STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No.: 2014005905 MERRITT ISLAND RHF HOUSING, INC. d/b/a COURTENAY SPRINGS VILLAGE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint Merritt Island RHF Housing, Inc. d/b/a Courtenay Springs Village against (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2013), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing May 12, 2014, and ending June 23 , 2014, and to impose an administrative fine in the amount of ($7,500.00) based on three Class II deficiencies. JURISDICTION AND VENUE 1, The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2013). 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 II, and 408, Part H, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. _ 4. Respondent operates a (96) bed nursing home, located at 1100 South Courtenay Parkway, Merritt Island, Florida 32952 and is licensed as a skilled nursing facility license number 11070961. 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 6. The Agency re-alleges and incorporates paragraphs one (1) through (5), as if fully set forth herein. 7. 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 receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities, and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. § 400.022(1)(), Fla. Stat. (2012). 8. That Florida law provides the following: “Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. A practical nurse is responsible and_accountable for-making_ decisions-that-are_based-upon-the-individual’s educational preparation and experience in nursing.” § 464.003(19), Fla. Stat. (2012). 9. On or about June 14, 2014, the Agency completed a complaint survey of the Respondent’s facility. 10, Based on interviews and record review, the facility failed to ensure that residents were free from significant medication errors for 2 of 43 residents reviewed for medication administration (#1 & 2). 11. Resident #1 was admitted to the facility with a history of cerebral vascular accident and hypertension. The resident's admission medications orders included Cardizem 60 milligrams (mg.) every 6 hours for hypertension, Metoprolol 25 mg. twice daily for hypertension, hold if systolic less than (<) 100, Coumadin 5 mg. daily for prevention of deep vein thrombosis, and Aspirin 81 mg. daily for cerebral vascular accident. The resident was receiving all nutrition and medications via gastrostomy tube. 12. His blood pressure at admission at 5 PM was 132/78 and pulse was 68. A review of the medication administration record (MAR) showed that Cardizem which was prescribed every 6 hours was transcribed as the same but the administration times were every 4 hours: 1 AM, 5 AM, 9 AM, 1 PM, 5 PM, and 9 PM, and not every 6 hours as ordered. The resident received the first dose of Cardizem 60 mg. at 9 PM on 4/18/14. He received another dose on 4/19/14 at 1 AM which was 4 hours later. Another dose was signed as given at 5 AM on 4/19/14 but a late entry documented that the nurse forgot to circle the MAR indicating not given. 13. A nurses's progress note dated 4/19/14 at 4 AM read that "blood pressure (BP) 98/62 and pulse (P)118." The note further read, "BP-97/44, P-75." At 8:35 AM, "BP-82/49" and at 8:40 AM, "BP-70/47." The resident was unresponsive and 911 was called. The resident was transferred to hospital and was admitted with hypotension and pneumonia. 14, There was no documentation to reflect whether the attending physician, the emergency room physician or the family were informed that the resident received at least 2 doses of Cardizem within 4 hours. The resident returned to the facility 8 days later. 15. An interview was conducted with the director of nursing on 5/13/14 at 12 PM. She stated that both the nurse who transcribed the wrong times and the nurse who gave the medication were both given verbal warnings on 4/22/14. 16. Review of the medical record for resident #2 revealed she was admitted to the facility on 5/02/14 with diagnoses including convulsions. Review of the 5/02/14 physician discharge orders and instructions from the hospital revealed an order for Levetiracetam (Keppra) 500 milligram (mg.), 2 tablets orally (po), 2 times a day (BID). 17. Review of resident #2 admission physician order sheet (POS) from the facility, dated 5/02/14, revealed an hand written order by licensed practical nurse (LPN) #F for Keppra 500 mg. po, | tablet twice a day for seizures. 18. Review of resident #2 May 2014 medication administration record (MAR) revealed a hand written entry for Keppra 500 mg. po BID. The MAR revealed that resident #2 received (17) doses of Keppra 500 mg. po, BID between 5/02-10/14. 19. Review of resident #2 February 2014, March 2014, and April 2014 MAR revealed she received Keppra 1000 mg. po, twice a day for seizures. 20. Review of the nurse's note, dated 5/10/14, revealed that on 5/10/14 at 6:30 PM, the resident #2 complained of tingling in her left arm and discomfort in her left leg. She was extremely short of breath, her face was red, and she was extremely anxious. Her blood pressure was 187/94, heart rate 152, respiratory rate 25, and oxygen level on 3 liters of nasal oxygen was 93%. The resident experienced_uncontrollable_extremity_movements_and_was frightened.—_The resident asked to go to the hospital. 21. Review of the physician order sheet dated 5/10/14 revealed an order to send resident to emergency room for evaluation and treatment. The resident remained in the hospital as of 5/14/14, the date of the survey. 22. In an interview with the administrator and director of nursing (DON) conducted on 5/13/14 at 11:20 AM revealed that they were aware that resident #2 was sent to the hospital with shaking and tingling of left arm and leg. The DON revealed that she found the Keppra medication error when reviewing resident #2 medical record after she was sent to the hospital. 23. The Respondent’s actions or inactions constituted an isolated Class II deficiency. 24. A Class II deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. §400.23(8)(b), Fla. Stat. (2013). 25. A Class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine shall be levied notwithstanding the correction of the deficiency. §400.23(8)(b), Fla. Stat. (2013). wwe WHEREFORE, the Petitioner, State of Florida, Agency for Health .Care Administration, intends to impose an administrative fine against the Respondent in the amount of $2,500.00. COUNT I Failure to follow Physicians Orders 26. The Agency re-alleges and incorporates paragraphs one (1) through five (5). 27. _ Under Florida law, pursuant to Rule 59A-4.107(5), Florida Administrative Code, 1) Each nursing home facility shall retain, pursuant to a written agreement, a physician licensed under Chapter 458 or 459, F.S., to serve as Medical Director. In facilities with a licensed capacity of 60 beds or less, pursuant to written agreement, a physician licensed under Chapter 458 or 459, F.S., may serve as Medical Consultant in lieu of a Medical Director. (2) Each resident or legal representative, shall be allowed to select his or her own private physician. (3) Verbal orders, including telephone orders, shall be immediately recorded, dated, and signed by the person receiving the order. All verbal treatment orders shall be countersigned by the physician or other health care professional on the next visit to the facility. (4) Physician orders may be transmitted by facsimile machine. It is not necessary for a physician to re-sign a facsimile order when he visits a facility. (5) All physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift. (6) Each resident shall be seen by a physician or another licensed health professional acting within their scope of practice at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. If a physician documents that a resident does not need to be seen on this schedule and there is no other requirement for physician’s services that must be met due to title xviii or xix, the resident’s physician may document an alternate visitation schedule. (7) If the physician chooses to designate another health care professional to fulfill the physician’s component of resident care, they may do so after the required visit. All responsibilities of a physician, except for the position of medical director, may be carried out by other health care professionals acting within their scope of practice. (8) Each facility shall have a list of physicians designated to provide emergency services to residents when the resident’s attending physician, or designated alternate is not available. ; 28. On or about June 14, 2014, the Agency conducted a complaint investigation of the wwe" Respondent. 29.—Based on interview-and-record-review-the facility-failed-to-meet-professional Standards of —————— ’ Quality Nursing Care as per the Nurse Practice Act by failing to follow physician orders in giving medications for 1 of 43 residents sampled for medication review (#1). 30. Resident #1 was admitted to the facility with a history of cerebral vascular accident and hypertension. The resident's admission physician orders included Cardizem 60 milligrams (mg.) every 6 hours for hypertension. 31. A review of the May 2014 medication administration record (MAR) showed that Cardizem which was prescribed by the physician every 6 hours was transcribed as the same but the administration times were every written every 4 hours: 1 AM, 5 AM, 9 AM, 1 PM, 5 PM, and 9 PM. The resident received the first dose of Cardizem 60 mg. at 9 PM on 4/18/14. He received another dose on 4/19/14 1 AM which was 4 hours later. 32. A nursing progress note dated 4/19/14 at 4 AM read that "blood pressure (BP) 98/62 and pulse (P)118." The note further read, "BP-97/44, P-75." At 8:35 AM, "BP-82/49" and at 8:40 AM, "BP-70/47." The resident was unresponsive and 911 was called. The resident was transferred to hospital and was admitted with hypotension. 33. | An interview was conducted with the director of nursing on 5/13/14 at 12 PM. She stated that both the nurses involved in the medication error were given verbal warning for not following the physician order for the medication, Cardizem. 34, The Respondent’s actions or inactions constituted an isolated Class II deficiency. 35. A Class II deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan er 7 of care, and provision of services. §400.23(8)(b), Fla. Stat. (2013). 36.__A Class II deficiency is subj ect_to_a_civil_penalty_of $2,500-for-an-isolated_deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine shall be levied notwithstanding the correction of the deficiency. §400.23(8)(b), Fla. Stat. (2013). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of $2,500.00. COUNT II 37. Under Florida law, the 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. 38. On or about June 14, 2014, the Agency conducted a Complaint investigation of the Respondent. 39:. Based on record review and interview the facility failed to assure a system for accurately transcribing physician's medication orders for 3 of 43 residents reviewed for medication administration (#1, 2 & 3). 40. Resident #1 was admitted to the facility with a history of cerebral vascular accident and hypertension. The resident's admission medications orders included Cardizem 60 milligrams (mg.) every 6 hours for hypertension. His blood pressure at admission at 5 PM was 132/78 and pulse was 68. 41. A review of the medication administration record (MAR) showed that Cardizem, prescribed every 6 hours, was transcribed_as_the-same_but the administration-times_were_written. every 4 hours: 1 AM, 5 AM, 9 AM, 1 PM, 5 PM, and 9 PM instead of every 6 hours. The resident received the first dose of Cardizem 60 mg. at 9 PM on 4/18/14. He received another dose on 4/19/14 at 1 AM, which was 4 hours later. Another dose was signed as given at 5 AM on 4/19/14 but a late entry documented that the nurse forgot to circle the MAR indicating not given. 42. A nursing progress note dated 4/19/14 at 4 AM read that "blood pressure (BP) 98/62 and pulse (P) 118." The note further read, "BP-97/44, P-75." At 8:35 AM, "BP-82/49" and at 8:40 AM, "BP-70/47." The resident was unresponsive and 911 were called. The resident was transferred to hospital and was admitted with hypotension. There was no documentation: to reflect whether the attending physician, the emergency room physician or the family were informed that the resident received at least 2 doses of Cardizem within 4 hours in error. 43. An interview was conducted with the director of nursing on 5/13/14 at 12 PM. She stated that both the nurse who transcribed the medication incorrectly and the nurse who administered the medication in error were both given verbal warnings on 4/22/14. 44. — Resident #3 was admitted to the facility with a history of atrial fibrillation. A review of the physician orders showed an order for Cardizem 90 mg. 4 times daily by mouth for hypertension at 6 AM, 12 PM, 6 PM, 12 AM, hold for systolic blood pressure less than (<) 100 or heart rate <60. Another physician order was Cordarone 200 mg. twice daily for atrial fibrillation, hold for systolic blood pressure <100 or heart rate <60. 45. A review of the MAR showed that that blood pressure and heart rate were being monitored for the times that Cardizem was given at 12 AM, 6 AM, 12 PM and 6 PM but not being monitored before Cordarone was given at 9 AM and 9 PM. 46. __An interview was conducted with the director_of nursing on 5/13/14 at 12:30 PM. She verified that the medication was not given accurately as per physician order. 47. Review of the medical record for resident #2 revealed she was admitted to the facility on 5/02/14 with diagnoses including convulsions. Review of the 5/02/14 physician discharge orders and instructions from the hospital revealed an order for Levetiracetam (Keppra) 500 mg., 2 tablets orally (po), 2 times a day (BID). 48. Review of resident #2 admission physician order sheet (POS) dated 5/02/14 revealed a hand written order by licensed practical nurse (LPN) #F for Keppra 500 mg. po | tablet twice a day for seizures. The order for Keppra upon admission to the facility was one tablet and not two tablets. 49. Review of resident #2's May 2014 MAR revealed a hand written entry for Keppra 500 mg. | tablet po, BID. The MAR revealed that resident #2 received (17) doses of Keppra 500 mg. po twice a day between 5/02-10/14. 50. Review of the nurse's note, dated 5/10/14, revealed that on 5/10/14 at 6:30 PM, resident #2 complained of tingling in her left arm and discomfort in her left leg. She was extremely short of breath, her face was red, and she was extremely anxious. Her blood pressure was 187/94, heart rate 152, respiratory rate 25, and oxygen level on 3 liters of nasal oxygen was 93%: The resident experienced uncontrollable extremity movements and was frightened. The resident asked to go to the hospital. 51. Review of the physician order sheet dated 5/10/14 revealed an order to send the resident to emergency room for evaluation and treatment. The resident remained in the hospital as of 5/14/14, the date of the survey. 52. In an interview conducted on 5/13/14 at 11:20 AM, the director of nursing (DON) revealed the Keppra error_was_caused_by_a_transcription-error_—The-DON_stated_that_LPN-#F received counseling related to incorrectly transcribing medications. 53. The Respondent’s actions or inactions constituted an isolated Class II deficiency. 54. A Class II deficiency is a deficiency that the Agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. §400.23(8)(b), Fla. Stat. (2013). 55. A Class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine shall be levied notwithstanding the correction of the deficiency. §400.23 (8)(b), Fla, Stat. (2013). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of $2,500.00. COUNT IV 56. Based upon Respondent’s three cited State Class II deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(a), Florida Statutes (2013). 11 WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a-skilled nursing facility_in the State_of Florida, pursuant to_§ 400.23(P),-Florida Statutes (2013) commencing May 12, 2014, and ending June 23, 2014. Respectfully submitted this 5 day of August, 2014. _/s/JohnEliotBradley John Bradley, Esquire Fla. Bar. No. 92277 Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1947 (office) 727.552.1440 (facsimile) John.Bradley@ahca.myflorida.com DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2011), Respondent shall post the most current license in a prominent place that is in clear and unobstructed public view, at or near, the place where residents are being admitted to the facility. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 412-3630. RESPONDENT IS 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No: (7010 0780 0001 9836 2640) Jessica Pierre, Administrator, Courtenay Springs Village, 1100 South Courtenay Parkway, Merritt Island, Florida 32952 on this 5 day of August, 2014. John Eliot Bradle John Eliot Bradley, Esquire Copy furnished to: Theresa DeCanio, Field Office Manager, Agency for Health Care Admin. Bernard Hudson, Long Term Care Unit Manager, Agency for Health Care Admin. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: MERRITT ISLAND RHF HOUSING, INC. d/b/a ACHA No. 2014005905 COURTENAY SPRINGS VILLAGE ELECTION OF RIGHTS This Election of Rights form is attached to an Administrative Complaint. It may be returned by mail or facsimile transmission, but must _be received by the Agency Clerk within 21 days, by 5:00 pm, Eastern Time, of the day you received the Administrative Complaint. If your Election of Rights form or request for hearing is not received by the Agency Clerk within 21 days of the day you received the Administrative Complaint, you will have waived your right to contest the proposed agency action and a Final Order will be issued imposing the sanction alleged in the Administrative Complaint. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights form to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: 850-412-3630 Facsimile: 850-921-0158 PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of fact and conclusions of law alleged in the Administrative Complaint and waive my right to object and to have a hearing. I understand that by giving up the right to object and have a hearing, a Final Order will be issued that adopts the allegations of fact and conclusions of law alleged in the Administrative Complaint and imposes the sanction alleged in the Administrative Complaint. OPTION TWO (2) I admit to the allegations of fact alleged in the Administrative Complaint, but wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed agency action is too severe or that the sanction should be reduced. OPTION THREE (3) I dispute the allegations of fact alleged in the Administrative Complaint and request a formal hearing (pursuant to Section 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed agency action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1, The name, address, telephone number, and facsimile number (if any) of the Respondent. 2. The name, address, telephone number and facsimile number of the attorney or qualified representative of the Respondent (if any) upon whom service of pleadings and other papers shall be made. 3. A statement requesting an administrative hearing identifying those material facts that are in dispute. If there are none, the petition must so indicate. 4. A statement of when the respondent received notice of the administrative complaint. 5. A statement including the file number to the administrative complaint. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. Licensee Name: Contact Person: Title: Address: Number and Street City Zip Code Telephone No. Fax No. E-Mail (optional) I hereby certify that I am duly authorized to submit this Election of Rights form to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Printed Name: Title: 15

Docket for Case No: 14-005239