 at 2:00 p.m., that stated Apidra was not on the medication cart and the pharmacy was notified; The medication administration record further documented that the resident had two blood sugar elevations over 400 during the period of January 14, 2011 at 5:00 P. m. to January 23 2011 when prescribed Apidra insulin wag not administered as follows: January 21, 2011 at 9:00 p.m. the resident’s blood sugat was 44g mg/DL and the resident was given eight (8) units of regular insulin and on January 23, 2011 at 4:30 p.m, the resident's blood sugar was 436 mg/DL and the resident again received eight (8) units of regular insulin; — The prescribed sliding scale order for regular insulin required, when blood glucose 331-360, give eight (8) units of insulin; There was no order regarding insulin doses for blood sugats above 360 mg/DL; . Both values exceeded the upper limits of the sliding scale for regular insulin; 27 Both readings occurred while the resident was not receiving prescribed Apidra; Absent from the records was any indication that the resident’s physician was notified on the nineteen (19) missed doses of Apidra or of the extreme’ high blood.glucose levels suffered by the resident during this period. That Petitioner’s representative interviewed the pharmacy representative regarding the ¢ ’ Apidra for resident number four (4) on J anuary.25, 2011 who indicated as follows: The pharmacy had no record of a contact from Respondent on January 22, 2011 regarding the Respondent’s need to fill the Apidra prescription; Acie Insulin was kept in stock and available at anytime for refill; She, researched the file for the resident and the last refill was called in on I anuary 23, 2011 and supplied to the fait on 1 January 24, 2011 in the early morning hours; The pharmacy was not informed of a broken bottle of the medication and the refill was processed routinely; A STAT order can be sent within four (4) hours; - Apidra was not special order and the cost was only an additional two dollars over routine insulin bottles; The insurance provider did not need to approve the medication. 28 46, That Petitioner’s representative interviewed resident number four (4) during the survey ‘who indicated as follows; a. The resident confirmed that prescribed Apidra Insulin was not provided to the x resident for multiple days; dD. The resident indicated that the nurse dropped the bottle and it was not réplaced; c The resident stated that at least twice during this period, blood sugar readings were elevated over 400 mg/DL. d. The insulin is currently being provided and the resident was doing fine. , ' 47. That Respondent’s nurse at the bedside of resident number four (4) during the interview indicated that she was aware of the omissions and stated she thought the refill was delayed related to insurance problems. 48. That Petitioner’s representative interviewed Respondent’s director of nursing during the survey regarding resident number four (4) and she indicated as follows: a, She was informed of the missed doses of insulin for the resident on January 24, 2011; b. - She was investigating the circumstances and she expected nurses to be disciplined related to the events; c. Later she informed the Petitioner’s representatives that four (4) nurses received written reprimands related to the missed doses of Apidra Insulin for the resident; “29 She confirmed that this resident resided on the second wing of the facility and the staff involved was in addition to the staff involved with resident number tow (2) on the other wing of the facility. : 49, That Petitioner’s representative interviewed the physician for resident number four (4) a. during the survey who. indicated the following related to the resident: He was not informed of the missed doses of insulin or the elevated blood sugars; He reviewed the resident's. record during the interview and confirmed the nineteen (19) missed doses and two elevated blood sugars over 400; He had visited the resident and been in the facility during the relevant time vot . i fn and was never informed of the situation; He verbalized dissatisfaction with the situation and confirmed that he was the Respondent’s medical director. 50. That Petitioner’s tepresentative. reviewed Respondent’s records related to resident number nine (9) during the survey and noted as follows: a. Per the face sheet, the resident was re-admitted to the facility on January 10, 2011 after hospitalization for an infected arm; The resident was forty-eight (48) years old, with cellulitis of the arm, ‘weakness, congestive heart disease, hypertension, diabetes, impaired renal function, diabetes, and glaucoma; 30 fe nes eee A physician history and physical, dated October 18, 2010, documented that the resident had a left elbow infection that was likely septic and exacerbation of hyperglycemia related to the infection; Hospital records, dated January 6, 2011 récorded that the resident had a PICC " line IV access for four weeks of planned antibiotic therapy; The hospital physician consultation of January 6, 2011, page two (2) of four _ (4), documented that the resident's elbow x-ray revealed an infection suggestive of possible gas gangrene and page three (3) of the consult stated the resident received a high dose of steroids with subsequent elevated blood glucose levels; The physician wrote the resident had poor wound healing and item number four (4) provided "watch [the patient] closely with other supportive measures and blood sugar control.”. - It was planned that the resident was to receive four weeks of intravenous antibiotic therapy; A hospital medication record, dated January 6, 2011, documented that the resident had an insulin pump to be maintained by the resident and his family; This information was not transcribed or located within the resident's record at the facility; The care plan list at the facility, dated January 10, 2011, item number four (4) stated DM (diabetes); 31 There was no mention of an insulin pump; Physician's admission orders of January 10, 2011 revealed no orders for insulin administration or an insulin pump; The January 11, 2011 facility physician history and physical form contained no information regarding the presence of an insulin pump; An order was located on the resident’s January 2011 medication administration record for blood glucose monitoring before meals and at bedtime; ‘There was no corresponding physician's order for glucose monitoring at the time of admission; Documented on the January 2011 medication administration record was "yesident has insulin pump” There was located no order for sliding scale insulin; The physical exam section stated that the abdomen was soft, non tender, and bowel sounds were present; The list of medications, confirmed by Respondent’s director of nursing as copied on the form by Respondent’s nurse number three (3) from the hospital medication list, failed to list insulin or the presence of an insulin pump; The Respondent’s self medication data collection and assessment sheet stated that the facility would administer all medications and was signed by two nurses; 32 aa. bb. cc. There was no documentation of an insulin pump; Absent from the resident’s records was any evidence that the admission nurse or subsequent nurses caring for the resident accurately assessed the resident or ' ‘contacted the physician regarding diabetic management and or the monitoring of the insulin pump; The’ resident’s January 2011 medication administration record’ documented that biood glucose checks were initiated on the resident commencing January 11, 2011 at 11:30 a.m, for before meals and at bedtime; A notation was written that the resident had an insulin pump; Absent from the resident’s records was any evidence of a physician's order to check the blood glucose, not was there an order for interventions with values requiring emergency intervention; The range of recorded blood glucose values was from 43 to 338 mg/DL; Respondent’s protocol for low blood sugar revealed that under the section “PROTOCOL” “A reading below 60 mg/DI. is to be managed while notifying the physician; The record reflects six (6) documented blood sugar values lower than sixty (60) mg/DL; ‘Absent from the resident’s récords was any evidence that the resident’s physician was notified of the resident’s blood glucose readings of under sixty (60) mg/DL 33 dd. - 66, &. ji. Absent from the, medical record was any physician contact informing him of any emergency procedures used by the resident. Respondent’s physician history and physical, dated January 11, 2011, had two different handwritings on the form with no documentation of the insulin pump or the dose of insulin received via the pump. The, physician signed the form; It. was. later determined that Respondent’s nurse number three (3) had transcribed the medications in the lower right area; A second form found in the facility medical record did not include diabetes in the medical history portion, though what appeared to be the same handwriting, nurse number three (3), listed Insulin pump as the first medication; A "self medication data collection, form’ stated “all medications would be administered by the nursing staff." , This document was. obtained on January 10,2011 upon the resident’s admission and signed by nurses numbered seven (7) and eight (8); There was no mention of the insulin pump. 51, That Petitioner’s representative observed resident number nine (9) on January 26, 2011 at 12:30 PM, noted the resident alert and oriented in an electric wheelchair, and: interviewed the resident who indicated as follows: a b. The resident had an insulin pump attached to the right middle abdomen; _ The resident demonstrated the pump; 34 “C. There’ was a very small catheter extending from the subcutaneous insertion site in the left abdomen to the hand held electronic pump; d, The resident demonstrated the pump setting varied three (3) times throughout the day, with adjusted rates of constant delivery of regular insulin at a concentration of 500 units per milliliter, five (5) times the normal concentration of insulin; “* @, -" Staff checked the resident’s blood sugars before meals and at bedtime, informed the resident of the results, and the resident keyed the information into the hand held pump and received a bolus dose of insulin if needed; f. The resident indicated the resident’s spouse obtained the insulin and the pump ‘was refilled every three days. 52. That the spouse of resident number nine (9) later indicated to Petitioner’s representatives _ that far very low blood sugar, the spouse administered an oral gel and called 911 for emergency medical services, though the spouse could not recell the exact number for such a low reading. 53. That Pétitionet’s representative interviewed Respondent’s director of nursing during the survey regarding resident number nine (9) and she indicated as follows: a. She was not informed that the resident had an insulin pump until January 25, 2011 during the Petitioner’s investigation of resident number two (20; b. . She requested that Respondent’s nurses numbered seven (7) and eight (8) attend the interview; 35 Both. nurses stated they were caring for the resident and were not aware of the concentration of insulin that the,pump provided, how the pump worked and what to do in case of an emergency/diabetic crisis; Both nurses stated that the resident administered own diabetic medication via the insulin pump; Neither nurse was aware of any interventions for the resident in case of a low or high blood glucose level and demonstrated a total lack of knowledge about the pump; Nurse number eight (8) stated that the resident received intravenous antibiotic therapy via a PICC line; Both nurses stated they were aware that antibiotics could affect blood glucose levels; .- an ‘The director of nursing’ stated ‘that nurse number’ three (3) obtained the information on the physician history and“ physical, dated January 11, 2011,from:the. 3008 form and the hospital record and confirmed that nurse number three (3) did not transcribe the insulin pump, onto the, facility physician history and physical form, dated January 11, 2011, for the physician, The director of nursing confirmed that there were no physician orders . wh concerning diabetic management for the resident from the admission on January 10, 2011 through January 26, 2011; 36 j- Nursing education will include management of an insulin pump and she would contact the manufacturer for details regarding the pump. 54, That Petitioner’s representatives were later informed by Respondent’s nurse number seven (7) that she had informed the physician of the need for diabetic management orders, . Provided the surveyors with a copy of the new orders of January 26, 2011 at 3:45 p.m., and stated she redid.the self medication data collection and assessment sheet to include the insulin _ pump. — 55, That’ Petitioner’s representative reviewed Respondent’s ‘records related to resident number ten (10) during the survey and noted as follows: a Per the facility face sheet, the resident was admitted to the facility on March “27, 2010 at 10:00 a.m,” The resident was eighty-one (81) years old with diagnoses of: Coronary Atherosclerosis, Difficulty Walking, Muscle Weakness, Senile Dementia, Psychosis, Diabetes Mellitus, Hypothyroidism, and Chronic Airway Obstruction; Nurse’s notes, dated January 17, 2011 at 11:30 am. documented the resident’s blood sugar of 490 mg/DL and the practitioner was called; Orders were received to give 10 units of Novolog insulin and repeat the blood sugar at 1:30 p.m. At 1:30 p.m., nurse's notes documented the resident’s blood sugar at $82 and the practitioner was called; 37 .f.._. Asecond dose of Novolin Insulin, 10 units was ordered and the blood sugar to be repeated at 4:30 p.m. g. At 4:30 p.m.,the blood sugar was recorded on the medication administration | oh record as 402 mg/DL; h Physician's orders dated January 17, 2011, no time specified, reflected the “’ ‘Advanced Registered Nurse Practitioner (ARNP) was called, was informed of the resident's blood sugar of 402 mg/dl, and an order. was received to give 10 units Novolog Insulin immediately (now) at 4:30 pam. and to;call the ARNP at 8:00 p.m. if the blood sugar was greater than 400; noo oh. > » The resident’s medication administration record reflected that the third dose of Novolog Insulin, 10 units, was not transcribed as a "now" order; je The 4:30 pm. blood sugar was recorded at 402 mg/DL and documented in the sliding ‘scale block a 4:30 p.m. with the 10 units of insulin written in the block ibelow; k. The resident’s medication administration record showed the 4:30 blood sugar ._ gliding scale upper limit was for 380 mg. /dl, and to give 6 units of insulin; 1. Respondent’s nurse documented 10 units of insulin in the sliding scale area indicating. a routine dose of insulin, not an exception to the routine management. 56. ; That: Petitioner’s representative reviewed Respondent’s records related to resident number six (6) during the survey and noted as follows: 38 cote EL. Per information from the facility face sheet, the resident was admitted to the facility January 12, 2011 at 2:51 p.m. ' The resident was cighty-two (82) years old and had diagnoses of: Transient Ischemic Attacks (TIA), Altered Mental Status (AMS), Squamous Cell Carcinoma of the tongue and mouth, Hemachromatosis, Diabetes Mellitus, Atrial Fibrillation and a history of Small Cell Lymphoma in 1994; Physician's orders dated January 12, 2011 required an insulin sliding scale for Humalog Insulin for Diabetic Management; Physician's orders required the blood sugars to be checked before meals and at bedtime; The Insulin sliding scale was prescribed as follows: 111-149-give 2 units, 150-199-give 4 units, 200-249-give 7 units, 250-299-give 10 units, 300-349- give 12 units, and greater 349-give 15 units; On January 13, 2011’ at 6:00 p.m. there was no documentation of the blood sugar value or the Insulin coverage given if needed; On January 22, 2011 at 6:00 a.m. the blood sugar was documented as 154 meg/DL, and the insulin coverage given was documented as 2 units of insulin though the physician's order would require the administration of 4 units of _ insulin; On January 24, 2011 at 6:00 a.m., there was no documentation of the blood sugar value or the Insulin coverage, if needed, for the resident, 39 » 57... That. Petitioner’s representative reviewed Respondent’s records related to resident number five (5) during the survey and noted as follows: a. Per'the facility face sheet, the resident was admitted to the facility January 11, 2011 at 7:30 p.m. .. “The ‘resident was seventy-four (74) years old and had diagnoses of: Cardiovascular Accident (CVA), Atrial Fibrillation, Muscle Weakness, Late Effect Hemiplegia, Aphasia, Benign Hypertension, Depression, Diabetes, and Hyperlipidemia;. Physician's order's dated January. 11, 2011 included a order for testing of the resident’s blood sugar before meals and at bedtime; A physician's order for Novolog Insulin coverage was of record, as needed, — per an Insulin sliding ‘scale; ° The Insulin sliding scale for Insulin was as follows: 150-199 give 2 units, 200- 249. give 4 units, and the upper limit, greater than 400 mg/DL, instructed the nurse to call the medical doctor (M.D);., That on the resident’s medication administration record for January 2011, the _ resident’s blood sugar on. January 24, 2011 at 6:30 a.m. was documented as 173.mg/DL; ’ Per the physician's order, the resident should have received 2 units of Novolog Insulin; 40 h. There was no documentation of the prescribed insulin administration for the resident on January 24, 2011 at 6:30 am. 58. That Pétitioner’s representative reviewed Respondent’s records related to resident number three (3) during the survey and noted as follows: a Per the facility face sheet, the resident was admitted December 20, 2007 and ‘ re-admitted on July 1, 2008 at 11:00 a.m. b. The resident was ninety (90) years old and had diagnoses of: Renal Failure, Adjustment Disorder with Anxiety/Depression, Diabetes Mellitus 2, with Insulin sliding scale, Difficulty Walking, Hypothyroidism, Hypertension, ‘Cardiac disease, and Vascular Dementia; “eg Physician's orders’ dated November 25, 2010 for December 2011 required blood glucose finger stick-testing twice daily, prior to meals, with sliding scale insulin coverage; | d. ‘The physician's order prescribed: Novolog 100 units per milliliter dose per sliding scale; e. The range was 150-180; give 2 units, 181-210; give 3 units, and 211-240 give 4 units, up to 8 units of Novolog Insulin for blood sugar values of 331-360 mg/DL \ f. The resident’s December 2010 medication administration record reflected four (4) extors or omissions related to blood glucose management per physician orders: 41 i. .December 6, 2010 at the 6:00 a.m. - there was no documentation of a - blood sugar value and no documentation of Insulin coverage; ii. December 15, 2010 at 4:30 p.m. - there was no documentation of a blood sugar value and no documentation of Insulin coverage; iii, December 16, 2010 at.4:30 p.m. - there was no documentation of a blood sugar value and no documentation of Insulin coverage; iv. December,28, 2010 at 6:00 a.m. - blood sugar was documented 158 however there: was no documentation of the Insulin coverage though ‘the _ physician orders. for insulin coverage required the resident be given two units of insulin, | -59,. That Petitioner’s representative interviewed. Respondent’s director of nursing regarding the above recited errors and omissions: and. she indicated "I could not find any insulin documented for those omissions.” . 60... That. Petitioner’s representative reviewed Respondent’s records related to resident number eight (8) during the survey and noted as follows: a. Per the facility face sheet, the resident was admitted to the facility April 9, 2010 at 4:30 p.m. b. The resident was fifty-one (51) years old with diagnoses of: Cellulitis of leg, Lymphedema,. Muscle Weakness, Difficulty. Walking, Diabetes Mellitus, Benign Hypertension, Atrial Fibrillation and Mental Retardation; 42 g Physician's orders for January 2011 included an order for blood glucose finger stick before meals and at bedtime and for Novolog Insulin, 100 units per milliliter, prescribed on an insulin sliding scale as needed based on the blood sugar results; : Insulin coverage began at 150-180 mg/DL; give 2 units, up to 331-360 mg/DL; give 8 units; The resident’s January. 2011: medication administration record reflected the January 25, 2011 6:30 a.m. blood sugar documented as 157; There is no documentation for insulin coverage; The physician’s order prescribed 2 units of insulin coverage. 61. That Petitioner’s representative reviewed Respondent’s records related to resident number twelve (12) during the survey and noted as follows: The resident was re-admitted to the facility on June. 10, 2010 after hospitalization for septicemia; Per the facility face sheet, the resident was eighty-four (84) years old with as history of cancer of the prostate, blindness, hypertension and diabetes; The resident’s care plan, dated November 17, 2010, documented diabetes with complications; Physician's orders for January 2011 required that the resident received blood glucose monitoring before each meal and at bedtime; 43 | e. The physician ordered insulin coverage for elevated blood sugars based on a sliding scale; f. The resident’s January 2011 medication administration record reflected the following errors or omissions: i, January 10, 2011 at 4:30 p.m. and 9:00 p.m., the amount of insulin for both incidences of glucose testing was unknown; ii. January 20, 2011 at 4:30 p.m. and 9:00 p.m. the blood glucose values were unclear and the amount of insulin administered was unknown. 62.. That Petitioner’s representative interviewed Respondent’s director of nursing regarding the above recited errors and omissions who confirmed the documentation errors and omissions, stated additional nurses would be disciplined, and concurred that the diabetic management was unsatisfactory and required additional education. 63. That the above reflects Respondent’s failure to provide adequate and appropriate health care and protective and support services consistent with the resident care plan and with established and recognized practice standards within the community including, but not limited to, where: a, Respondent failed to take action to assure that care and services for the diabetic condition of a resident were addressed where the Respondent knew a resident had an insulin pump; b, Respondent failed to contact resident physician’s where glucose values required the same; 44 c. Respondent failed to manage low blood glucose level of a resident including the: failure to notify the resident’s physician despite Respondent’s protocol requiring such action; d.’ Respondent failed to contact a resident’s physician where prescribed insulin treatments were not being provided; e, Respondent failed to take action necessary to obtain prescribed insulin though Respondent knew the same was not being provided; f. Respondent failed to assess and intervene for known behavior of the removal of medical devices by a resident; ‘g. Respondent failed to transcribe physician orders correctly to medication records; h. Respondent failed to maintain documentation to accurately reflect the treatment milieu of diabetic residents. 64.°. That the Agency determined that these failures relate to a situation in which immediate cortective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility and cited this deficient practice as an Patterned State Class I deficiency. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of. twelve thousand five hundred dollars ($12,500.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2010). . COUNT I] . 65. The Agency re-alleges and incorporates paragraphs one (1) through five (5S) and Counts I and I as if fully set forth herein. 45 _ Statutes (2010).commencing January 28, 201.1. , 66, Respondent has been cited for one (t) al Class I deficiency and therefore is subject to a six (6) month survey cycle fur a period of ears and a survey fee of six thousand dollars ($6,000) pursuant to Section 400.19(3), Florida Statutes (2010), WHEREFORE, the Agency intends to i se & six (6) month survey cycle for a period of two years and impose a survey fee in the ambunt of six thousand dollars ($6,000.00) against "Respondent, @ skilled ‘nursing Facility i in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (201 0). 67, The Agency re-alleges and incorporates p agraphs one (1) through five (5) and Counts I ‘and Hof this Complaint as if fully set forth horeitl, 68, Based upon Respondent's two (2) cited Sthte Clasa T deficiencies, it was not in substantial compliance at the time of the survey with nit a established under Part 11 of Florida Statute 400, or the rules adopted by the Agoncy, a violation subjecting it to aysignment of.a conditional licensure status under § 400,23(7)(a), Florida Stathtes (2010), WHEREFORE, the Agency intends i assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400,23(7), Florida Thenias J. Walsh If, Esquire la. Bar. No, 566365 gdney for Health Care Admin, 523 Mirtor Lake Drive, 330G St. Petersburg, FL 33701 727,552.1947 (office) 46 Pursuant to § 400,23 (7)(e), Fla, Stat. (2009), Respondent shal] post the most current Ucense in a prominent place that is in clear and unobstructed public view, at or near, the place where residenis aro being admittad to the Facility, Respondent is notified that it has a right to request an administrative hoaring pursuant to Seotion 120.569, Florida Statutes. Respondent has the ght to retain, and be represented by an attorney in this matter. Specific aptions for administrative action are set out in the attached Eleotion of Rights. All requests for hearing shall ba made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Makan Drive, Bldg #8, MS #3, Tallahassee, Florida, 32308, (850) 922-5873, RESPONDUNT I8 FURTHER NOTIFIED THAT |A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT Of THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY, . THEREBY CERTIFY that a true and corréet copy of the foregoing las beanyserved by U.S, Certified Mail, Return Receipt No; 7008 0500 0001 9503 7634 on February (” 2011 to Jonathan 8. Grout, Esquire, Counsel for Respondamt, 2431 Aloma Avenue Suite 249, Winter Park, FL 32792, ‘ alsh Ii, Esquire 47 _ Copies furnished to: Jonathan S. Grout, Esq. Thomas J. Walsh II, Esquire | Counsel for Respondent Senior Attorney i 2431 Aloma Avenue Suite 249° Agency for Health Care Admin. Winter Park, FL 32792 525 Mirror Lake Dr., N., #330G i (US. Certified Mail) St. Petersburg, Florida 33701 ; : wd Interoffice) ‘ i ~ | Patricia, Caufman : (Interoffice Mail) 48 we LL. USPS ~ Track & Confirm 7 : Page 1 of 1 Track & Confirm Search Results Label/Receipt Number: 7008 0500 0001 8503 7634 Scueersar ae Fania Service(s): Certified Mail™ . Tradk & Contin Status: Delivered . Enter Label/Recelpt Number. Your Item was delivered at 10:42 am on February 18, 2011 in WINTER anermencne tem mars PARK, FL 32792. : Detailed Results: « Dolivered, February 18, 2071, 10:42 am, WINTER PARK, FL 32792 » Arrival at Unit, February 18, 2011, 7:38 am, WINTER PARK, FL 32792 Notifigatlon Options Track & Confirm by email Get current event information or updates for your item sent to you or others by email. { do> } SiteMan —-»- Gusfomer Service ==» Forma = Govt Services «= Greets = Paivacy Policy ==» Tenmeofsa Business Customer Guleway e $9emd Aejectant e Rgeniortonamas Copyright® 2010 USPS. All Rights Reserved, NoFEARActEEO Data FOIA Passage Tae end Vg tealing bay http:/Arkenfrm 1 .smi.usps.com/PTSInternetWeb/InterLabelInquiry.do 02/22/2011 4 | SENDER: COMPLETE,ZUIS SECTION f COMPLETE THIS SECTIQRLON DELIVERY , Date atsive fille 17 iver. YES, sinter dolvery address helow: No 431 Aloma Avenue Suite 249 , Winter Park, FL 32792 ‘a Certified Mall (1 Express Mall GAReglatered = Cl Return Recelpt for Merchandle . a tnsurad Mal “. 6, 0.0. _ PS Form 3811, February 2004 - 102696-02.M-18

Docket for Case No: 11-001508