STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2015001966 CANA CORPORATION d/b/a THE VINEYARD INN., Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, Cana Corporation d/b/a The Vineyard Inn ( the “Respondent”), pursuant to Section 120.569 and 120.57, Florida Statutes (2014), and alleges: NATURE OF THE ACTION This is an action against the Respondent’s assisted living facility license to impose an administrative fine for $5,000.00 based upon one Class II deficiency. PARTIES 1. 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. 2. The Respondent operates a licensed assisted living facility located at 10929 Ridge Road Seminole, Florida 33778 and was at all times material required to comply with all applicable state and federal rules and statutes. COUNT I SUPERVISION 3. Under Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. Facilities shall offer personal supervision, as appropriate for each resident, including the following: (a) Monitor the quantity and quality of resident diets in accordance with Rule 58A-5.020, F.A.C. (b) Daily observation by designated staff of the activities of the resident while on the premises, and awareness of the general health, safety, and physical and emotional well-being of the individual. (c) General awareness of the resident’s whereabouts. The resident may travel independently in the community.(d) Contacting the resident’s health care provider and other appropriate party such as the resident’s family, guardian, health care surrogate, or case manager if the resident exhibits a significant change; contacting the resident’s family, guardian, health care surrogate, or case manager if the resident is discharged or moves out.(e) A written record, updated as needed, of any significant changes as defined in subsection 58A-5.0131(33), F.A.C., any illnesses which resulted in medical attention, major incidents, changes in the method of medication administration, or other changes which resulted in the provision of additional services. 58A-5.0182(1), Fla. Admin Code. 4. On or about February 2, 2015, the Agency conducted a complaint survey of the Respondent. 5. Based on interview and record review the facility failed to provide proper care and services ,including personal supervision, appropriate to meet the needs for one (Resident #1) of three Residents to prevent falls. 6. Survey findings include the following facts: A review of closed record for Resident #1, conducted on 2/2/15, of the health assessment dated 9/3/14 revealed a medical history and diagnoses of abnormality of gait, lack of coordination, diabetes with neuropathy and dementia. The physical limitation section was left blank and the nursing/treatment/therapy service required revealed HHC (home health care) for left foot wound. The activities of daily living section revealed; Ambulation- S (needs supervision) with ambulation and notes "needs reminders to use cane/walker" and bathing S with a note "SBA (Stand by Assistance) for safety." Review of the staff observation notes dated 8/28- 9/4/14 indicated the resident was forgetful to use cane or walker. A note dated 10/6/14 by the DON revealed "On 10/4/14 at approximately 8:35 a.m. resident was FOF (found on the floor) at base of stairs". A Resident Aide reported earlier in the day the resident was seen following a female resident up the stairs to the second floor. A few minutes later, the resident was seen leaving a female resident's room area. A dietary aide stated around 8:30 a.m. she was _ escorting EMS (Emergency Medical Services) up the staircase room when she saw the resident coming down the last section of stairs and seconds later they heard a "thud" and resident was lying on the floor at the base of the stairs. Review of the medical records of the initial psychological evaluation dated 8/28/14 revealed behaviors such; obsessive, excessive anxiety, restless, trembling/shaking, confused and poorexecutive functioning, disruptive behavior, psychosis and dementia. Review of the Resident #1's paramedic run sheet, dated 10/4/14, revealed a narrative note at 9:00 a.m. for Resident #1 revealed he had "A witnessed fall down a flight of 5 steps at about 4 feet. Witness reports a + LOC (positive loss of conscious) post fall. Patient (Resident #1) is confused and staff states that he may be more confused than his baseline." Review of the hospital emergency room physician's notes, dated 10/4/14 at 10:40 a.m., revealed the resident sustained a fall down the flight of stairs at the assisted living facility. In the Emergency Department the resident received a CT (computed tomography) scan of his brain which revealed acute subarachnoid hemorrhage (brain bleed), intracranial hemorrhage (brain bleed), right temporal bone (skull) fracture, respiratory failure secondary (cardiac arrest) to traumatic brain injury status. The cardiac arrest occurred during the emergency room evaluation and while in the CT. The Resident was transferred to the ICU (Intensive Care Unit) on vent support. Other documented injuries and observations from the emergency room physician revealed blood coming from his right ear, abrasions over the occipital (at the back of the head) scalp, abrasions over both hands and elbows, with an amputated big toe on his left foot which had a small shallow ulcerated (sore) area measuring 2.5 centimeters. The resident went into cardiac arrest during CT scans at 12:00 p.m. The Resident's past medical history revealed diagnoses including, but not limited to, diabetes, diabetic neuropathy, and Alzheimer's dementia, acute osteomyelitis of the left foot and on the following medications ciprofloxacin, clindamycin, Plavix, carvedilol, atorvastatin, aspirin, metformin, synthroid, donepezil and quetiapine. The "Discharge Summary" revealed the resident's "condition remained unchanged and he had limited improvement in his neurological status and was initiated on Provigil on 10/9/14. It was noticed that his (residents) vital signs and diagnostic imaging have remained unchanged. The resident was discharged to Hospice care." In an interview on 2/2/15 at 10:30 a.m. with the Administrator, she stated that she considered all of the residents as assisted in the facility. Interview with the DON confirmed on 10/4/14 that the elevator was not working and fire rescue was called to the facility due to the elevator not functioning. She confirmed that staff were not monitoring the stairs and the doors to the stairs and did not have a monitoring device. She further confirmed Resident #1 fell while walking unattended up the stairs while the elevator was not available for use. She added the resident fell from the first step and hit his head and sustained a head laceration and he was sent out to the hospital by ambulance and later died. Interview with DON on 2/26/15 at 11:50 a.m. confirmed the health assessment for Resident #1 indicated that he needed supervision for ambulation. She stated the needs supervision "usually assistance just means to remind them (the residents) to use their walkers or canes." The DON further added they (the facility) wouldn't allow canes or walkers on the stairs and that the main stairs were not monitored on a regular basis to stop residents from using them and the stairs were not roped off or blocked. Review of the facility policy; Standards services to meet the Resident's needs policy stated "The Vineyard Inn will provide personal supervision as appropriate for each resident, including the following as needed." Bullet #2 read "observing resident's daily for general health, safety, and well-being of the Resident" and Bullet #3, be aware of the resident's general whereabouts." Interview with the DON stated the policy basically meant the staff would give verbal reminders to use their walkers or cane but the staff did not escort residents around. The DON reviewed two health assessment records for Residents #1 & #2 which revealed "assisted" in ambulation or all other ADL's. The DON stated staff are there to help with their baths but remind the residents to use their walkers or canes. The DON added, "I do not interpret that to mean to help them walk." Sanction 7. 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 present an imminent danger to the clients of the provider or a substantial probability that death or serious physical or emotional harm would result therefrom. The condition or practice constituting a class I violation shall be abated or eliminated within 24 hours, unless a fixed period, as determined by the agency, is required for correction. The agency shall impose an administrative fine as wo! ~ provided by law for a cited class I violation. A fine shall be levied notwithstanding the correction of the violation.§ 408.813(2)(a), Fla. Stat. (2014). 8. Under Florida law, the Agency shall impose an administrative fine for a cited class I violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. § 429,19(2)(b), Fla. Stat. (2014). Wherefore the Petitioner, State of Florida, Agency for Health Care Administration, seeks an administrative fine against the Respondent in the amount of $5,000.00. /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 St Petersburg, Florida 33701 Phone: (727) 552-1944 John.Bradley@ahca.myflorida.com NOTICE The Respondent is notified that it/he/she has the right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes. If the Respondent wants to hire an attorney, it/he/she has the right to be represented by an attorney in this matter. 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, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to the below named persons/entities by the method designated on this 19 day of May 2015. 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 St Petersburg, Florida 33701 Phone: (727) 552-1944 John.Bradley@ahca.myflorida.com Pat Caufman, Field Office Manager Local Field Office Agency for Health Care Administration (Electronic Mail) Sandra Bollenback Administrator The Vineyard Inn 10929 Ridge Road . Seminole, Florida US. Certified Mail - (7010 0780 0001 9836 2602) Catherine Avery, Unit Manager Licensure Unit Agency for Health Care Administration (Electronic Mail) STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Re: The Vineyard Inn AHCA No. 2015001966 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed agency action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights may be returned by mail or by facsimile transmission, but must be filed within 21 days of the day that you receive the attached proposed agency action. If your Election of Rights with your selected option is not received by AHCA within 21 days of the day that you received this proposed agency action, you will have waived your right to contest the proposed agency action and a Final Order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter120, Florida Statutes, and Chapter 28, Florida Administrative Code.) Please return your Election of Rights to this address: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. 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 facts and law contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint and I waive my right to object and to have a hearing. [| understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where J may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3) I dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I 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 to the Agency for Health Care Administration on behalf of the licensee referred to above. 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Docket for Case No: 15-003731