STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION”, . y.) HOR Vie 4 Oo: YD STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. _ AHCA NO: 01-00-076-NH BAYSIDE MANOR, 00-4132. Respondent. / ADMINISTRATIVE COMPLAINT 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 fine in the amount of $10,000.00 upon Bayside Manor. As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1. The Agency has jurisdiction over the Respondent pursuant to Chapter 400 Part II, Florida Statutes. 2. Respondent, Bayside Manor, is licensed by the Agency to operate a nursing home at 4343 Langley Avenue, Pensacola, Florida 32504 and is obligated to operate the nursing home in compliance with ‘Chapter 400 Part II, Florida Statutes, and Rule 59A-4, Florida Administrative Code. 3. On August 17, 2000 a survey team from the Agency’s Area 1 Office conducted a survey and the following Class I deficiency was cited: c c 3A. Pursuant to 59A-4.122(1), Florida Administrative Code, the facility shall provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible. This requirement was not met as evidenced by the following observations: _ ~ ~ / 1. Based on facility record review and staff interviews, the facility failed to ensure cleaning solutions were stored so they were inaccessible to residents. This past-noncompliance at F323 resulted in immediate and serious threat to at least one facility resident, who ingested cleaning solution on August 9, 2000 and subsequently died. Findings include: | (a) Based on review of nursing notes for resident #1, the resident was found in her room on August 9, 2000 at 9:05 PM with an open bottle of a liquid chemical identified as Sani-Kleen (product name Broad-Cide 128) on the overbed table next to the resident, who was in her wheelchair. The resident had a raspy voice, difficulty swallowing, and she was crying. The resident was sent to the hospital for an evaluation and treatment. (b) Review of the medical record from the hospital indicated the following diagnoses: Respiratory failure, aspiration pneumonia, accidental ingestion of C detergent and severe esophagitis noted at autopsy (the resident expired on August 10, 2000). 2. Based on staff interview on August 16 and 17, 2000, the facility lacked a system at the time of the incident to ensure safe keeping of cleaning solutions. Staff “Interviews during the complaint investigation revealed the facility implemented procedures on August 11, 2000 (prior to the complaint investigation) to monitor resident areas twice daily for cleaning chemicals, housekeeping and direct care staff were inserviced on safe keeping of chemicals. Facility staff now perform a count of all chemicals at the end of the 7-3 shift, when all chemicals are locked until the next day. The surveyor reviewed these procedures, inservices and noted no chemicals to be available to residents during survey. All chemicals were noted to be stored in a locked closet during survey. 4. Based on the foregoing, Bayside Manor has. violated the following: a) Tag F698 permits imposition of a civil monetary penalty for past noncompliance with Tag F323. The administrative fine imposed for this uncorrected violation is $10,000.00. 5. The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.23(8)(a), Florida Statutes, in c C 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 ‘Tight 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-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. 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, 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 i C Administration, Attention: Christine T. Messana, Esquire, 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 THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Issued this NSS day of November, 2000. Bu Heiberg Field Office Manger, Area #1 Agency for Health Care Administration Health Quality Assurance 2639 N. Monroe Street, Suite 208 Tallahassee, Florida 32303 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original complaint wand Mail, Return Receipt Requested, to: Martha Perez, amine ie So VY ia Bayside Manor, 4343 Langley Avenue, Pensacola, Florida, 32504 on this fi Gtlday of November, 2000. I -\ Christine T. Messana, Esquire Office of the General Counsel Copies furnished to: Christine T. Messana Area 1 Office Attorney Gloria Collins, Finance & Accounting Agency for Health Care Administration 2727 Mahan Drive Mail Stop #3 Tallahassee, Florida 32308 Pete J. Buigas, Deputy Director Managed Care and Health Quality Agency for Health Care Administration 2727 Mahan Drive, Building 1 Tallahassee, Florida 32308-5403

Docket for Case No: 00-004922