* JUL-31-00 MON 09:54 AM THE MAGNOLIAS FAX NO. 8504321625 P, 02 UW ww) A yp STATE OF FLORIDA Og “Wy b AGENCY FOR HEALTH CARE ADMINISTRATION “ip, 7°. 4 . <7 a STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO; 02-00-062-NH THE MAGNOLIAS NURSING AND CONVALESCENT CENTER (Pensacola Health Care Services, LLC d/b/a The Magnolias, Respondent, . con / ADMINISTRATIVE COMPLAINT YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from reccipt of this Complaint, the State of Florida, Agency for Health Care Administration (‘Agency’) intends to impose an administrative fine in the amount of $10,000.00 upon The Magnolias Nursing and Convalescent Center (Pensacola Health Care Services, LLC d/b/a The Magnolias). As grounds for the imposition of this administrative fine, the Agency alleges as [ollows: 1. The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part I, Florida Statutes. . JUL-31-00 MON 08:55 AM THE MAGNOLIAS FAX NO, 8504321625 Uo. VU 2. Respondent, The Magnolias Nursing and Convalescent Center, is licensed by the Agency to operate a nursing home at 600 W. Gregory Street, Pensacola, Florida 32501 and is obligated to operate the nursing home in compliance with Chapter 400 Part II, Florida Statutes, and Rule 594-4, Florida Administrative Code. 3. On July 14, 2000 a survey team from the Agency’s Arca 1 Office conducted a complaint investigation and the following Class | deficiency was cited. 3A, Pursuant to 42 CFR 483.13(b), the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion, ‘This requirement was not met as evidenced by the following observations: (1) Based on clinical record review, Resident #6 was admitted to the facility May 19, 2000 with diagnoses which included Reactive Psychosis, Chronic Mental IlIness and Senile Dementia, She was admitted from another nursing facility where she was known to have behavior problems that included wandering, verbal abuse to other residents, slapping residents and other violent behavior. Based on the record, this resident had been denied a nursing home level of care (meaning she was not appropriate for nursing home care) due to her aggressive, inappropriate behaviors. (a) The first Resident Assessment Instrument, dated June 7, 2000, assessed the resident with mood and behavior problems to include wandering into others rooms, verbal and physical abuse, socially inappropriate and resistive to care, Nursing notes and social service notes indicated the resident began exhibiting maladaptive behaviors upon admission. » 03 . JUL-31-00 MON 09:55 AM maps THE MAGNOLIAS FAX NO, 8504321625 CJ ; UY (b) Physician progress notes beginning May 23, 2000 note her agitation and aggressiveness with subsequent notes from the psychiatrist that she is angry, combative and hostile. By June 8, 2000 she js more intrusive and her psychoactive medication was increased. On June 9, 2000 the resident hit another resident and was sent to the hospital for evaluation and admission to a psychiatric unit. {c) The facility placed the resident on an 8-day bed hold. The resident was re-admitted to the facility on June 14, 2000 and began exhibiting behaviors again, particularly wandering in other resident's rooms. There was no documentation that the resident was stable upon return from the psychiatric unit and no evidence the facility addressed her intrusive behaviors. The care plan addressed some hehavior issues but did not speak of interventions used for the intrusive behavior that so often ended in altercations with others. (4) On July 1, 2000 the resident was observed by staff hitting and choking another resident who was wheelchair bound in that resident's room, On July 5, 2000 the resident is noted to have continued behaviors of yelling at people and continually roaming into other residents rooms--not easily’ redirected. Her psychoactive medication was increased. ‘(c) On July 12, 2000 the resident was observed in an altercation with another resident and later in the day she was sent to the hospital for a change in mental status. Interview with hospital staff on July 14, 2000 at 3:30 P.M., revealed the resident "finally settled down and the psychiatrist was continuing to adjust her medication", (f) The facility again put the resident on an 8-day bedhold. Other than increase psychoactive medications, there was no evidence the facility implemented effective measures to prevent further incidents of aggressive behavior between this resident and other facility residents. . 04 - JUL-31-00 MON 09:56 AM THE MAGNOLIAS FAX NO. 8504321625 (g) Interview with three alert and oriented residents on July 14, 2000 at 2:30 p.m, confirmed resident #6 had attacked two residents on the second floor of the nursing home. One of these residents was involved in the choking incident and still had a bruise on her upper right arm from the attack. (h) During an interview at 5:30 p.m. on July 14, 2000, one sampled resident revealed that he/she was awakened on July 12, 2000 at approximately 6:45 am. by resident #6 attempting to enter another resident's room. The resident interviewed called out to resident #6 stating, "Do not go in there, it is not your room and you need to go back to your own room." Resident #6 entered this resident's room using profuse profanity. Resident #6 then proceeded td’ attempt to knock the TV to the floor, (i) The resident who was interviewed also stated that on July 4, 2000 at approximately 3:00 am., resident #6 had come into his/her room, removed a full ice pitcher from the bedside table and struck the resident's sleeping roommate in the forehead. ‘The resident being interviewed called for staff assistance. A staff member came to the room and was able to rouse the roommate only after several attempts. ‘The resident who was interviewed stated that no one from administration had come to discuss the incident, though he/she had told several staff members about the situation, (j) Record review for all three residents involved revealed no documentation of the incident, The resident interviewed is assessed (on the current care plan) as being cognitively intact, with no documentation of behavior concerns, » 05 - JUL>31-00 MON 09:57 AM THE MAGNOLIAS FAX NO. 8504321625 tp, VW (2) Resident #14 was admitted to the facility on March 31, 2000. Review of the clinical record, Social Service notes, Nursing progress notes, History and Physical, and the Incident report and a State reporting form for June 7, 2000, revealed that resident #6 had entered the room of resident #14 at 3:15 a.m., removed the sheet from the bed and placed it on the sink. Resident #14 got out of bed and struck resident #6 in the mouth causing the lip to swell, but with no broken skin. Resident # 14 was sent to a local hospital for evaluation to be admitted to the psychiatric facility located on campus. Resident #14 was returned to the facility with no change in interventions to address volatile behaviors, {a) Social Services notes of June 7, 2000, reveal resident #14 has a history of wandering and combativeness, with many negative behaviors occurring in the previous facility. Review of the history and physical reveal the resident has an above average potential for violence, emotional lability, and is easily agitated. Poor impulse control, history of aggression, and potential! for further aggressive behavior, were also noted as concerns. (b) Resident Assessment Protocol (RAP) summary dated April 14, 2000, triggers the following areas related to mental status for care planning: Cognitive loss, mood state, and behavioral symptoms. Approaches include: refer to psychiatrist for consult as needed, all staff to anticipate and meet needs daily and provide reassurance, monitor for changes in behavior and safety, explain all care, redirect and reorient as needed. (c) Nurses notes dated July 13, 2000, states "wandered hall most of shift with no altercations with other residents." Nurses notes indicate no evidence of care plan alternatives in place to prevent aggressive behavior. ‘ . JUL-31-00 MON 09:57 AM = THE MAGNOLIAS FAX NO, 8504321625 WU. VU (a) ‘Incident report and nursing note dated July 11, 2000 at 12 midnight, indicated that a CNA observed resident #14 in the hall hitting another resident. The other resident responded by hitting resident #14, and causing 3 small skin tears on the right side of the face. Review of documentation indicated both residents had been wandering the hall throughout the shift. The only intervention documented as result of the altercation was both residents received Ativan. No evidence of further approaches to prevent a recurrence of the altercation was documented, (3) Resident #12 was admitted to the facility from a psychiatric hospital on March 31, 2000 with a history of Mood Disorder secondary to multiple etiologies. Review of the last progress note from the psychiatric hospital revealed the resident to have a long psychiatric history with verbal and physical aggression toward staff and residents, to include biting and scratching. The resident was documented as having low frustration tolerance and poor social judgement. The overall conclusion documented on the assessment was that the resident is an above average risk for aggression. (a) Prior to being admitted to the psychiatric facility, the resident had resided in a local nursing home, but was transferred out due to agitation, aggressiveness and combativeness, The current resident assessment revealed the resident to be cognitively classified as having some difficulty in new situations only. Mood indicators are documented as a sad face, and not easily altered. (b) Review of the clinical record revealed entries from April 19, 2000 through June 5, 2000, referring to "Increasing periods of agitation", "will scratch, kick and bite if you get too close", "has become aggressive and will pull other resident's hair or push them out of the way". An order for Ativan 0.5 mg. every 8 hours was obtained in April, with no specific occurrence noted, then on July 3, following an altercation, the dose was increased to a frequency of every four hours. (c) According to the clinical record, the resident historically has not responded to various antipsychotic medications. . OT - JUL+31-00 MON 09:58 AM (4) THE MAGNOLIAS FAX NO, 8504321625 (a4) On June 13, 2000 the resident grabbed a nursing assistant’s arm, causing a 3 to 4" scratch. (e) Nursing notes of July 1, 2000 indicate the resident was involved in an altercation with another resident at which time, while on the elevator with two staff and the other resident, resident #12 bit the other resident's buttocks, causing an abraded area, The bitten resident responded by striking resident #12 in the face. Incident report documentation reflects a final disposition of the incident as "Resident instructed on inappropriateness of behavior.". The clinical record reflects mo further interventions to prevent a recurrence. Resident #1 was originally admitted on Juhe 22, 1999 with a medical history including depression, anxiety and cellulitis of the leg (based on clinical record review), The current care plan indicates the resident's primary concern as "Impaired Coping Skills", evidenced by frequent health related complaints and requests for medications. The current assessment (5-24-00) indicates the resident is independent cognitively with only 1 behavior concern, that of repetitive health complaints. (a) The nurses’ notes from May 12, 2000 through June 24, 2000, reveal no "acting out" or aggressive behaviors. On June 25, 2000, the resident became irate, threw canned formula to the floor and verbally "berated" the staff. On July 1, 2000, after being bitten by another resident, resident #1 slapped the resident and lunged at the resident, requiring physical intervention by staff. (b} On July 12, 2000, resident #1 was observed hitting another resident in the face and head. The other resident was sitting on the floor, hanging on to resident #1's leg. Upon interview at the time, resident #1 explained that upon hearing an argument he/she attempted to intervene and was then attacked by the other resident who attempted to choke him/her. » 08 . JUL-31-G0 MON 09:58 AM THE MAGNOLIAS FAX NO. 8504321625 WwW, Nw, (c) Nursing notes state that Resident #1 was counseled by staff about the inappropriate behavior, On July 15, 2000, resident #1 was seen slapping another resident “over the use of the telephone". The resident was taken out on a Voluntary Baker Act, and returned to the facility 6 hours later. Based on interview with staff, the resident's plan of care was revised July 17, 2000 after 5:00 p.m. to include monitoring on a ‘resident tracking form" every 30 minutes. (a) The clinical record, including the current patient care plan, contains no evidence of revisions and/or interventions to address this resident's recent aggressiveness, (5) Based on resident and staff interviews during both the complaint investigation of July 14, 2000 and the partial extended survey of July 18, 2000, review of mcdical records, incident reports, and reports to the State, it was determined that the facility violated Chapter 400.022(o}, F.S., for failing to prevent occurrences of residents being assaulted by other residents, failing to report the altercations to the appropriate authorities in a timely manner and failing to implement systems to avoid reoccurrence of ongoing resident to resident abuse, resulting in immediate jeopardy. 4, Bascd on the foregoing, The Magnolias Nursing and Convalescent Center (Pensacola Health Care Services, LLC d/b/a The Magnolias has violated the following: a) Tag F223 incorporates 42 CFR 483.13(b) and Section 400.022(0), F.S. The administrative fine imposed for this Class I violation is $10,000.00, S. The above referenced violation constitutes grounds to levy this civil penalty pursuant to Section 400,23(9}(c), Florida Statutes, in that the above referenced conduct of Respondent constitutes a violation of the minimum standards, rules, and regulations for the operation of a Nursing Horne. JUL-31-09 MON 09:59 AM THE MAGNOLTAS FAX NO, 8504321625 NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Florida Statutes, to be represented by counsel {at its expense), to take testimony, to call or cross-cxamine witnesses, to have subpoenas and/or subpoenas duces teciun issued, and to present written evidence or argument if it requests a hearing. In order to obtain a formal proceeding under Section 120.57(1), Florida Statutes, Respondent’s request must state which issues of material fact are disputed. Failure to dispute matcrial issues of fact in the request for a heating, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Stalutes. All requests for hearing should be made to the Agency for Health Cace Administration, Attention: Sam Power, Agency Clerk, Senior Attorney, 2727 Mahan Drive, Mail Stop #3, Tallahassce, Florida 32308. All payment of fines should be made by check, cashier’s check, or money order and payable to the Agency for Health Care Administration. All checks, cashicr’s checks, and money orders should identify the AHCA number and facility name that is referenced on page 1 of this complaint. All payment of fines should be sent to the Agency for Health Care Administration, Attention: Christine T. Messana, 2727 Mahan Drive, Mail Stop #3, Tallahassee; Florida 32308-5403. JUL-31-00 MON 10:00 AM = THE MAGNOLIAS FAX NO. 8504321625 Pe ft RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY YHE AGENCY, 5 ~ “day QQ, 2000. C Aral \ Donah Heiberg * Field Office Manger, Area #1 Agency for Health Care Administration Health Quality Assurance 2639 N. Monroe Street, Suite 208 Tallahassee, Florida 32303 Issued this ¢ CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that the original complaint was sent by U.S. Mail, Retum Receipt Requested, to: Administrator, The Magnolias Nursing and Convalescent Center {Pensacola Health Care Services, LLC d/b/a The Magnolias, 600 W. Gregory Street, Pensacola, Florida 32501 on this 2 “lteday of » shy , 2000. ° Christine T. Messana, Esquire Office of the General Counsel smo

Docket for Case No: 00-003494