STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA , AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO: 10-01-0043 NH DELTA HEALTH GROUP, INC., d/b/a Ol . Al 4 7 MARGATE HEALTH CARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT. YOU ARE HEREBY NOTIFIED that after twenty one (21) days from the receipt of this Complaint the Agency for Health Care Administration (hereinafter referred to as the "Agency") intends to impose a civil penalty in the amount of Ten Thousand ($10,000) Dollars upon Delta Health Group, Inc., d/b/a Margate Health Care Center (hereinafter referred to as Respondent"). As grounds for the imposition of this civil penalty the Agency alleges as follows: 1. The Agency has jurisdiction over Respondent by virtue of the provisions of Chapter 400, Part II, Florida Statutes. 2. Respondent is licensed to operate at 5951 Colonial Drive, Margate, Florida 33063, as a nursing home in compliance with Chapter 400 Part II Florida Statutes and Rule 59A-4, Florida Administrative Code. 3. The Respondent has violated the provisions of Chapter 400, Part Il, Florida Statutes, and the provisions of Chapter 59A-4, Florida Administrative Code, in that it failed to correct within the mandated time frame of Januaryl2, 2000 (Section Fes ime 400.23(4)(c), Florida Statutes) (2) Class I deficiencies, cited during the survey of January 8-10, 2000. These deficiencies set forth below were still uncorrected when a follow-up visit was made on January 27, 2000. (a) Tag F224. Staff Treatment of Residents. The facility did not implement policies and procedures that prohibited the neglect (failure to provide necessary care and services) of a resident. During the survey conducted on 01/10/00 it was found that based on observation, record review and interview, the facility did not implement written policies and procedures that prohibited the neglect of one of 29 residents. The findings were: qd) Resident #13 had been admitted 12/20/99 to the facility and at the time of the survey had been diagnosed with a fractured hip, CHF, COPD, and dementia among other health conditions. At 1:30 pm on 12/31/99 the resident received an order for Imodium (one capsule after each loose stool), which was subsequently reordered on 01/09/00 (two capsules every 4 hours as needed for diarrhea). At 7:00 am on 01/09/00 and again at 9:00 am on 01/09/00 Resident #13 experienced a loose bowel movement, however Imodium was not administered to the resident following each incident. (2) Upon reviewing the resident’s December 99 and January 2000 medication administration records the surveyor determined that: neither order for Imodium had been entered on the resident’s medication administration record; and that upon discussing this issue with the Consultant Pharmacist between 10:35 am and 11:19 am on 01/09/00 the ‘Surveyor confirmed that: 1) at the time of Resident #13’s episodes of diarrhea there were no Imodium capsules in the facility for Resident #13; 2) the pharmacy had not sent (and the facility had not ordered) any Imodium for Resident #13 since it was initially ordered on 12/31/99; 3) no doses of Imodium had been removed from the emergency drug supply; and finally 4) Resident #13 had dropped from 83 pounds on 12/27/99 to 74.6 pounds at the time of the survey. 2 (3) As Resident #13 lost 8.4 pounds between 12/27/99 and the date of the survey, and as medication to contro] Resident #13’s diarrhea had not been sent by the pharmacy (or ordered by the facility) and was not available when it was needed to control Resident #13’s diarrhea it was determined the facility had not provided goods and services necessary to avoid physical harm, and mental anguish. (4) In addition, the resident’s skin was observed on 01/09/00 to be ~ extremely reddened and excoriated. (2a) Based on record review and staff interviews it was determined during a Class II revisit conducted on 01/27/00, that the facility did no ensure that necessary care and services to manage identified risks to a Resident were provided for 1 of 7 Residents sampled for Nutritional needs. The findings were: ad During the review of Resident #3’s medical record it was observed that the resident’s diagnoses includes Senile Dementia, Cerebral degeneration and Depression. The clinical record contained documentation, which evidenced that the " Resident was receiving Hospice care. Care plan #3 dated 01/14/00 was developed and established for the problem “Resident currently receiving Hospice care. Anticipated weight loss as evidenced by terminal condition.” Approach #5 of this Care Plan specified “comply with Resident and family wishes for no aggressive nutritional measures.” (2) A review of the Resident’s Advance Directives contained in the clinical record revealed that the Advance Directives had not been effectuated, because it had not been signed by the designated health.care surrogates. In addition, the Directives did not contain any directives regarding the withholding or withdrawal of nutrition sustenance. (3) The weight record contained in the record revealed that on 01/12/00 the Resident weighed 155 pounds. On 01/18/00 the Resident weighed 149 pounds, indicating a weight loss of 6 pounds in 6 days. A review of the nurses notes from 01/14/00-01/26/00 revealed that the Resident consumes on average 24% of meals, 3 ecm ae corp es i i as well as that the Resident’s appetite is poor.” As of the time of record review the facility did not intervene to assist the Resident in achieving a good appetite or to consume a significant proportion of meals. (4) During interview with the Director of Nursing, the Registered Dietitian and the Dietary technician, the staff was asked for documentation in accordance with Florida Statutes 765.306 to evidence that 2 Physicians had determined the Resident’s health status as terminal (as stated in the care plan). All three staff was unable to locate and/or provide the required documentation. In addition, when asked about the reason why the Resident’s nutritional parameters were not maintained as identified in the Dietary assessment at the usual body weight of 155, or at the ideal body weight range of , 155-189, the staff responded that weight management is per the Hospice policy because the Resident is receiving Hospice care. Upon being asked to be provided the criteria by which a Resident is determined as needing Hospice care, for review, the surveyors were informed Hospice is called and they assess the resident and place the resident on Hospice care. The facility did not have available criteria/policies and procedures specifying for who and or when Hospice care is to be referred. (5) The Dietary assessment dated 01/10/00 contained in the clinical record, documented, “stated appetite was good, stated problems. chewing, will refer to Social Service for dental consult.” 6) ‘It was observed during the record review that at the time of admission 01/10/00, the resident’s appetite was good; however subsequently (according to Nurses’ notes) the Resident’s appetite has become poor. During an interview on 01/27/00 at 3:00 pm with the Dietitian who documented the above assessment and the Social Service personnel, Social Service personnel denied receiving a referral for a dental consult. When asked, the Dietitian stated the referral was given to ‘Social, Service verbally. The ‘Facility’ s policy did not specify written referral procedures to be performed. The Dietitian agreed that a written referral was not performed. As a result, 4 5.5 haa agen et ieaasleare ber cacatiseits aE the Resident’s problems with chewing had not been addressed as of 01/10/00-01/27/00; during this time the Resident had lost 6 pounds. The facility did not provide the necessary care and services to manage the identified problems of chewing difficulties as it relates to the Resident’s risk for weight lost. This is in violation of section 400.022(1)(1), F.S., uncorrected Class II deficiency, carrying in this instance a $5,000 civil penalty. (b) Tag F325. Quality of Care. The facility did not ensure that residents maintained acceptable parameters of nutritional status such as body weight and protein levels. During the survey conducted on 01/8-10/00 and based on the resident’s comprehensive assessment, the facility did not ensure that two of 29 sampled residents maintained acceptable parameters of nutritional status, such as body weight and protein Jevels. The findin gs were: (1) Based on record review, resident #3 was admitted on 10/29/99 with diagnosis of End stage COPD and receiving Hospice services. Based on clinical ~~ observation on 01/08/00 at 9:00 am, the resident appeared thin, pale with poor skin turgor shortness of breath and dry chapped lips. Further observations at lunchtime revealed the resident’s tray table to be approximately one foot from the bed with the meal tray untouched. Upon interview the resident stated, “I can’t eat that stuff, and I told them, but they said that’s all they have on the menu.” Based on subsequent record review on 01/08/00, itv was ‘noted that ‘the resident ‘weighed 122 ‘Tbs on the initial MDS of 11/1 1/99, and was asse: sed as Oss, ,Teceiving ‘autftional supplements, but was not assessed as having nutritional problems with food intake. Further record review revealed the facility had documented additional weights as follows: 11/15/99-126lbs; 11/19/99- 126 Ibs, and 12/06/99-126 Ibs. | (2) : Upon request to the nursing staff for documentation of January weights, surveyor was given a weight record sheet with weights of 110 lbs on 01/07/00 and 108 Ibs on 01/09/00. These weights reflect a loss of 18 Ibs in 1 month. Surveyors 5 were informed by staff that the resident had been receiving a regular no added salt diet, which was changed to a puree, then switched to a mechanical soft diet and back to a regular diet. The staff went on to say the resident’s intake has been 25-50%, which resulted in the weight loss. (3) Further review of the nutritional screening assessment of 11/02/99 revealed the Dietitian assessed the resident’s usual weight as 133 Ibs, with an ideal body weight of 166 lbs. The calculation of the resident’s estimated nutrient needs was documented as 2128 calories, 100-125 grams of Protein per day. In review of the assessment, the Dietitian documented the nutritional plan was to work with the hospice nurse on food requests, monitor weight, labs, food intake and preferences. On 11/01/99 a plan of care identified the resident at 78% of the ideal body weight, with a goal of weight gain of 3-6 Ibs as evidenced by an oral intake of at least 75% of all meals/fluid provided by next review. A review of the CNA flow record sheet for December 99 and January 2000 revealed the resident was consuming between 25-50% of meals. Subsequent review of the hospice notes for this time period revealed the resident was identified as having a poor appetite, consuming 25-50% and having anorexia. (4) An interview with the unit manager on the South Wing on 01/10/00 at 9:00 am regarding the resident’s weight loss revealed, the facility weighs monthly unless there is a problem, then weights are done weekly. This staff member also reported a problem could also be identified with eating by reviewing the meal intake records, and by the same CNA’s and nurses, who picked up daily meal trays who would know if there was an eating problem. The nurse stated according to the care plan Resident #3 was supposed to be eating 75% of all meals and the meal intake sheet showed the resident was consuming less. However, the resident was not weighed weekly, when identified as having nutritional problem with food intake. Therefore, the nurse stated to surveyors: “we didn’t take any action, we should have.” tee ETRE TT (5) An interview with a family member on 01/10/00 at 3:40 pm revealed that although the facility provides meals for the resident, the family member tries to come to the facility during mealtimes to assist with feeding because the facility staff did not provide assistance during meals. (6) Based on record review, resident #13 was readmitted to the facility from the hospital on 12/20/99 after sustaining a hip fracture. During the initial tour of the South Wing on 01/08/00 at 9:30 am, resident #13 appeared thin, frail, had poor skin turgor and dry flaky lips. Based on review of the initial MDS of 01/02/00, the resident’s height was recorded as 56 inches, with a weight of 81 lbs. The resident was assessed on the MDS as having diarrhea, a chewing problem, on a mechanically altered diet, receiving a supplement, having poor intake, and requiring assistance with eating. A review of the nutritional screening & assessment on 12/21/99 revealed the Dietitian had recorded the resident’s height as being 63 inches, with an ideal body weight of 115 Ibs. Additionally, lab values from 12/14/99 referenced in the Dietitian’s note which serve as indicators of poor nutritional status, revealed the resident had a low albumin (2.2), low hemoglobin (8.7) and low hematocrit (26.9). The Dietitian at that time recommended a speech therapy screen for thickened liquids due to the family members informing the staff the resident had coughed on swallowing water. The nutritional plan documented by the Dietitian was to monitor oral intakes, labs and weights, provide shakes and fortified foods. (7) ‘Based on observations of lunch on 01/08/00 with family members present, the resident refused to eat the pureed diet. When the surveyor inquired to nursing staff if the resident had dentures, staff then took a full set of dentures left in the emesis basis in the dresser drawer and attempted to place them in resident’s mouth. The resident grimaced and indicated she was uncomfortable, and staff removed the dentures. A review of the CNA record for recording meal intake indicated the resident’s lunch intake to be 50%. Further review of weights in the chart revealed a weight of 83 lbs on 7 2 bets, # & 12/27/99 and on 01/03/00 a weight of 77 Ibs, a decline of 6(six) lbs. Five days after the six Ib weight decline and on the first day of the survey, the Dietitian documented a progress note, which recorded the resident as having a significant weight loss and being lactose intolerant. Additionally, this staff made an updated entry on the care plan of 12/30/99, which had already addressed the resident to be at compromised nutritional status. Further record review and interview with the Dietitian and Unit Manager revealed _ the resident’ swallowing skills had not been assessed by the speech therapist, nor had any attempts been made to obtain these services from the therapy department. (8) The following morning at 7:15 am the staff reported to surveyors, resident #13 needed to be changed because of diarrhea. At 8:40 am, surveyor observed " the resident in bed with her breakfast tray on the over bed table positioned at the opposite and of the resident’s bed untouched. When surveyors inquired from staff if the resident had refused breakfast, a CNA came into the room and brought the over bed table alongside the bed and stood while attempting to feed the resident. Upon review of the tray card the fortified hot cereal had been crossed out and substituted with regular hot cereal. Additionally, the resident was provided with a glass of milk like substance labeled on the cap “DE”. The CNA feeding the resident informed surveyors the resident had diarrhea and could not have this milk because of lactose intolerance. Surveyors told the CNA that the label “DE” on the glass stood for Dairy Ease, a lactose free milk substitute that the kitchen had _ Provided for the | Tesident to drink. - After these observations, surve ors re uested Nursing obtain a current weight for resident #13, which “was “observed to be 74, 6 Ibs. This new weight reflects an additional 2.5 Ibs. weight decline and a total 8.5 Ib weight loss since 12/27/99. (9) At 8:55 am, the surveyor observed with nursing staff present, the resident’s incontinent brief to be soiled with loose stool, perineum area extremely red and excoriated. A subsequent interview with the Dietitian on the south wing revealed the resident had an order for Imodium to alleviate the diarrhea PRN. A Pea ee Cat eo review of the chart & MAR with the Dietitian, Nurse, and Pharmacist present indicated an order for Imodium had been obtained 12/31/99 and re-ordered 01/09/00 for resident | #13, but had never been given after the resident had loose stools, nor obtained from the pharmacy. (9) Based on the observations, record reviews and interviews during the three days of the survey, it was determined staff responsibilities to assist the resident to maintain acceptable parameters of nutritional status were not clear, timely nor effective, and thereby further compromised the resident’s nutritional status. (2b) Based on observations, seven record reviews and interviews during the Class II revisit of 01/27/00, it was determined that the facility had not corrected the Class Il issued under F325 during the survey of 01/10/00 for two sampled residents as “evidenced by the these additional findings: () Based on clinical observations during a tour of the South Wing ‘with the Unit Manager at 9:30 am, resident #2 appeared frail, had poor skin turgor and dry chapped lips. A subsequent record review at 10 am revealed resident #2 was readmitted to the facility on 01/03/00 with diagnosis of Ulcer/Decubitus and Hypertension. According to the weight sheet in the record, the facility documented the resident had an admission weight of 123 Ibs on 01/04/00, on 01/10/00 a weight of 119 Ibs, and on 01/18/00 a weight of 108 lbs. This reflects a total weight decline of 15 Ibs in fourteen days. On 01/21/00 resident #2 \ was placed on Hospice services for Debility Unspecified and Renal Failure. (2) A review of the nutritional assessment of 01/04/00 by the Diet ~ Technician revealed the resident was assessed at high nutritional risk due to stage II decubitus and varied oral intake consumption of 25-100% of meals. The assessment went to say that the resident remained at high risk for further defect in nutritional status. The Diet Technician recommendations included multi vitamins, vitamin C as ordered, a change in diet to high calorie, high protein, monitor weight weekly, and document % of 9 ce cmeeggeesreereeres re wee weet all oral intake. However, the recommendation for the diet change was never implemented until 01/21/00 after the resident sustained a 15 Ib weight loss. (3) Furthermore, a telephone order sheet and the Medication Administration Record revealed the physician had ordered Vitamin C 500 mg twice daily on 01/04/00. However, the MAR documentation indicated the Vitamin C had been administered only once a day since 01/04/00. During an interview with the south wing unit manager and DON, surveyor was informed the physician’s order for the twice a day administration had been written incorrectly on the MAR by the nurse and incident report would be completed on the medication error. (4) In addition, a social services entry in the record on 01/13/00 indicated the resident was not eating and was gradually losing weight. At that time the social worker documented she spoke to the resident’s health care surrogate, discussed the “possibility of the resident going on Hospice, got the surrogate to sign a DNR and ; informed Dietary of the “weight ‘loss. However, there was no further dietary documentation in the record for another week until 01/20/00 regarding the resident’s weight decline, even though nursing staff continued to record percentages of poor meal intakes averaging 0% to 25% of all three meals. (5) On 01/20/00 the Dietitian wrote a note, which indicated the resident had an 11 lb weight loss and documented that nursing stated the resident was unable to swallow at times. The Dietitian recommended the resident’s diet be downgraded to puree and requested a speech therapy screen due to the swallowing problems. On 01/22/00 the Speech Therapist completed a screen and indicated with a “check mark on a department for “rehab not indicated”. The therapist did not document any reasons for the resident’s change in swallowing status or reasons why therapy was not indicated. Observations of the resident during lunch in her room on the south wing revealed the resident refused all pureed foods and would only take the liquids on her meal tray. 10 og ee & Spb hee ‘ana RCE (6) On 01/25/00 the Dietitian wrote an additional progress note documenting the resident was now receiving Hospice Care, had poor intakes, a Stage I ulcer on the left heel, and an additional 2 lb weight loss to 106 Ibs on 01/24/00, for a total weight loss of 17 Ibs since 01/04/00. There was no indication in the notes the Dietitian had reviewed the Speech Therapy screening. In addition on the same day, a new care plan was documented with a problem stating “Resident currently receiving Hospice Care Anticipated weight loss as evidenced by terminal condition.” However, a subsequent interview with the Dietitian, Diet Technician and Nursing Director at 3:30 pm in the conference room revealed staff could not identify which terminal condition the resident had that would cause the weight loss. (7) Based on record review, resident #6 was admitted on 12/27/99 with diagnosis of Fractured Right Tibia, Fibula, Dislocated Right Shoulder, and History of Recent Left ‘Wrist Fracture. During lunch observations on the south wing, resident #6 ate “only soup, ice cream, and complained of lack of appetite. When surveyor inquired if the resident had a nutritional supplement to drink such as Ensure, the resident stated the Ensure was “too heavy”, and made her feel like throwing up. Further record review revealed on 1 12/28/99 the resident was admitted at a weight of 140 Ibs, and gradually _ declined to 131 Ibs by 01/18/00. At the request of the surveyor, the resident was weighed at 2 pm and was found to be 130 Ibs, a decline of 10 Ibs. (8) A review of the hutritional assessment of 12/28/99 by the Diet Technician revealed the resident to have a poor appetite and not wanting to eat much of anything. At that time the nutritional recommendations were for Ensure twice daily, monitor acceptance, monitor % of meal intake, monitor weight, and cater to food preferences. Furthermore, on 01/06/00 the facility identified a care plan problem, which identified resid nt # #6 to bi at uttitional tisk due to varied oral intake of 50-75% of meals, nutritional requirements as increased protein needs due to several fractures. A il meres a tee a subsequent review of the % of meal intake record for January revealed the CNA’s had documented an average of 50% meal consumption f or breakfast, lunch and dinner. (9) According to the Medication Administration Record, the dietary recommendation for Ensure twice daily was not started until 01/07/00. In addition, the nurses documented the resident either refused the Ensure or consumed only 50% of the supplement since ordered. Even though the nursing staff had documented the resident as eating poor, not consuming sufficient amounts of the Ensure, and losing weight, there were no further Dietary progress notes or other interventions implemented to prevent further nutritional decline for resident #6. . (10) Based on the above findings during the Class II revisit of 01/27/00, surveyors determined the facility did not implement methods to ensure residents would not sustain further decline in nutritional status. This is in violation of rule 59A-4.110, F.A.C., uncorrected Class I deficiency, carrying in this instance a $5,000 civil penalty. 4, The above referenced violations constitute grounds to levy this civil penalty pursuant to Section 400.102(1), 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. 5. Notice was given in writing 1 to the respondent of each of the above violations and the time frame for correction, ELECTION AND EXPLANATION OF RIGHTS FORMS ATTACHED 6. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY ONE en DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN Al ADMISSION OF THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. 12 5 Reames i te ae 2 1 HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Mark Fowler, Administrator, Margate Health Care Center, 5951 Colonial Drive, Margate, Florida 33063, Delta Health Croup, Inc., 125 West Romana Street, Pensacola, Florida 32501, and to CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on XT, 2001. DIANE AND, Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, FL 33407 Copy to: Nursing Home Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Alba M. Rodriguez, Assistant General Counsel Agency for Health Care Administration 8355 N.W. 53rd Street Miami, Florida 33166 Gloria Collins _ Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 NOTE: In accordance with the Americans with Disabilities Act, persons needing a special accommodation to participate in this proceeding should contact Alba M. Rodriguez, Assistant General Counsel no later than fourteen (14) days prior to the proceeding or hearing at which such special accommodation is required. Alba M. Rodriguez may be. contact at 8355 NW 53rd Street, Miami, Florida 33166. Telephone: (305) 499-2165 or 1-800-955-8770 (voice) via Florida Relay Service. 13 wee ceeniee mri cerenmem ie gee nee pe wen

Docket for Case No: 01-003147