STATE OF FLORIDA G i, AGENCY FOR HEALTH CARE ADMINISTRATION “AF ey . _ cxienitien ‘ls > Return Reebipt’Req Sted 7000-0600-0026¢7844- 1.8941. STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. ' AHCANO: 01-01-0086-NH O1- 1993 TANDEM HEALTH CARE OF PENSACOLA, 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 seventy-six thousand dollars ($76,000.00) upon Tandem Health Care of Pensacola (“Respondent” or “Facility”). As grounds for the imposition of this administrative fine, the Agency alleges as follows: 1. The Agency has jurisdiction over the Respondent pursuant to 0 Chapter 400 Part U, ‘Florida Statutes. 2. “Respondent, “Tandem: Health Care of Pensacola, is licensed by the Agency to operate a nursing home at 235 West Airport Boulevard, Pensacola, Florida 32505 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 March 3-4, 2001 a survey team from the Agency’s Area 1 Office conducted a complaint investigation survey and the following “Class I deficiencies were cited. 3A. Pursuant to 42 CFR 483.25(m)(2), the facility must ensure that residents are free of any significant medication errors. This requirement was not met as evidenced by the following observations: (1) Review of resident #1’s clinical record reflected an original admission date of August 18, 1997. The record revealed medical diagnoses to include: multiple sclerosis; seizures; confusion; and quadraplegia. The admission Transfer and Continuity of Care form was in the record and- signed by the physician on August 12, 1997, listing allergy and drug sensitivities to iodine, sulfa and codeine. The medical record contained a second Transfer and Continuity of Care form dated September 21, 2000, again listing as allergy and drug sensitivity: “Sulfonamides, Codeine, IVP Dye”. A history and physical also stamped in red ink read “Do Not Remove”, listing the resident’s allergies in capital letters, with the first stated as “SULFA”. The February 2001 Medication Administration Record in the clinical record listed at the bottom of the page just below the medications the resident received read “Allergies: SULFONAMIDES”. a. Nurse’s notes dated February 20, 2001, at 2:00 p.-m., state the resident complained of burning and increased pressure in the bladder. Then again on February 21, 2001, the nurse’s notes state the resident complained of bladder discomfort and burning. “PA to see today” was noted in the record. _ An entry dated February 21, 2001, and timed at 11:00 “ p.m., states “C/O pain from toes to waist, ask for Septra.” The note further states the Physician’s “ Assistant was notified and an order for Septra 1 by mouth twice daily was obtained. A telephone order for — Septra 1 by mouth, twice a day was written at 8:00 p.m. on February 21, 2001, and noted off by the same staff nurse at 8:10 p.m. Nurse’s notes reflect the resident was medicated at 8:30 p.m. with Septra. On February 22, 2001, at 1:00 am., the resident complained of lower back pain and stated "My legs are 2 killing me".. On February 22, 2001, at 7:45 a.m., a Licensed Practical Nurse was alerted by a Certified Nursing Assistant and upon entering the room found the resident "Flushed, respirations 28-30, rapid and shallow”. The resident's heart rate and temperature were elevated, blood pressure unobtainable, and the resident was unresponsive. Oxygen was started, the physician and family were notified via telephone, and the resident was sent to the hospital at 8:10 a.m. The resident expired in the hospital on February 24, 2001. b. Review of the facility’s Emergency Drug Kit Use Log revealed an entry on February 21, 2001, at 8:10 p.m., revealed the nurse on duty removed a Septra for use for resident #1. The medication in the emergency drug kit was Septra DS (SMX-TMP) Tabs, according to the description list attached to the kit. Interview with the nurse on March 3, 2001, at approximately 4:45 p.m., revealed the nurse had not checked the resident's record for allergies when contacting the physician’s assistant to obtain an order. The nurse stated the resident had specifically requested Septra, therefore the nurse did not feel there was a concern. Further, after obtaining the telephone order, the nurse transcribed the order to the resident's February 2001 medication record and gave the medication. c. A handwritten note dated February 22, 2001, and not timed was presented to the surveyors on March 3, 2001, at 5:30 p.m. The note stated the Director of Nursing received a call from the Medical Director of the facility to follow up on the order for Septra for the resident. The note further indicated that the pharmacy, upon receiving the order in the morning called to alert the facility the resident was allergic to Septra, and therefore the medication was never sent from the pharmacy. d; Review of the facility’s Policy and Procedure for Allergies revealed the procedure in place contained provided guidelines, which states in part: 1. Obtain information on admission if resident is allergic to drugs or any specific food items including type of reaction. 2. Record allergies in red on the resident care plan in admitting notes, on the order sheet “and the medication administration sheet and any other appropriate forms as required. . 3. Attach adverse reaction label to outside of chart holder. State type of allergy. 4. Advise resident's physician and pharmacy of stated allergies. e. Interview with nursing management on March 3, 2001, at approximately 3:00 p.m., revealed that after a medication error occurs, the staff member must complete a Medication Error Report. Review of the Medication Error Report for administration of Septra to Resident #1, revealed the form was incomplete in the areas of:: . results of error; . who notified the physician; . physician's comments; . . has the physician seen the resident since the . . .error was made?; and 5. precautions taken to prevent a similar error. BONN f. The Director of Nursing (DON) stated during interview on March 3, 2001, at approximately 3:00 p.m., any disciplinary action forms for staff would be found in the staff member's personnel file. Review of the personnel file for the nurse who failed to note the ~ resident's allergies, called and requested the order for “Septra, took the order, transcribed it to the medication “administration record, and administered the Septra to “the allergic resident, revealed no documentation of follow up action. The facility could not provide “evidence that counseling, disciplinary action, further medication education, or reassignment of duties occurred. : : “On March 3, 2001, at 6:30 p.m., review of a Q) Medication Error Report for resident #2, revealed that on ary 13, 2001, at 9:00 p.m., the resident was given ular Insulin 14 units, subcutaneously. Review of the resident's medication administration record revealed the 4 resident was to receive accuchecks before meals and at bedtime. _A large note at the bottom of the medication administration récord stated: "No Sliding Scale Insulin was to be given with the bedtime accucheck." Further review of - “the medication administration récord revealed that the resident had received 5 units of regular insulin at 4:30 p.m., as the result of a blood sugar reading of 101. When the error was discovered at 11:00 p.m., a physician was notified and an order was obtained to awaken the resident early and offer a snack. The precautions to prevent a similar error were listed as to check the medication administration record more thoroughly next time. Review of the nurse's personnel file revealed no follow-up action occurred. (3) Review of physician's order sheets for resident #3, revealed a telephone order dated January 22, 2001, to hold Coumadin until further notice; continue daily protime and INR levels (both indicators of blooding clotting). a. Review of the resident's medication administration record reveals the resident received Coumadin 7.5 mg at 5:00 p.m. on January 22, 2001 and January 24, 2001, and Coumadin 5 mg at 5:00 p.m. on January 23, 2001. b. A hand written investigation of the occurrence reviewed on March 3, 2001 revealed that the nurse receiving the order via telephone had verbally notified the 3-11 shift, but had failed to note the order on the resident's medication administration record. c. Laboratory values recorded on the handwritten note revealed the resident had a protime listed . . as being on January 22, 2001 at 41.96 seconds; cosceesc ces, On January 23, 2001 at 40.4; and on January ne 24, 2001 at 39. On January 25, 2001, the resident was recorded as having a protime as 48. Normal limits for protimes stated in the Seventeenth Edition Merck Manual are 10 to 12 “seconds. The nurse involved in not noting the error was terminated. Education on Coumadin administration was subsequently provided by the pharmacy. No medication error report was poe eer we I nae heme nhl = oh completed. The resident was discharged to ; home on January 25, 2001. (4) Review of the medication administration record (MAR) “for resident #4, revealed an order transcribed to the MAR on October 26, 2000, for 60 milligrams of Phenobarbital per tube feeding, 15 cc TID (three times daily). A medication error report dated December 25, 2000, reveals that 180 milligrams of Phenobarbital was given. The explanation for the error was misreading the MAR, and that the MAR was confusing. Precautions taken to prevent a similar error listed on the medication error report state: "Label on Bottle also confusing" and "Order on MAR needs written in less confusing manner." The only signature on the report is that of the nurse who made the administration error. The report areas listed as: “Report Reviewed by: Director of Nursing, Administrator/Manager, and Resident/Patient's Physician”, were blank as of March 3, 2001. Review of the nurse's personnel file revealed no documentation of follow up action as a result of the error. a. Interview with the Director of Nursing and the Assistant Director of Nursing on March 3, 2001, at 8:00 p.m., failed to disclose evidence of any quality assurance follow-up on the significant medication errors noted to have occurred. The facility was unable to provide evidence that a review of the system in place, or consideration of a new system to prevent further significant -medication errors, had taken place. (5) Based on observation, interview with nursing staff, and record review, it was determined that the facility violated Rule 59A-4.107(5), of the Florida Administrative Code, for failing to ensure that four residents (#1, 2, 3 and 4), were free from significant medication errors. veveble ee ie nite ee etait Lede, 3B. Pursuant to 42 CFR 483.60(a), a facility must provide pharmaceutical services (including procedures that assure the accurate. acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This requirement was not met as evidenced by the following observations: 3c. “(1) «Cross reference to Tag F333 (under paragraph 3A). Although the facility staff identified four significant medication errors since December 25, 2000, they failed to implement procedures (including use of medications from the emergency drug kit) relating to medication administration to prevent further occurrences of such errors. This failure ultimately resulted in staff administration of '-.Septra to a resident allergic to sulfa drugs. (2) Based on record review and staff interviews on March 3, 2001, it was determined that the facility violated Rule 59A-4.1121(1), of the Florida Administrative Code for failing to provide pharmaceutical services including administration of medications in a manner to prevent ongoing significant medication errors, potentially, seriously, and adversely affecting resident safety and well-being. Pursuant to 42 CFR 483.75, a facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well- -being of each resident. This requirement was not met as evidenced by the following observations: rie “Cross “Telerence tc to Tag” F333 “(under ‘paragraph “SA). -Although the: facility staff identified four significant ~ medication errors since December 25, 2000, administrative “staff failed to identify the trend of medication errors and .. implement systemic changes to prevent further occurrences of such errors. (2) Based on record review and staff interviews on March | 3, 2001, it was deteremined that the facility violated Rule ° _59A-4.1288 for failing to administer in a manner to prevent ongoing significant medication errors, potentially, seriously and adversely affecting resident safety and well being. 4. On November 2, 2000 a survey team from the Agency’s Area 1 Office conducted an annual survey and the following Class III ‘deficiency. was cited. 4A. Pursuant to 42 CFR 483.75(e)(8), the facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must-- (i) be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; (ii) address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff; and (fii) for nurse aides , providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.. This requirement was not met as evidenced by the following observations: (1) Five of five (5) CNA personnel and staff education records reviewed did not have documentation of the required twelve (12) hours per year of regular in service education. (2) Through observation, interview with staff, and review of five of five (5) CNA's personnel and staff education records it was determined that the facility violated Rule 59A- 106(5), of the Florida Administrative Code, by failing to complete a performance review of every nurse aide at least once | évery 12 months, and failing to provide regular in- . service education: based on. the outcome of these reviews. gue te apne Ep :CppOImimepTI-E-—ancane waetuerane (2 Semper wt ap si pepe wee ww 5. On March 3-4, 2001 a survey team from the Agency’s Area 1 Office conducted a complaint investigation survey, as well as a follow-up “survey and the following repeat Class III deficiency was cited 5A. Pursuant to 42 CFR 483.75(e)(8), the facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must-- (i) be sufficient to ensure ; the continuing competence of nurse aides, but must be no less than 12 hours per year; (ii) address areas of weakness as determined in nurse © aides’ performance reviews and may address the special needs of residents as determined by the facility staff, and (iii) for nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.. This requirement ‘was not met as evidenced by the following observations: (1) C.NLAL (Certified Nursing Assistant) #1 was hired in 1997. She had 1.25 hours of in-service training documented for the year 2000. = (2) C.N.A. #3 was hired in 1997. She had no documented on Haining for the year: 2000. (3) C. NA. #4 was ‘hired | in “1996. She had « one hour of ~ documented training for the year « 2000. ; (4) In an interview on the evening ‘of 3- 3-01, the Assistant -Director of Nursing stated that she had provided the surveyor with all documentation related to C.N.A. in- services. Ton “Based on “personnel record reviews and in-service training records for the year 2000, it was determined that the facility violated Rule 5S9A-4.106(5), of the Florida Administrative Code, for again failing to ensure sampled staff members received the required twelve hours of in-service training. 6. - Based on the foregoing, Tandem Health Care of Pensacola has violated the following: a) Tag F333 incorporates 42 CFR 483.25(m)(2) and Rule 59A-4.107(5), F.A.C. The administrative fine imposed for this Class I violation is $25,000.00. b) Tag F426 incorporates 42 CFR 483.60(a) and Rule 59A-4.1121(1), F.A.C. The administrative fine imposed for this Class I violation is $25,000.00. c) Tag F490 incorporates 42 CFR 483.75 and Rule 59A- 4.1288, F.A.C. The administrative fine imposed for this Class I violation is $25,000.00. d) Tag F497 incorporates 42 CFR 483.75(e)(8) and Rule 5S9A-4.106(5), F.A.C. The administrative fine imposed for this repeat Class III violation is $1,000.00. 7. The above referenced violations constitute 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 Home. NOTICE Respondent is notified “that ‘it has a Fight 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 10 rere cere pce ee 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 i is referenced on page 1 of this complaint. Al 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. 11 freer 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. yO Issued this ."\_day of X (ew , 2001. Donah 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 was sent by U.S. Mail, Return Receipt Requested, to: Administrator, Tandem Health Care of Pensacola, 235 West Airport, Boulevard, Pensacola, Florida 32505 on this /Y¢cday of Mave b, , 2001. . Copies furnished to: Christine T. Messana Attorney _ Agency for Health Care Administration 2727 Mahan Drive Mail Stop #3 Tallahassee, Florida 32308 pazatem Dusk, ACTING DEPUTY SECRETARY Managed Care and Health Quality Agency-for Health Care Administration 2727 Mahan Drive, Building 1 Tallahassee, Florida 32308-5403 Area 1 Office Gloria Collins, Finance & Accounting

Docket for Case No: 01-001993