STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Nos, 2014000809 2014000811 SUMMERVILLE AT OCALA WEST LLC, Wb/a EMERITUS AT OCALA WEST Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State Of Florida, Agency For Health Care Administration (hereinafter “the Agency”), by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Summerville at Ocala West, LLC d/b/a Emeritus at Ocala West (hereinafter “the Respondent”), pursuant to sections 120,569 and 120.57, Florida Statutes (2012), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of ($13,500.00), based upon three class II violations and two survey fees. PARTIES 2. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable state statutes and rules governing assisted living facilities pursuant to the Chapter 408, Part II, Chapter 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code, respectively. 3. The Respondent operates a s (120)-bed assisted living facility located at 9070 SW 80TH AVE OCALA, FL 34481 and is licensed as an assisted living facility and was at all times material hereto required to comply with all applicable rules and statutes. COUNT 1 Resident Care - Rights & Facility Procedures 4, Florida Administrative Code Rule 58A-5.0182(6) states in pertinent part: Resident Care Standanis. An assisted living facility shall provide care and services appropriate to the needs of Residents accepted for admission to the facility. (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Council shall be posted in full view in a freely accessible Resident area, and included in the admission package provided pursuant to Rule S8A- 5.0181, F.A.C. (b) In accordance with Section 429.28, F.S., the facility shall have a written grievance procedure for receiving and responding to Resident comphints, and for Residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt of a complaint. (c) The address and telephone number for lodging complaints against a facility or facility staff shall be posted in full view in a common area accessible to all Residents. The addresses and telephone numbers are: the District Long-Term Care Ombudsman Council, 1(888)831-0404; the Advocacy Center for Persons with Disabilities, 1(800)342-0823; the Florida Local Advocacy Council, 1(800)342-0825; and the Agency Consumer Hotline 1(888)419-3456. (d) The statewide toll-free telephone number of the Florida Abuse Hotline “1(800)96-ABUSE or 1(800)962-2873” shall be posted in full view in a common area accessible to all Residents. 5. Section 429.28 Florida Statutes states in pertinent part: Resident bill of rights— (1) No Resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a Resident of a facility. Every Resident ofa facility shall have the right to: (a) Live in a safe and decent living environment, free ftom abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. RK (h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular and frequent intervals except when prevented by inclement weather. () Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefS or practices, nor any attendance at religious services, shall be imposed upon any Resident. KR () Present grievances and recommend changes in __ policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, interference, _ coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure fo facilitate the Residents’ exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. (2) The administrator of a facility shall ensure that a written notice of the rights, obligations, and prohibitions set forth in this part is posted in a prominent place in each facility and read or explained to Residents who cannot read. This notice shalt include the name, address, and telephone numbers of the local ombudsman council and central abuse hotline and, when applicable, the Advocacy Center for Persons with Disabilities, Inc., and the Florida local advocacy council, where complaints may be lodged. The facility must ensure a Resident’s access to a telephone to call the local ombudsman council, central abuse hotline, Advocacy Center for Persons with Disabilities, Inc., and the Florida local advocacy council (3a) The agency shall conduct a survey to determine general compliance with facility standards and compliance with Residents’ rights as a prerequisite to initial licensure or licensure renewal. (b) In order to determine whether the facility is adequately protecting Residents’ rights, the biennial survey shall include private informal conversations with a sample of Residents and consultation with the ombudsman council in the planning and service area in which the facility is located to discuss Residents’ experiences within the facility. (c) During any calendar year in which no survey is conducted, the agency shall conduct at least one monitoring visit of cach facility cited in the previous year for a class I or class II violation, or more than three uncorrected class III violations. (d) The agency may conduct periodic followup inspections as necessary to monitor the compliance of facilities with a history of any class I, class Il, or class III violations that threaten the health, satéty, or security of Residents. (e) The agency may conduct complaint investigations as warranted to investigate any allegations of noncompliance with requirements required under this part or rules adopted under this part. (4) The facility shall not hamper or prevent Residents from exercising their rights as specified in this section. HER (7) Any person who submits or reports a complaint conceming a suspected violation of the provisions of this part or concerning services and conditions in facilities, or who testifies in any administrative or Judicial proceeding arising from such a complaint, shall have immunity from any civil or criminal liability therefor, unless such person has acted in bad faith or with malicious purpose or the court finds that there was a complete absence of a justiciable issue of either law or fact raised by the losing party. 6. On or about 11/21/2013, a complaint survey was conducted of the Respondent and its facility. 7. Based on Record Reviews and Interviews the facility failed to provide a safe living environment free from neglect for 1 of 5 residents (res. #1). 8. On 11/21/2013 a record review was conducted on resident #1 facility records. It was observed that on 4/10/2009 resident #1 executed a Do Not Resuscitate Order in coordination with her daughter, who was her legal power of attorney. On 6/07/2010 a Memo e-mail was sent to the Emeritus West Administrator advising him that the family wanted the DNRO removed ftom resident #1 file, The POA stated she would be willing to sign the necessary paper work to do so. On 1/10/2012 a new DNRO policy was signed by the POA and Administrator stating "NO" to the question, "Does resident have a Do Not Resuscitate Order". 9. On 11/21/2013 at approximately 3:08 PM an interview was conducted with staff member E in reference to finding resident #1 unresponsive on 8/15/2013 at 8:30 AM. According to staff member E resident #1 got up that morning and took her medication and got ready for her normally second seating for breakfast. She was waiting inside her apartment sitting in her wheelchair waiting for staff to come and take her to breakfast. Staff E stated when he arrived at resident #1 apartment he found her slumped over in her wheelchair. He attempted to get her to respond but she would not. Staff member E immediately went and got help and had staff call for Emergency Medical Services. When he returned to the room, with the assistance of another staff member they lifted resident #1 from her wheelchair and laid her on the floor and checked her breathing, pulse and heart beat. He stated there was no sign of life. He was about to commence CPR when another staff member pulled resident #1 DNRO file from the 911 folder for the resident and stated do not administer CPR she has a DNRO. 10. On 11/21/2013 during a record review of resident #1 Service Notes it states; EMS arrived and pronounced resident #1 at 8:55 AM. 11. The Respondent’s actions or inactions constituted a class I violation, 12. Class “I” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the Agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations, § 408,813(2)(b), Fla. Stat. (2012). 13. Under Florida law, the Agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation, 14. A fine shall be levied notwithstanding the correction of the violation. § 429.19(2)(b), Fla. Stat. (2012). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. COUNT Resident Rights Standards 15, Florida Administrative Code Rule 58A-5.0182(6) states in pertinent part: Resident Care Standards. An assisted living facility shall provide care and services appropriate to the needs of Residents accepted for admission to the facility. (6) RESIDENT RIGHTS AND FACILITY PROCEDURES. (a) A copy of the Resident Bill of Rights as described in Section 429.28, F.S., or a summary provided by the Long-Term Care Ombudsman Council shall be posted in full view in a freely accessible Resident area, and included in the admission package provided pursuant to Rule 58A- 5.0181, F.A.C. (b) In accordance with Section 429.28, F.S., the facility shall have a written grievance procedure for receiving and responding to Resident complaints, and for Residents to recommend changes to facility policies and procedures. The facility must be able to demonstrate that such procedure is implemented upon receipt ofa complaint. (c) The address and telephone number for lodging complaints against a facility or facility staff shall be posted in full view in a common area accessible to all Residents. The addresses and telephone numbers are: the District Long-Term Care Ombudsman Council, 1(888)831-0404; the Advocacy Center for Persons with Disabilities, 1(800)342-0823; the Florida Local Advocacy Council, 1(800)342-0825; and the Agency Consumer Hotline 1(888)419-3456, (d) The statewide toll-free telephone number of the Florida Abuse Hotline “1(800)96-ABUSE or 1(800)962-2873” shall be posted in full view in acomnion area accessible to all Residents. Section 429.28 Florida Statutes states in pertinent part: Resident bill of rights — (1) No Resident of a facility shall be deprived of any civil or legal rights, benefits, or privileges guaranteed by law, the Constitution of the State of Florida, or the Constitution of the United States as a Resident of a facility. Every Resident of a facility shall have the right to: (a) Live in a safe and decent living environment, free from abuse and neglect. (b) Be treated with consideration and respect and with due recognition of personal dignity, individuality, and the need for privacy. RE (h) Reasonable opportunity for regular exercise several times a week and to be outdoors at regular and frequent intervals except when prevented by inclement weather. @ Exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, nor any attendance at religious services, shall be imposed upon any Resident. eK () Present grievances and recommend changes in __ policies, procedures, and services to the staff of the facility, governing officials, or any other person without restraint, interference, coercion, discrimination, or reprisal. Each facility shall establish a grievance procedure to facilitate the Residents’ exercise of this right. This right includes access to ombudsman volunteers and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. (2) The administrator of a facility shall ensure that a written notice of the rights, obligations, and prohibitions set forth in this part is posted in a prominent place in each facility and read or explained to Residents who cannot read. This notice shall include the name, address, and telephone numbers of the local ombudsman council and central abuse hotline and, when applicable, the Advocacy Center for Persons with Disabilities, Inc., and the Florida local advocacy council, where comphints may be lodged. The facility must ensure a Resident’s access to a telephone to call the local ombudsman council, central abuse hotline, Advocacy Center for Persons with Disabilities, Inc., and the Florida local advocacy council. (3)(a) The agency shall conduct a survey to determine general compliance with facility standards and compliance with Residents’ rights as a prerequisite to initia! licensure or licensure renewal. (b) In order to determine whether the facility is adequately protecting Residents’ rights, the biennial survey shall include private informal conversations with a sample of Residents and consultation with the ombudsman council in the planning and service area in which the facility is located to discuss Residents’ experiences within the facility, (c) During any calendar year in which no survey is conducted, the agency shall conduct at least one monitoring visit of each facility cited in the previous year for a class I or class II violation, or more than three uncorrected class IE violations. (d) The agency may conduct periodic followup inspections as necessary to monitor the compliance of facilities with a history of any class I, class IH, or class Il violations that threaten the health, safety, or security of Residents. (e) The agency may conduct complint investigations as warranted to investigate any allegations of noncompliance with requirements required under this part or rules adopted under this part. (4) The facility shall not hamper or prevent Residents from exercising their rights as specified in this section. ERE (7) Any person who submits or reports a complaint concerning a suspected violation of the provisions of this part or conceming services and conditions in facilities, or who testifies in any administrative or judicial proceeding arising from such a complaint, shail have immunity from any civil or criminal liability therefor, unless such person has acted in bad faith or with malicious purpose or the court finds that there was a complete absence of a justiciable issue of either law or fact raised by the losing party, 16. On or about 12/13/2013, a complaint survey was conducted by the Agency. 17. Based on interview and record review the facility failed to ensure 1 (Resident #3) of 5 residents sampled were free from abuse by not immediately removing the resident from dangerous situation. 18. On 11/19/2013 at approximately 11:00 a.m, The Resident Care Director (RCD) was interviewed. The (RCD) stated the facility ' s policy if there is an allegation or suspicion of abuse the staff must contact the RCD and if the RCD is not available the staff must contact the Executive Director before taking action. She stated the executive director or resident care director per policy are to report facility allegations of abuse and neglect. 19. On 11/19/2013 at 4:45 AM an interview was conducted with the Executive Director (ED) and the RCD. Both stated that visitors are to sign-in and out when visiting a resident. Between 5:00 PM - 7:00 PM, there is not a staff person on-duty at the front desk to monitor visitation. 20. On 12/12/2013 at 8:40 AM another interview was conducted with the RCD. The RCD confirmed she received a phone call from facility regarding an issue in Resident #3 ' s room where resident #3 was heard screaming. The RCD stated it took her approximately 10 minutes to arrive to the facility. The RCD stated when she arrived to the facility she went to Resident #3 ' s room along with Staff A and Staff B. The RCD confirmed Resident #3 ' s male visitor was still in the room at that time. 21. On 12/12/2013 at approximately 8:50 PM an interview was conducted with Staff D. Staff D stated on 11/11/2013 she was passing the evening medication near Resident #3 ' s room and heard Resident #3 yelling, " That hurt." Staff D stated she unlocked Resident #3 '' room door and entered the room. Staff D described Resident #3 's room as dark. Staff D stated when she walked in the room she observed a male visitor with Resident #3 and added the male visitor threw covers over Resident #3 when she waked into the room. Staff D stated this was a, "red fag " for her. Staff D stated she told Resident #3 she would retum with the evening medications. Staff D adinitted she left Resident #3 in the room with the male visitor and went to call the RCD, Staff D reported approximately 15 minutes elapsed between the time she contacted the RCD and the time it took for the RCD to arrive at the facility then go to Resident #3 ' s room (along with Staff A and B). Staff D stated the facility’ s abuse and neglect policy is to report all suspected abuse and neglect to the RCD or call the abuse hotline. 22, A Review of Resident #3 Event First Responder Worksheet report revealed staff D had to contact the RCD (Resident Care Director) before intervening in the incident dated 11/11/2013. Written statement ftom the RCD indicated that she received a phone call that Resident #3 was heard saying to her male visitor "Stop, stop that hurts." The statement revealed that the direct-care staff went into the room and "all the lights were off except residents TV." The statement revealed the staff person “walked into the resident ' s room the male visitor threw residents blankets over her.” The statement revealed that the direct-care staff person contacted the RCD via telephone. According to the written statement the RCD came to the facility, entered Resident #3’s bedroom with two direct care staff and discovered that the resident did not have on her undergarments. The facility was unable to provide a written protocol for reporting abuse on 11/19/2013. 23. A review of a written statement from Staff D (dated 11/11/2013) revealed Staff D' s action on 11/11/2013. 24. Staff D wrote, "J was outside the door of the Resident #3 and J heard her yelling and saying, " ‘that hurt' “, and the gentleman in the room said, " ' just stay stil’ ", than he said, " ' ket me go wash my hands, '" Than [ unlock her room door it was very dark in the room he threw the blanket over Resident #3, and I told Resident #3 I will be in to give her 8 PM meds, I told the other med tech and the two RA What I heard and observed. I call the RCD. I informed her of what is going on and what I heard and observe. She said that she is calling the EDD, Than she call back shortly and said she was on her way. " 25. A review of the local sheriff's office report revealed on 11/12/2013 Staff D was interviewed by a detective. The detective wrote, "She (Staff D) Advised that she observed the suspect, now known as the defendant, with his hands on the victim ' s [genitals]. She advised the victim did not have any under garments on. She then told the victim that she was going to provide her with her 2000 hours (8:00 PM) medications. She left the room and contacted other personnel so she could report this. " 26. A review of a written statement ftom Staff B (dated 11/11/2013) revealed Staff B's observations of Resident #3 and the male visitor on 11/11/2013 after Staff D left Resident #3 and the male visitor in the room. Staff B wrote, "1 walked in her [Resident #3 ' s] room with another co-worker and seen Resident #3 ' s [male visitor] with his hand on her (Resident #8 ' s) private area and he covered her up real fast and we pulled the cover back Resident #3 had on no underwear. " The statement revealed Staff A, then got Resident #3 out of bed and too her into the bathroom, " Resident 43 " ask me to stay with her and she wanted that man out of her room. 27. A review of the facility ' s policy on Abuse Prevention, Identification and Reporting (Provided on 12/12/2013) revealed the facility's policy is to, " Protect residents from physical, mental fiduciary (financial), sexual and verbal abuse. " The facility ' s policy states immediate action in response to alleged abuse is to remove resident(s) from immediate danger. A continued review of the policy revealed the facility defines abuse as: 28. " Any form of non-consensual contact including but not limited to unwanted or inappropriate touching, rape, sodomy, sexual coercion, sexually explicit photographing and sexual harassment. This includes any sexual contact between a staff person and a resident, whether or not it is consensual. 29. Review of the facility's guest policy requires visitors to sign in and out when visiting the facility. There is not a staff person at the front desk between the hours of 5:00 PM - 7:00 PM, and at 7:00 PM, the facility doors are locked. Review of the visitors log revealed that guests are not signing in and out after 500 PM. 30. The Respondent’s actions or inactions constituted a class II violation. 31. Class “II” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the Agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. § 408.813(2)(b), Fla, Stat. (2012). 32. Under Florida law, the Agency shall impose an administrative fine for a cited class II violation in an amount not kss than $1,000 and not exceeding $5,000 for each violation, 33. A fine shall be levied notwithstanding the correction of the violation. § 429,19(2)(b), Fla. Stat. (2012). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $2,500.00 against the Respondent. COUNT 1 Assessment of Survey Fee 34. The Agency re-alleges and incorporates by reference Count I as if fully set forth herein, 35. The Agency re-alleges and incorporates by reference Count I. 36. The Agency received a complaint about the Respondent. 37. In response to the complaint, the Agency conducted a complaint survey of the Respondent and its Facility on November 21, 2013, 38. As aresult of the complaint survey, the Respondent was cited for violations. 39, The basis for the violation alleged in this Administrative Complaint relates to the comphint made against the Respondent and its Facility. 40. Under Florida law, in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of the facility's biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statutes, to verify the correction of the violations, § 429.19(7), Fla. Stat. (2012). 41. In this instance, the Agency is entitled to assess a survey fee of $500.00 against the Respondent. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully secks to impose a survey fee against the Respondent in the amount of $500.00. Count IV Assessment of Survey Fee for Count II 42. The Agency re~alleges and incorporates by reference Count II. 43. The Agency received a comphint about the Respondent. 44. In response to the complaint, the Agency conducted a complaint survey of the Respondent and its Facility on December 13, 2013. NH 45. As aresult of the complaint survey, the Respondent was cited for violations. 46. The basis for the violation alleged in this Administrative Complaint relates to the complaint made against the Respondent and its Facility. 47, Under Florida law, in addition to any administrative fines imposed, the Agency may assess a survey fee, equal to the lesser of one half of the facility's biennial license and bed fee or $500, to cover the cost of conducting initial complaint investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under Section 429.28(3)(c), Florida Statutes, to verify the correction of the violations. § 429.19(7), Fla. Stat. (2012). 48. In this instance, the Agency is entitled to assess a survey fee of $500.00 against the Respondent. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully seeks to impose a survey fee against the Respondent in the amount of $500.00. Count V DO NOT RESUSCITATE ORDERS 49. Florida Administrative Code Rule 58A~5.0186(11) states in pertinent part: Each assisted living facility (ALF) must have written policies and procedures, which delineate its position with respect to state laws and rules relative to DNROs. The policies and procedures shall not condition treatment or admission upon whether or not the individual has executed or waived a DNRO. The ALF must provide the following to each resident, or resident's representative, at the time of admission: 1. A copy of Form SCHS-4-2006, “Health Care Advance Directives — The Patient’s Right to Decide,” April 2006, or with a copy of some other substantially similar document, which incorporates information regarding advance directives included in Chapter 765, F.S. Form SCHS-4-2006 is available from the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop 34, Tallahassee, FL 32308, or the agency’s Web site at: http//ahca. myflorida.com/MCHQ/Health_Facility_Re gulatio”HC_Advance_Directi ves/docs/adv_dir.pdf; and 2. Written information concerning the ALF’s policies regarding DNROs; and 3. Information about how to obtain DH Form 1896, Florida Do Not Resuscitate Order Form, incorporated by reference in Rule 64J-2.018, F.A.C. (b) There must be documentation in the resident’s record indicating whether or not he or she has executed a DNRO. If a DNRO has been executed, a copy of that document must be made a part of the resident’s record. If the ALF does not receive a copy ofa resident’s executed DNRO, the ALF must document in the resident’s record that it has requested a copy. 12 (2) LICENSE REVOCATION. An ALF shall be subject to revocation of its license pursuant to Section 408.815, F.S., if as a condition of treatment or admission, it requires an individual to execute or waive a DNRO. (3) DNRO PROCEDURES. Pursuant to Section 429.255, F.S.,an ALF must honor a properly executed DNRO as follows: (a) In the event a resident experiences cardiopulmonary arrest, staff trained in cardiopulmonary resuscitation (CPR), or a licensed health care provider present in the facility, may withhold cardiopulmonary resuscitation. (b) In the event a resident is receiving hospice services and experiences cardiopulmonary arrest, facility staff must immediately contact the hospice. The hospice procedures shall take precedence over those of the assisted living facility. (4) LIABILITY. Pursuant to Section 429.255, F.S., ALF providers shall not be subject to criminal prosecution or civil liability, nor be considered to have engaged in negligent or unprofessional conduct, for following the procedures set forth in subsection (3) of this rule, which involves withholding or withdrawing cardiopulmonary resuscitation pursuant to a Do Not Resuscitate Order and rules adopted by the department. 50. On or about November 21, 2013, the Agency conducted a complaint investigation of the Respondent. 51. Based on record reviews and interviews the facility failed to rescind a Do Not Resuscitate Order from 1 or 5 residents (#1) records, which caused resident #1 not to receive Cardio Pulmonary Resuscitation when needed. 52, On 11/21/2013 a record review was conducted on resident #1 facility records. It was observed that on 4/10/2009 resident #1 executed a Do Not Resuscitate Order in coordination with her daughter, who was her legal power of attorney. On 6/07/2010 a Memo e-mail was sent to the Emeritus West Administrator advising him that the family wanted the DNRO removed from resident #1 file. The POA stated she would be willing to sign the necessary paper work to do so. On 1/10/2012 a new DNRO policy was signed by the POA and Administrator stating "NO", to the question, "Does resident have a Do Not Resuscitate Order". 53. On 11/21/2013 at approximately 3:08 PM an interview was conducted with staff member E in reference to finding resident #1 unresponsive on 8/15/2013 at 830 AM. According to staff member E resident #1 got up that morning and took her medication and got ready for her normally second seating for brealcfast. She was waiting inside her apartment sitting in her wheelchair waiting for staff to come and take her to breakfast. Staff E stated when he arrived at resident #1 apartment he found her slumped over in her wheelchair. He attempted to get her to respond but she would not. Staff member E immediately went and got help and had staff call for 13 Emergency Medical Services. When he returned to the room, with the assistance of another staff member they lifted resident #1 from her wheelchair and laid her on the floor and checked her breathing, pulse and heartbeat. He stated there was no sign of life. He was about to commence CPR when another staff member pulled resident #1 DNRO file from the 911 folder for the resident and stated do not administer CPR she has a DNRO. 54. On 11/21/2013 during a record review of resident #1 Service Notes it states; EMS arrived and pronounced resident #1 at 8:55 AM. 55. On 11/21/2013 at approximately 4:45 PM during an exit interview with the Administrator, she stated that staff did very thing right with resident #1 except that the DNRO was never removed from her 911 folder. She stated every resident has a 911 folder which goes with them to the hospital and that folder will contain the DNRO if they have one. 56. The Respondent’s actions or inactions constituted an uncorrected class II violation. 57. Class “Il” violations are those conditions or occurrences related to the operation and maintenance of a provider or to the care of clients which the Agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations. § 408.813(2)(b), Fla. Stat. (2012). 58. Under Florida law, the Agency shall impose an administrative fine for a cited class II violation in an amount not Jess than $1,000 and not exceeding $5,000 for each violation. 59, A fine shall be levied notwithstanding the correction of the violation. § 429.19(2)(b), Fla. Stat. (2012). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, seeks to impose an administrative fine of $5,000.00 against the Respondent. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief: 1. Make findings of fact and conclusions of law in favor of the Agency. 14 2. Impose the relief against the Respondent as set forth above. Respectfully submitted on this 17" day of April 2014. /s/ John Bradley __ John E. Bradley, Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Telephone: (727)552-1944 Facsimile: (850) 921-0158 John.Bradle y@ahca.my florida.com NOTICE THE RESPONDENT IS NOTIFIED THAT IT HAS THE RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. SPECIFIC OPTIONS FOR ADMINISTRATIVE ACTION ARE SET OUT IN THE ATTACHED ELECTION OF RIGHTS FORM. THE RESPONDENT IS FURTHER NOTIFIED IF THE ELECTION OF RIGHTS FORM IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED. THE ELECTION OF RIGHTS FORM SHALL BE MADE TO THE AGENCY FOR HEALTH CARE ADMINISTRATION AND DELIVERED TO: AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG 3, MAIL STOP 3, TALLAHASSEE, FL 32308; TELEPHONE (850) 922-5873. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Ekction of Rights form has been served to: Janet Wyman by U.S. Certified Mail, Return Receipt Requested (7004 1350 0004 2776 1533) 9070 SW 80 Street, Ocala, Florida 34481 on this 17" day of April, 2014. . van __/sJohnBradley. John E, Bradley, Assistant General Counsel Florida Bar No. 92277 Office of the General Counsel Agency for Health Care Administration 525 Mirror Lake Drive North 15 St. Petersburg, Florida 33701 Telephone: (727)552-1944 Facsimile: (850) 921-0158 John.Bradle y@ahca.myflorida.com Copy furnished to: Kriste Mennella, Field Office Manager rive P SENDER: COMPLETE THIS: SECTION : Janet Wyman | 9070.SW 80 Street, Ocala; Florida 34481 Ene citus Act Otol west |

Docket for Case No: 14-003131