ABR RL ee eee Voreo Fr .uwMerule ruees ( \w/ ww STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, ig Uf a: Wp, Oo “4g Petitioner, OS “by vs. AHCA NO: 01-00-q64-NH CROSS CREEK NURSING & \ CONVALESCENT CENTER, : Respondent. ‘ / 4 ADMINISTRATIVE COMPLAINT i YOU ARE HEREBY NOTIFIED that after twenty-one (21) days from receipt of this Complaint, the State of Florida, Agency for Health Care Administration (“Agency”) intends to impose an administrative fme in the amount of $4,000.00 upon Cross Creek Nursing & Convalescent Center. As grounds for the imposition of this administrative fine, the Agency alleges as follows: { } 1. | The Agency has jurisdiction over the Respondent pursuant \ { 2. Respondent, Cross Creek Nursing & Convalesceng Center, is to Chapter 400 Part I], Florida Stanutes. licensed by the Agency to operate a nursing home at 10040 Hillview | Road, Pensacola, Florida 32514 and is obligated to operate the nursing home in compliance with Chapter 400 Part , Florida Stannes, and Rule 594-4, Florida Administrative Code. | I ("789 P.003/017 = F-225 w yw 3. On September 2, 1999 a survey team from the Agency’s Area 1 Office conducted a survey and the following Class TI] deficiyncies were cited. 3A. Pursuant to 42 CFR 483.15(a), the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality. This requirement was not met as eviderlced by the following observations: : (1} Resident #18 was observed to he urinating in the facility courtyard on August 31, 1999 at 3:00 p.m. and again on September 2, 1999 at 8:15 am. Although the resident’s care plan stated to “encourage resident not ‘to void in inappropriate places,” observations during thei first three days of the survey revealed the resident spending ‘most of the day unsupervised in the facility courtyard. ! (2) On September 1, 1999 at 2:20 p.m., an ‘unsampled resident was observed laying in bed with his/her entre backside exposed, the hall deor only partially iclosed and within full view of individuals passing by. (3) Observation of resident #2 an August 30, 1p99 at 9:15 a.m, during tour of the facility revealed the resident lying in ped with no clothes or sheet covering her. The door was open and the curtain was pulled to the end of the bed. The resident was exposed ta her roommate and anyone walking into the ream. Staff was with her in the room. (4) Based on observation, it was determined that the facility violated Rule S9A-4.1288, F-.A.C., for failing to ensure the dignity and respect of 2 of 28 sampled resiqents and 1 unsampled resident. 7-789 -P.004/017 w uw: 3B. Pursuant to 42 CFR 483.20(k), the faciliry must develop a i) comprehensive care plan for each resident that includes measurable ( . objectives and timetables to meet a resident’s medical, nursing, and , mental and psychosocial needs that are identified in the conjprehensive : ; . | . assessment. This requirement was not met as evidenced by the following observations: (1} Resident #10 was receiving the medication Risperdal. The care plan dated July 7, 1999 and the Resident Assessment Protocol (RAP) summary dated July 5, 1999 for Psychotrepic Drug Use stated “Do not proceed: See ADL care plan for approaches to moniter medication and behavior." i (a) Review of the ADL care plan revealed no documented approaches for monitoring theiside effects of psychotropic drug use as of August’ 30, 1999. Interview with staff revealed that these approaches had been forgotten and was corrected at the time of survey... . | (2) Record review and observation revealed resident #4 had a Stage III pressure sore on her coccyx and iStage II on burtocks when she was hospitalized on June 1}, 1999 for diabetes. The resident has'a diagnosis of MS and:spends her days propelling self in a wheelchair. (a) Care plans done June 29, 1999 had one intervention “wound care nurse to monitor skin conditions per protocol under problem #12 nurition." The Pressure Sore RAP was triggered and “proceed with care plan" was dacumented; however, no care plan for pressure sores was in the resident's record. (b) Observation on September 1, 1999 'at 10 a.m. revealed the pressure sores healed, but four areas of past breakdown were evident. The facility did not have a comprehensive care plan to prevent further breakdown or treat past pressure sores. F-225 3C. T-789 =P 005/017 \w w (3) Resident #7 experienced a 12 pound weight loss between January and August 1999. A care plan written November 10, 1998 addressing the resident's “Alteration in ADL function" had interventiong regarding = the encouragement of meals and supplements and: offering of substitutions. t 4 (a) On September 2, 1999, additional interventions were added which included increasing the frequency af the supplements and increased supervision with meals. The resident's care plan did mot identify problems specific to weight loss nor did! it inchide measurable objectives and goals relating:to his/her weight. ‘ (4) Through observation, record review and interview, it was determined that the facility violated Chapter 400.2(3)(1)(), F.S. and Rule 59A-4.106(2), F.A.C., for failing to ensure thar the comprehensive care plans for 3 out of 28 sampled residents inclhided measurable objectives and timetables to meet the resident's medical, nyrsing and mental and psychosocial needs. , Pursuant to 42 CFR 483.25(c}, based on the comprchensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop préssure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary - . . ° ' treatment and services to promote healing, prevent Infection and prevent any new sores from developing. This requirement was pot met as evidenced by the following observations: ‘ 4 (1) Record review revealed that resident #1 was admitted to the facility on August 12, 1998 with diagnoses of IDDM, HTN, arthritis, asteoparosis, COPD, chronic skin ulcers and anemia, The resident weighed 108 Ibs. in January 1999 and had gone to 92 lbs. (89 Ibs. in weight loss book) by August 1999. | F225 (2) T7789 P. 006/017 1 (a) Review of the weckly decubitus reports revealed a stage Il pressure sore was found April’ 16, 1999. Wound care progress note of July 27, 1999 states "extensive undermining in her sacral pressure sore. Request consult with surgeon.” Nurse's notes of August 20, 1999 state "Coccyx 1.0 x 0.5 x|1.5" and a note on August 27, 1999 states "1.5 cm x }.0 x .5 erm undermining 2.3. cm." Interview with! sraff on September 1, 1999 at 10 a.m. revealed "This mattress has low pressure, I know this is from poor nutrition.” (b}) Observations on August 30, 1999 at 9:30 a.m., 1 p.m. and 3:05 p.m. and on August 31, 1999 at 8 a.m., 8:30 a.m., and 3:30 p.m. revealed the residenr to he lying on her back. Interview with the resident at 3:30 p-m. on August 31, 1999 revealed "No, they don't roll me over." : (c} Observation at 10 a.m. on September 1, 1999 revealed the resident to be lying on her back and when staff rolled her over, liquid feces was on and between her buttocks. The resident had a stage Ij] pressure sore on her coccyx measuring 1 x1.5 em with extensive undermining. (a) The resident was assessed as being lat risk for pressure sores and caré plans of May 18,-1999 and August 5, 1999 include interventions 1) keep resident turned from side to side - wedge for positioning, 2) Prime air mattress, 3) treatment as ordered, 4) MVI and zinc as ordered 5) keep clean and dry - rurn side ta side every 2 hours, 6) wound care center 2 times per month, 7) up in chair bi-weekly as tolerated. The facility did not prevent a pressure sore from ‘developing and did not consistently implement interventions of positioning the resident off the pressure area as identified in her plan of care. Record review revealed that resident #2 has had a pressure sore on her left trochanter since April of 1996. An MDS assessment completed on February 29, 1999) revealed a Stage Il] pressure sore measuring 1.8 x 2.0 x 0.] em. The resident has had a Foley catheter since at least February 1999 to promote healing. F~225 OVE CE CUVY Te -NSPI rrom= 7-789 P.007/017 F225 \w ~~ (a) A review of monthly weights reveal the resident has lost 14 lbs. since January 1999. Nurse’s notes on March 23, 1999 revealed (late entry for 2/23/99) "L. trochanter decubutus reduced in size - continues to have excoriations on burtocks."” Notes om April 12, 1999, May 8, 1999, and June 8, 1999 say the same. On August 1999, notes state “treatment to L. trochanter as ordered and treatment to abyaised area on buttocks. Left trochanter area 3.0 x 2.0 x 2.0 cm, Foot healed.” t (o) The resident was hospitalized on August 9, 1999 for a UTI and septicemia according to the hospital discharge summary. A care plan written August 18, 1999 included interventions of: 1) keep resident clean and dry, 2) weekly skin assessments, 3) !administer MvI, Vit C, and tube feeding, 4) turning sheet to prevent friction. (c) Observation on August 30, 1999 at 9:15 am. during the initial tour of the facility rdvealed the resident lying in bed on her left side, with no clothes or sheet, with feces on her buttecks. (a) ‘Interview with staff on September 4, 1999 ar 10:30 a.m. revealed "She has had this for 4 years (regarding pressure sores). We almost had it healed but her family demanded we keep her up in the chair too long." There were no interventions on the care plan to turn resident or ta address the approach to the family. : (e) Observation on September 1, 1999 ari 10:30 a.m. revealed a Stage II] pressure sore on the left trochanter measuring 3 cm x 2 cm x 2 cm deep. The facility did nat care plan necessary interventions to promote healing of the pressure sore nor did they consistently implement the interventions established. (3) Based on observation, interview and record review, it was determined that the facility violated Rule 49A-4.1288, F.A.C., for failing to ensure that 2 of 28 sampled residents did nat develop pressure sores or received pppropriate treatment to promote healing of pressure sores. 1 T-789 — P.008/017 \w ww 3D. Pursuant to 42 CFR 483.65(a}(1)-(3), the facility must establish an infection control program under which it investigates, controls, and prevents infections in the facility; decides what procedures, such as isolation should be applied to an individual resident; and maintains a record of incidents and corrective actions | related to infections. This requirement was nat met as evidenced by the following . 4 observations: ; i (1) On August 31, 1999 an unsampled resident was observed on the 100 Hall with a tracheostomy. | A suction catheter was abserved laying on the top of the |nightstand only partially contained in a paper bag. This catheter was observed at 8:30 a.m., 10:00 a.m., 1:30 p.m. and 3:30 p.m., at which time a staff nurse was informed of the unsterile catheter and it was replaced. (a) On September 1, 1999, at 3:00 p.m:, a suction catheter was again observed on the ‘nightstand uncovered. On September 2, 1999, at 2:30,p.m., there was an opened suction kit on the bedside table and the suction catheter again on the nightstand uncovered. {h) Review of the faciliny Focused Compliance Rounds form on Maintenance of Traqhenstomies revealed that criteria includes equipment heing changed every 24 hours, sterility heing maintained with all catheters and sterile technique being used for suctioning/cleaning. The facility did not follow their policy and procedure for preventing infection. facility violated Rule S9A-4.106(3), (4) and (I), |F.A.C., for failing to follow their infection cantrol program r arding the maintenance of tracheastomies in 1 unsampled resident, and in the development of corrective action for identified infections. (2) Based on observation, it was aa he that the F-225 T-789—P.009/017 WW ww 4. On June 21, 2000 a survey team from the Ageney’s Area 1 Office conducted a survey and the following repeat Class Ill deficiencies ' ‘ were cited. : 4A. Pursuant to 42 CFR 483.15(a), the facility must promote care for residents in a manner and in an environment thar jaintains or enhances each resident's dignity and respect in full recognition of his or her individuality. This requirement was not met as evidenced by the following observations: (1) Interview with a sampled resident on Junc 20, 2000 ar approximately 10:30 a.m. revealed that the repident was at times required ta wait for staff assistance after using his/her call bell, resulting in the resident having to "wet myself." The resident expressed emharrassment over these incontinent episodes. : | (2) 10 of 15 residents during the group interview on June 20, 2000 at 11:00 a.m. revealed call bells are not answered in a Gmely manner. They related at times they have to wait 45 minutes and the situation is worse on weekends and on the 3 to 11 p.m. shift. t (3) During observations of skin care and posjtianing on June 20, 2000 at 2:10 p.m., resident #3, was observed in bed, covered with a light blanket and a sheets Two staff members repositioned the resident for ohservation of skin and positioning devices. The resident's feet and buttocks were the areas of concern, therefore, the ‘observation required uncovering the resident from the waist down. The outdoor window curtain was completely open and neither staff member attempted to close the curtain before or during the observation and repasitioning. F225 T-789-P.O10/017 i} \w \/ (4) On June 21, 2000, at approximately 7:5Q a.m., one unsampled resident was observed lying in hed with only a hospital gown on, clearly visible fram the hall putside the room. The gown was up around the resident's waist, exposing the resident from the midriff down. The top sheet was at the foor of the bed, out of the resident's reach. A large, formed bowe] movement was noted on the resident's buttocks and bed pad. : (a) At approximately 8:10 a.m., the resident was observed with the sheet pulled up around his/her hips. At the request of the surveyor, a nurse entered the room, spoke to the resident, and observed the feces still on the bed pad, at which time, she requested assistance from floor staff. (6) On June 20, 2000 at 9:30 a.m., during interview, a sampled resident stated that on June 19, 2000, at approximately 11:00 p.m., two staff members awakened the sampled resident and the unsampled roommate by entering their room and turning on the overhead light. The resident further stated that that the staff members were in the room approximately one hour laughing, talking loudly and using profanity. The residents indicated a lack of understanding as to why the staff members were present and !stated that they should have been "in the woods” because of the language that they were using. Both residents were offended by the treatment of the staff members. ; (6) Interview with a sampled resident related 2 instances where staff did not maintain or enhance her, dignity as follows: 1) On ane occasion when resident asked a CNA to assist her in dressing, the CNA stated "You're a hig girl now, and you should do it yourself. 2) On another occasion another CNA was asked to assist her by getting her a can of soda out of her dresser drawer and the CNA responded "for God's sake, can't you reach in that drawer?” : (7) Based on observations, individual interviews and group interview, it was determined the facility violated Rule 59A-4.1288, F.A.C., for again failing to promota care in an environment which maintains and enhances each residents dignity for 4 sampled residents, 2 unsampled residents and 10 of 15 residents in the group interview. : F~225 1-789 PLON/OI7 «F225 \w/ wo 48. Pursuant to 42 CFR 483.20(k), the facility must develop a comprehensive care plan for each resident that includes jneasurable objectives and timetables to meer a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, This requirement was not met as evidenced by the following observations: (1) Resident #4 was observed on June 20, 2000 in her room in bed for breakfast and lunch meals. During breakfast, served at 9:00 a.m., the resident was‘in bed with her breakfast tray to her left and staff was ohserved feeding the resident. Staff revealed at that time that the resident could nat feed herself. During the noan meal served at 1:45 p.m., staff was again attempting to feed the resident with the resident resisting and refusing. . (a) Review of the residents’ current; care plan regarding nutrition revealed thar ir states "To main dining room for breakfast and/or lunch daily. Set up tray for ease of left hand feeding, cue [her to eat, repeating as often as needed to promote sclif feeding. Feed her remainder of meal praising her accamplishments each meal." : (b}) Interview with staff on June 20, 2000 at 3:55 pm. revealed staff agreed the care plan did not describe the resident's current nuritional needs for dining. The resident entered the facility obese and has rapidly lost weight. Some weight loss was desirahle, but the staff verbalized concerns with the resident refusing food anc feel she needs much more assistance at this time and needs to be fed, ( {2) Review of the clinical record, reflected thatiresident #9, was admitted to the facility on January 25, 2000 from a local hospital, with a diagnosis of coma as a result of a head injury. At that time an indwelling urinary catheter was present. ‘ i BT) t AuBTEee™ CVU ICs) IPM 4c. From- (3) 1-789 P.012/017 \w wi (a) An admission Minimum Data Set (MDS) was completed on February 1, 2000 and the Resident Assessment Protocol (RAP) summary indicated that care planning for the catheter was triggered; however a decision not to proceed with care planning was documented. A care planning note on Kebruary 4, 2000 indicated that because the catheter was present and there was no urinary incontinence, 4 care plan was not developed. : (bk) A nursing note on May 14, 2000 at 9:45 a.m. indicated that resident was hot and clammy and had a blood pressure of 112/50, pulse of 150, respirations of 32 and a rectal temperature of 104.2. A urinalysis ordered at that time reflected high red and white blood cell counts and many bacteria. The urine culture results from this specimen revealed greater than 100,000 colonies of é-coli. The resident was admitted to the hospital with ae diagnosis of sepsis. (<) Failure to plan for care of the indwelling catheter and potential for urinary tract infection (UTI) could have contributed to this resident's subsequent illness. Through observation, record review, jand staff interview, it was determined that the facility violated Section 400.2(3)(1)(1), F.S. and Rule 59A-4.109(1)(2)(3), F.A.C., for again failing to develop comprehensive care iplans that described the services to be furnished in accordance with the resident's needs for 2 of 25 sampled residents. Pursuant to 42 CFR 483.25{c), based on the comprehensive assessment of a resident, the facility must ensure that a résident who enters the facility without pressure sores does not develop préssure sores unless the individual’s clinical condition demonstrates thar they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent evidenced by the following observations: any new sores from developing. This requirement was not met as Ml F225 Siete tind 4D. rrom 1-789 P.013/017 . : . 1 i \e/ ! (1) Resident #14 was admitted to the facility on February 3, 2000 after falling at home and breaking her right hip. Her initial assessment determined the resident to bel at risk for pressure sore development due to her decreased mobility and weight bearing ability. Facility staff, however, chase not to develop a care plan at that time for the jpurpose of prevention of pressure sore development bécause the resident had "no breakdown present at this time. Not at high risk presently." No interventions were established for monitoring the resident's skin condition. {a) On February 18, 2000, the resident re-injured her right hip and had to have surgical intervention for re-alignment of the fracture. She returned to the facility on February 21, 2000 with continued limitation in her mobility and by March 22, 2000, the resident had developed a Stage III breakdown on her right heel. The facility developed a plan of care for the treatment of the pressure sore after it developed. . (b) They did not, however, provide aggressive preventive measures and care to prevent the breakdown from occurring for this resident who was determined by assessment to he at risk for the development of breakdown. (2) Based on interview and record review, it was determined that the facility violated Rule S9A-4.1288, F.A.C,, for again failing to ensure thar 1 of 25 sampled residents who entered the facility without pressure sores did not develop a pressure sore. Pursuant to 42 CFR 483.65(a)(1)-(3), the facility must establish an infection control program under which it investigates, controls, and prevents infections in the facility; decides whatipracedures, such as isolation, should be applied to an individual resident; and maintains a record of incidents and corrective actions! related to infections. This requirement was not met as evidenced by the following observations: ' ‘ F225 puBvce"euyuyu 1c. 1cpm From 5. T-789— P.O14/017 \w/ Ww ()) Observations of resident #9 on June 19, 2900 at 2:00 p.m. and June 20, 2000 at 10:45 a.m. revealed a gespiratory suction catheter on the bedside table completely! uncovered and attached to the suction machine. This resident breathes through a tracheastomy, is totally dependent on staff for all care, and has had numerous upper respiratoryi infections, inchiding an admission to the hospital on May 29! 2000 with pneumonia. | (2) During the initial tour of the faciliry an Jaye 10, 2000 at approximately 9:45 to 11:00 am., the following abservanons were made: 1} Tooth brushes open! unlabeled an backs of toilets in roams 125 and 128. 2) A bed pan and bath basin on the bathroom flpor in 126; 3) Wet, sailed wash cloths an the floor of the bathroom in 125; 4) An open urinal sitting on the bedside table in room 131, 58) A contaminated urinary catheter bag with tubing draped over the handrail of the bathroom in room 109; and 6) A half-full urinal standing on the bedside table of one unsamipled resident on the 200 hall. : (3) Based on observations, it was determined that the facility violated Rule 59A-4.106(3)(4)(, F.A.C.,! for again failing to have an established infection contral Program and for failing to follow precedures to prevent infectigns for 1 of 25 sampled residents and 5S unsampled residents: Based on the foregoing, Cross Creck Nursing and Convalescent Center has violated the following: a) Tag F241 incorporates 42 CFR 483.15(aj and Rule 59A-4.1288, F.A.C, The administrative fine imposed for this repeat deficiency is $1,000.00. ' t b) Tag F279 incorporates 42 CFR 483.20(k), Chaprer 400.2(8)(1)(1), F.S. and Rule S9A-4.109(1)(2}(3), RAC, The administrative fine imposed for this repear deficiency is $1,000.00. c) Tag F314 incorporates 42 CFR 483.25(c} and Rule 59A-4.1288, F.A.C. The administrative fine imposed for this repeat deficiency is $1,000.00. ! | | ‘ %3 { F~225 OMB BET EUYYU 1C-+1 Spi rrome I, T-789—P.OFS/017 . ‘ a) 4 r4¢41 incorporates 42 CFR 4 3.05(aI{1)- ~{3} and Rule 5S9A-4.106(3)(4)(], F.A.C. The administrative fine jmposed for this repeat deficiency is $1,000.00. | 6, The above referenced violations constimute grounds to levy this civil penalty pursuant to Section 400.23(8}{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 Home. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.57, Flarida Starutes, to be represented by counsel (at its expense], to take testimony, to call or cross-examine witnesses, to have subpoenas and/or subpoenas duces tecum 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 material issues of fact in the request for a hearing, may be treated by the Agency as an election by Respondent for an informal proceeding under Section 120.57(2), Florida Statutes. All requests for hearing should be made to the ‘Agency for Health Care Administration, Attention: Sam Power, Agency Clerk, Senior Attorney, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. F~225 ome ee eve ~ Fess OMI From T-789P.016/017 Ww wo! All payment of fines should he made by check, cashier's check, or . money order and payable to the Agency for Health Care Administration. All checks, cashier’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, 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 TRE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. a Issued this WS aay of Sua, 2000. Dénah Heiberg Field Office Manger, Area #1 Agency for Health Care | Administration Health Quality Assurance 2639 N. Monroe Street, Suite 208 Tallahassee, Florida 32303 15 F-225 nuececrevyy Tee 14pm FF OM= T-789)P.OI7/017 I . : : ' \w ‘ew CERTIPICATE OF SERVICE : I HEREBY CERTIFY that the original complaint was sent by U.S. | Mail, Return Receipt Requested, to: Administrator, Cross Creek Nursing & Convalescent Center, 10040 Hillview Road, Pensacola, Florida 32514 on this Heteqay of Assaust 2000. : ' Christine T. Messana, Pha Office of the General Counsel Copies furnished ro: Christine T. Messana Attorney Agency for Health Care Administration (Interoffice Mail) Pete J. Buigas, Deputy Director 1 Managed Care and Health Quality ' Agency for Health Care Administration , (Interoffice Mail) Gloria Collins, Finance & Accounting Area 1 Office F225

Docket for Case No: 00-003663