: OL S266 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO 8-01-0078 NH FLORIDA LIFE CARE, INC., cs d/b/a INTEGRATED HEALTH SERVICES ~~ OF VENICE NORTH, Respondent / a - ADMINISTRATIVE COMPLAINT ALND ERS COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, files this Administrative Complaint against Florida Life Care, Inc., d/b/al Integrated Health Services of Venice North (“hereinafter IHS of Venice’) pursuant to 28-106.201 Florida Administrative Code (2000) (F.A.C.) and Chapter 120, Florida Statutes ("F.S.") and hereinafter alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Seventy Five Thousand dollars ($75,000), pursuant to Section 400.121 F.S. JURISDICTION AND VENUE UNIV S. See 2. This court has jurisdiction pursuant to Section 120.569 and 120.57 F.S. and Chapter 28-106 F.A.C. 3. Venue lies in this Court, Department of Administrative Hearings, pursuant to 120.57 F.S and Chapter 28 F.A.C. PARTIES 4. AHCA, is the enforcing authority with regard to skilled nursing facility licensure law pursuant to Chapter 400, Part Il, F.S. and Rules 59A-4 F.A.C. 5. JHS of Venice is a skilled nursing facility, located at 437 South Nokomis Avenue, Venice, Florida 34285 and is licensed under Chapter 400, Part Il, F.S. and Chapter 59A-4. F.AC. COUNT I IHS OF VENICE FAILED TO KEEP RESIDENT FREE OF ABUSE 59A-4, 1288 F.A.C. 415.102 (1) F.S. AND 400.022(1) F.S. (Tag F223 - ABUSE) CLASS II _ 6. AHCA realleges and incorporates (1) through (5) as if fully set forth herein. 7. Based on interviews, conducted 7/25-26/01, of Resident #29, a random sampled s very little vision in the other eye) and resident (who only has one leg, is blind in one eye and ha: her family member, and staff and record review, the facility failed to provide the resident with an environment free of verbal and/or mental abuse, on at least one occasion. 8. On 07/25/01, Resident #29, in the presence of her family member, told surveyor that she had had trouble with the staff not responding to her call lights in a timely manner and that about two weeks prior to this interview, she had to yell for help because the staff would not respond to the call light. She further stated that the staff member who answered her call, a third shift nurse, demanded she stop hollering and threatened to make her stay in bed all day, something which made her cry and feel like "a caged animal”. 9. The resident also stated staff did not always help set her meals so that she could eat and drink and mentioned that, given her poor vision and only one leg, she was increasingly dependant on staff to the point of having to ask them to identify for her what food items she was being served. 10. Review of the resident's Minimum Data Set (MDS) revealed that Resident #29’s cognitive skill for daily decision making had been assessed at 0, or “Independent-decisions consistent/reasonable”. 11, The facility’s policies and procedures define mental abuse as: humiliation, harassment, threats, punishment or deprivation and verbal abuse as: oral, written, or gestured language including, but not limited to, disparaging or derogatory terms directed to or within patient’s resident's hearing distance. 12. Based on the foregoing, IHS of Venice violated 59A-4.1288 F.A.C. and 400.022(1) F.S. and 415.102(1) F.S. herein classified as a class II violation, and carrying, in this case, an assessed fine of $2,500.00. . COUNT I IHS OF VENICE FAILED TO MAKE PROMPT EFFORTS TO RESOLVE RESIDENT GRIEVANCES. 400.022(1)(d) F.S. (Tag F 166 - GRIEVANCES) CLASS II 13. AHCA realleges and incorporates (1) through (5), as if fully set forth herein. 14. Based on interviews conducted 07/25-26/01, with a Resident #29, her family member, staff and record review the facility failed to resolve a grievance, filed on or about 7/10/01 by a family member, on behalf of the resident, concerning the issue that a third shift nursing staff member had verbally abused the resident and caused the resident mental anguish on 7/09/01. 15. During the interview with surveyor, Resident #29 stated that she formally ° complained, through the facility's written grievance process concerning the abuse noted in paragraph 8 above, by completing a grievance form, provided by a day shift nurse, to whom the resident recounted what had happened and to whom she and her family member submitted the completed form. 16. According to the resident and her family member, a couple of days later, the same nurse was asked if there had been any response to the grievance, and after checking, she told the family member that no action had been done on it yet. 17. The family member, who provided the surveyor with notes about the incident and her efforts to get a response from the facility, stated she had filed a total of three grievances during the past few months and had also spoken to the Administrator about resident’s concerns, but that the facility had failed to respond to any of these grievances. , 18. One of the notes, submitted by the family member, recounted: "Third Shift: Mother had her light on for a long time... finally had to yell for help because she had to go to the bathroom. Finally, staff member came and asked who was yelling. Mother said, ‘It's me, I need abed pan...” Mother got it, she did her job, but the staff said she had wet the bed (Maybe Staff didn't know how to place it.) Staff had threatened that Mother might have to stay in bed all the next day." 19. Another note recounted how staff member, who had received the grievance from the family member, had read it, after it was given to her; had taken it downstairs and placed in an incoming mailbox for the Administrator and/or Director of Nursing (DON); and had, after being asked by the family member, asked the DON about the grievance, and related back to the family member that the DON had stated she had no knowledge of the grievance. 20. Review of the 11/00-7/01 grievance logs by surveyor, failed to produce any trace of the grievance. 21. On 7/26/01, and again during the exit conference, the Administrator was asked to furnish a copy of the grievance filed by Resident #29, but was unable to do so. 22... The facility’s policies and procedures concerning the investigation of alleged abuse or neglect state, in part: “ ...health care center collects, retains, and safeguards all information and evidentiary material pertinent to the investigation of the alleged abuse or neglect. Investigations are always prompt, comprehensive and responsive to the situation, well conducted, and contain founded conclusions.” 23. Based on the foregoing, IHS of Venice violated 400.022(1)(d) F-.S., herein classified as a class II violation, and carrying, in this case, an assessed fine of $2,500.00. COUNT III IHS OF VENICE FAILED TO DEVELOP AND/OR IMPLEMENT WRITTEN POLICIES AND PROCEDURES TO PROHIBIT MISTREATMENT, NEGLECT AND/OR ABUSE OF RESIDENTS. 59A-4.1288 F.A.C. (Tag F224 - STAFF TREATMENT OF RESIDENTS) CLASS I 24. | AHCA realleges and incorporates (1) through (5) as if fully set forth herein. 25. Based on record review, observation, and interview, it was determined the facility permitted at least 4 of 27 active residents to be neglected by failing to assure that residents: (a) did not have avoidable declines in Activities of Daily Living (ADLs); (b) who are declining in their ability to feed themselves, receive appropriate, timely assistance to maintain good nutrition; (c) who are experiencing weight loss, receive appropriate, timely evaluation by the Registered Dietician (RD); (d) with weight loss or abnormal fluctuations in weight, are re- weighed in accordance with facility policy and procedure; (€) at risk for pressure, sores do not develop avoidable pressure sores; (f) who develop pressure sores, are appropriately assessed by the interdisciplinary team; (g) who have developed pressure sores, have appropriate care plans, that are reviewed and updated, as needed; (h) who are on psychotropic medications, are evaluated on a monthly basis by a RD; (i) do not develop adverse drug reactions; and, (j) with repeated falls, have appropriate interventions. 26. The facility also failed to assure communication systems were in place so that Certified Nursing Assistants (CNAs) alert nurses to changes in residents’ conditions and nurses communicate these changes to RD, physicians and other professionals involved in the residents’ care. 27. Resident #9 was admitted to the facility on 8/25/98, with diagnoses, which included psychosis, organic brain syndrome, anemia, and dementia other than Alzheimer’s, hypothyroidism and depression. 28. Neglect of this independent resident by facility staff, contributed to his becoming total care and bedfast within 8 weeks. 29. On 4/5/01, using the MDS, Resident #9 was assessed an (al) for Mood and Behavior for making negative statements up to 5 times a week; a (b2) for asking repetitive statements almost daily; an (i2) for making repetitive anxious complaints almost daily; and an (n2) for having repetitive physical movements almost daily. 30. On 6/11/01, a significant change was completed concerning this resident, in which the resident was noted as withdrawing from activities almost daily (02); and having reduced social interaction (p2), with all other behaviors on both assessments coded as not occurring in the past 30 days (0). 31. Under Section G1, (Physical Functioning and Structural Problems), the resident had been assessed, on 4/5/01, as continent of bowel and bladder, independent in the self performance of ADLs; needing no ADL support from staff for bed mobility, transfer, walk in room, walk in corridor, locomotion on unit, dressing, eating, and toilet use; and, with only a need for assistance with personal hygiene, where she was assessed as needing extensive assistance with one person physical assist. 32. On 6/11/01, the resident was assessed as incontinent of bowel and bladder and needing: limited assistance and one person physical assist to bed mobility; extensive assistance and one person physical assist for transfer; extensive assistance and two person physical assist for walking in room; and, total assistance with one person physical assist for locomotion on the unit and off the unit, dressing, eating, toilet use, and personal hygiene. 33. On 4/5/01, the resident was assessed as having no problem conditions but, by 6/11/01, the resident was assessed as having unsteady gait. 34, On 4/5/01 the resident’s weight was noted at 149 pounds, while on 6/1 1/01, it was recorded at 133 pounds, denoting a 10.7% weight loss in approximately 9 weeks. 35. Record review of nurses’ notes from 3/10/ - 4/2/01, reveal that Resident #9, on at least 16 documented instances, walked to the nurse's station and requested food and a note on 3/20, indicated that a request had been "sent to dietary requesting an increase in portion size as the resident complains of being hungry throughout the day”, while another note, from 3/27/01, states, "continuously asking for food and shovels food in her mouth all at once - displays almost compulsive behavior for food - difficult to redirect." The surveyor could not find any documentation, in dietary notes, that these requests for increased food portions were ever i 1 ; 0 See BARRE TE implemented and 4/4/01 dietary notes concerning this resident indicated the resident to be on regular diet. . 36. From 4/3 through 4/26/01, nurses’ notes document resident requested food at least 14 more times, and facility food consumption records for the month of April 2001, reveal that up until 4/16/01, the resident usually consumed 100% of her breakfast, 25 to 50% of her lunch, and 50 to 75% of dinner, but, that, after April 16", the resident was noted to consume about 50 to 75% of her breakfast, 50% of her lunch, and 25 to 50% of her dinner. Her weight was noted to be 147.2, down from the 149.2 pound weight recorded on 4/2/01. 37. On 4/11/01, a Care Plan meeting was held and a nurses’ note entry on that date states, "Care plan reviewed. Continue plan of care. All disciplines present. Legal guardian present.” 38. Food Consumption documentation during May, continued to show decreased intake by the resident and by 5/31/01, the resident's weight was recorded at 135.6 pounds, denoting a 7.88 % weight loss in 30 days. 39. On6/11/01, the resident was reassessed, due to a significant change in status since the resident had had severe weight loss, was falling, could no longer ambulate independently, was utilizing a wheelchair, could no longer feed herself, had become incontinent of bowel and bladder, and required extensive assist with ADLs. Her diet was downgraded from regular to pureed food, due to difficulty with chewing. 40. A 6/4/01 dietary note by the Certified Dietary Manager (CDM), indicated the resident to be on Med Pass 2.0, to be increased to 120 cc's three times a day, however, a physician's order for Medpass 2.0 was not obtained until 6/4/01, so the dietitian could not request , an increase to the Medpass 2.0 until then. A review of the Medication Administration Record (MAR) indicated that the resident was not on Med Pass 2.0. 41. On6/5/01, the facility obtained new laboratory data which revealed that the resident had a mildly low Calcium level of 8.2 (8.4 -10.2 MG/DL), a mildly low T. Protein level of 5.9 (6.3 - 8.2 G/DL), and a moderately low Albumin level of 2.4 (3.0 - 5.0), but there was no additional dietary intervention. 42. On6/8/01, a note shows the CDM requested a "diet consistency downgrade to Puree. Resident not wanting to chew-trial was tolerated and accepted, resident is being fed by staff." and that on 6/11/01, the CDM assessed the resident to need 1522 calories per day, 60 grams of protein, and 1800 cc's of fluid. - 43. The facility's Dietetic Services Standards of Practice (DSSP), provided to the surveyors, states in part: "The Nursing staff notifies the Dietetic Services Department if a patient/resident meets any of the following criteria: 1B. Weights - Weight loss/gain of 3% in one week, 5% or more in 30 days, 7.5% or more in 90 days, 10% or more in 180 days. 1C. Appetite - Decrease in oral (p.o.) intake to less than 50% over a 3-day period (4 points in 8 point system). 1D. Labs: Abnormal values for the following: Albumin/Prealbumin, NA+/K+/CL-, Iron, Hbg/Het, Hbg AIC, B12, BUN/Creat, Glucose, Folic Acid, Fluctuating finger-stick glucose results. Refer to: _Table of No Normal Lab Values i in appendix. 2. After notification of changes or . problems, the Dietetic Services Director or designee and/or Dietitian develop and implements : an appropriate action plan within 3 days. The problem and specific actions taken to correct the problem are noted in the nutritional care progress notes and in the plan of care." Nonetheless, a RD did not evaluate the resident until 7/26/01, after surveyor discovered 2 Stage TI pressure ulcers. 44, On 7/25/01, surveyor discussed the resident’s condition with the DON, MDS Coordinator and RD and in response to the surveyor's question about the weight loss, staff stated that they did not know that the resident had lost weight until she was reweighed at the end of May. . 45. The surveyor then asked what system was in place for nursing to communicate concerns to Dietary and the RD responded that she had only been at the facility since 7/6/01 and that she had established a system for lab results to be placed in a box, but that she was not sure what system the previous RD had utilized. 46. During survey, on at least two separate occasions, the facility was asked for a copy of its policy regarding communication between Dietary and Nursing, but the facility did not produce the requested documentation. 47. On 7/26/01, during an interview with surveyor, the resident’s attending Psychiatrist stated, that he had seen the resident on 5/4/01 and again on 6/15/01, but that the facility had failed to inform him of the significant change in the resident's weight. 48. A review of nurses’ notes revealed the resident had fallen in the dining room on 4/6/01, and that by 5/10/01, she was lethargic and utilizing a wheelchair to ambulate. The notes recorded that resident suffered falls on 4/26/01, 5/7/01, 5/16/01, 5/23/01, 5/28/01 and 5/29/01, with increasing lacerations, and with 5 falls occurring within the month of May. 49. Anurse’s note, dated 5/16/01, noted that the resident’s legal guardian, "requests that medications be reduced,” and that "Fax sent to Dr. (name omitted).” 50. The facility had incident reports indicating the resident falls, but the only recommendations noted to prevent further falls was a request for Physical Therapy (PT) . é evaluation on 5/7/01, and on 5/29/01 request to check with the physician for possible urinary tract infection. 51. Areview of the resident's care plan indicates that, in response to the resident many falls, the facility removed the bedside table and moved the resident to a bed by the door, added a pressure monitor to the bed and added a TABS unit to her wheelchair. 52. On 7/23/01, surveyor observed the resident in her room finishing her lunch. The next day, surveyor spoke to the resident and noted that the resident appeared very thin, and was jumpy in bed, with lots of involuntary leg and arm movement and with tongue thrusts. The next day, the surveyor again observed the resident in bed, and noted that the resident still had involuntary leg and arm jerking. At approximately 4:45 P.M. on the same day, the surveyor, this time accompanied by another surveyor, again observed the resident’s jumpy behavior, involuntary leg and arm movements and tongue thrusts. oo 53. Failures of assessment and communication between facility staff, consultant pharmacist and attending psychiatrist, also allowed Resident #9 to develop adverse drug reactions. 54, Review of the resident’s April MAR, revealed the following medications: Risperdal 0.5 mg. 1 tablet by mouth (PO) at hour of sleep (HS); Prozac 20 mg. 2 capsules PO every moming; Megace 40 mg/ml oral suspension 20 ml once a day; Cytomel 5 meg tablet take 1 1/2 once daily; Mag Delay tablet SA (64 mg.) 1 tablet PO three times a ay (TID); Depakote 500 mg. tablet EC (enteric coated) 1 tablet PO TID. On 4/3/01, the following medications were started: Klonopin 0.5 mg. at HS PRN (as needed) (discontinued on 4/6/01); Risperdal 0.5 mg. 1 tablet PO at HS, changed to 5 PM and Risperdal 1.0 mg. 1 tablet at HS added; Tigan 100 mg. 11 twice a day before meals as needed for nausea, and Exelon 1.5 mg. twice a day (BID) after meals (@C). 55. In May, medication changes included dadding Ambien 5 mg. at HS times 1 month; Depakote 500 mg. EC, changed to Depakote 500 mg. ER (carly release); Tigan discontinued on 5/4/01; and Risperdal, discontinued on 5/18/01, after guardian requested decrease in medications. 56. InJune, medication changes included discontinuing the Depakote ER on 5/31/00; changing the Exelon 1.5 mg. capsules on 6/15/01 from BID PC to Exelon 1.5 mg. PC every morning and 3 mg. every evening PC; and adding Periactin 2 mg. PO before (AC) dinner on 6/15/01. 57. In July, medication changes included discontinuing the Prozac on 7/5/01; discontinuing the Megace on 7/11/01; discontinuing the Exelon on 7/23/01; starting Trazodone 25 mg. 1 tablet every morning and at 1 PM and Trazodone 50 mg. 1 tablet at HS on 7/6/01; discontinuing the Trazodone on 7/19/01; adding Seroquel 25 mg. 1 tablet PO BID on 7/19/01 and then increasing it to 50 mg. 1 tablet PO BID on 7/21/01. 58. Side effects of Klonopin, include drowsiness, tremors, confusion, psychosis, agitation and Ataxia. This medication was discontinued by Psychiatrist on 4/6/01, when he learned from staff that resident had been complaining of dizziness and drowsiness since she began receiving the medication. 59. Side effects of Depakote, include sedation, emotional upset, depression, psychosis, hyperactivity, behavior deterioration, muscle weakness, tremor, lack of coordination, increased appetite, increased weight gain, and anorexia. A note by the attending Psychiatrist on 5/4/01, noted, “Doing a little better but staff report up at night and up and down during the day. 12 ecm Food ok. Medication evaluated. No nausea, Tigan has been discontinued. Appetite decreased but eating enough. Weight is stable. Will add Ambien for 1 month.” 60. Side effects of Mag Delay, taken by the resident since at least 4/01 include flaccid paralysis, drowsiness, and stupor and those for Cytomel, include nervousness, insomnia, tremor, and weight loss. 61. Side effects of Risperdal, taken by the resident since at least 4/01, include extrapyramidal symptoms, insomnia, agitation, anxiety, tardive dyskinesia, and aggressiveness and this medication was discontinued on 5/18/01, only after the legal guardian requested a decrease in medication and after the resident had fallen several times. 62. Side effects of Prozac, include nervousness, anxiety, insomnia, drowsiness, tremor, anorexia, and weight loss and this medication, taken by the resident since at least April, was discontinued on 7/5/01. 63. Side effects of Exelon, include decreased appetite and dizziness. 64. Side effects of Periactin, include drowsiness, dizziness, fatigue, sedation, sleeplessness, in coordination, confusion, restlessness, insomnia, tremors, seizures, and weight gain, 65. Side effects of Trazodone, include drowsiness, dizziness, nervousness, fatigue, confusion, tremors, weakness, insomnia, anorexia, nausea, and vomiting. 66. Side effects of Seroquel, include anorexia. 67. Anote from Psychiatry on 6/15/01, reveals the following: “History of patient reviewed with staff. Appetite ok - needs to be fed. Sleep - ok. Now needs to be fed. Non ambulatory. Staff reports physical decline. Medication adjustments made since last visit due to decline and to falls,” and “Diagnosis ETOH (Alcohol) Dementia. Off Depakote and Risperdal due to falls, which is better. Still gets restless. Will increase Exelon. Do weekly weights - same scale. Add Periactin.” 68. | Anote from Psychiatry on 7/5/01 reveals the following: “History reviewed with staff. Appetite good. Sleep poor. Up at night, restless. Restless most of the time per staff. Support given, and “History reviewed with staff, Remains very restless. Says she can't stop it. Sleep poor. Will discontinue Prozac as (not legible) syndrome can have this presentation. Will go with Desyrel instead. Support given. Continue with regular assessment of her condition and manage psychotropics.” 69. Areview of Behavior Monitoring sheets for April, May, and June 200 1, reveal that the resident as having no adverse effects from the Risperdal, which was being monitored for anxiety and restlessness, and the July sheet revealed the resident as having no adverse effects from the Seroquel. "70. Review of the monthly Consulting Pharmacy reviews, reveal that the Pharmacist did not make any recommendations concerning possible drug interactions during April, May, or June, except to note, on 4/30/01, that Depakote ER was now available and was preferred over Depakote EC due to cost equal to or less than current therapy and fewer Gastrointestinal and central nervous system side effects. 71. The Pharmacist also recommended avoiding the use of Tigan in elderly patients due to extrapyramidal side effects, but the resident did not receive any PRN Tigan in April or May and the medication was discontinued on 5/4/01. | 72. The only other recommendation made by the Consulting Pharmacist on June 27, was to note that Megace and Periactin were duplicate drug therapy and to recommend discontinuance of Megace, which was done. 14 73. The Consulting Pharmacist report did not address possible drug interactions which might be contributing to the resident’s rapid decline in ADLs, falls, weight loss, and possible causes of involuntary muscle movements and tongue thrusting. 74. On 4/3/01, after a 4/2/01, request was made for evaluation by a Psychiatrist, who increased the resident's Risperdal from 0.5 mg. 1 tablet at bedtime to Risperdal 0.5 mg. at 5 PM and Risperdal 1.0 mg. at bedtime and started the resident on Exelon 1.5 mg., twice daily after meals. 75. Resident #9 also developed two unidentified, avoidable Stage II pressure sores at the facility, which were observed by a staff nurse and surveyor during survey, on the resident’s left buttocks. The wound care nurse (wc nurse), unaware of these pressure ulcers, was summoned, and she measured the pressure ulcers to be approximately 5 cm round and 1.0 by .7 em. A review of skin checks by the CNAs, revealed that the resident's skin was noted to be clear from 7/17 through 7/24/01 and the skin check, was not completed when the pressure ulcer was discovered. 76. Review of the resident's care plan revealed that, on 6/1 1/01, the resident was noted to be at risk for significant decline in continence of both bowel and bladder; with potential for skin breaking down; and, bedfast, by choice, most of the time. It stated, as goal, to have no skin breakdowns and prescribed that resident was to be checked and repositioned every 2 hours, to be provided skin care with incontinence, moisture barrier cream to skin; have briefs changed when soiled; be assessed for signs of skin breakdown during incontinence care; and have weekly body checks with documentation. Facility staff was also to notify MD for treatment upon signs of breakdown. 77. Areview of a Braden Scale Risk Assessment, used to predict resident risk of pressure sores (Braden Scale) rated the resident at a 12 for risk of a pressure sore in June and at a 13 in July. The Braden Scale rating considers that, "Adult patients with a score of 18 or below are considered at risk.” 78. During the survey, the resident was never observed out of bed, was always noted on her back and nursing staff could not explain why the resident had developed the pressure ulcers other than to suggest that her involuntary movements might have caused skin shearing. 79. Acare plan for care of the Stage I pressure sores was not completed until after discovery of the pressure ulcers by surveyors on 7/25/01. 80. Anote was sent to the resident's primary care physician on 7/17/01, regarding the resident continuing, "to have constant repetitive movements. Jumping up and down - punching the pillows over and over - pulling off pants and removing feces getting it everywhere. Currently taking Deseryl TID. Not helping at all. Pleas Advise.” The primary care physician suggested that the attending psychiatrist be consulted, who changed medications, as noted above. 81. The consulting pharmacist review, dated 2/28/01, revealed that, Abnormal Involuntary Movement (AIMS) retesting “is now due.” Nurse response notes, "done", but a review of the resident record revealed that the AIMS test had been initiated on 3/1/01, but had not been completed. In an interview with the DON, RD, and MDS Coordinator on 7/25/01, surveyor showed the incomplete AIMS test to the DON and asked if she knew why it had not been completed, but the DON could not explain why the test had not been completed. 82. On 7/25/01, during an interview with surveyor, the attending psychiatrist stated that he had been first been made aware of the involuntary movements and tongue thrusting of the resident on 7/5/01. 83. As noted above, the resident was reported to have no adverse effects from the use of Risperdal by facility staff on the Behavior Monitoring Sheets. 84. Resident #26 developed a severe weight loss of 11% over 6 months and failure by the pharmacist and interdisciplinary team to assess, intervene and communicate resulted in an avoidable weight loss. 85. Resident #26 was admitted to the facility 11/18/99 with diagnoses including seizure disorder, hypertension, depression, severe dementia, and cerebral vascular accident and his medications included Levothroid, Dilantin, Norvasc, Lanoxin, and Glucophage. 86. The most current quarterly MDS, dated 5/10/01, coded the resident as needing extensive one person physical assistance with eating. 87, 5/13/01 laboratory values results, concerning the resident, documented the following values, all outside of desirable range: calcium 9.2 (desirable 9.4 to 10.2), an indicator of protein malnutrition, glucose elevated at 134 (desirable 65 to 105), and blood urea nitrogen/creatinine ratio, an indicator of hydration status, slightly elevated at 21 (desirable 8 to 20). 88. The most recent nutritional assessment by an RD dated on 6/17/00, specified usual body weight at 124 pounds. All succeeding assessments and progress notes on this resident were entered into the record by the CDM. 89. Facility weight records reflect the resident's weight at 127 pounds on 1/03/01 and at 118 pounds on 3/15/01, showing a 7.1% weight joss in 2% months. 90. On3/19/01, the CDM entered the following progress note into the medical record: "Resident continues with gradual weight loss. PO (by mouth) intakes are minimal at times. Request a fax to Dr. for order of Med Pass 2.0, 2 oz. QUID (four times daily). Nonetheless, the order for the supplement was not obtained until 3/30/01. 91. On 5/7/01, CDM did note a slight increase in weight, with the addition of the supplement and noted no food issues at this time, recommending to continue with current plan of care, and follow through Standards of Care meetings. 92. The most current dietary progress note, entered on 5/16/01, as a result of a care plan meeting for quarterly update, noted that the care plan had been reviewed and updated and stated: "Continue with CPOC (current plan of care). "But, the note did not address the 5/13/01 laboratory values that were out of desirable range. 93. The updated 5/16/01 care plan, listed the problem of continued weight loss related to poor and fluctuating oral intakes of food and fluids and noted the stated goal as "Weight to remain above 115# through NRD (next review date). "No recommendations were made for laboratory values to assess status of protein stores, determine hydration status, or monitor glucose control, despite documented poor oral intake. No recommendation was made to increase the supplement to promote weight gain to previous usual body weight. 94. Further review of the facility's weight record revealed that the resident's weight had declined from 119 pounds on 6/01/01, to 113 on 7/01/01, or an 11% weight loss over a 6 months period. No weights, after 7/01/01, were found for this resident, at the time of survey. At surveyor request, the resident was weighed on 7/26/01 with clothing, and her weight was recorded at 106 pounds, showing 16.5% weight loss since 1/03/01 and a 13.1% weight loss in less than 3 months. 95. Review of the 7/3/01 Standards of Care Meeting minutes, showed that this resident was discussed at, that meeting and the resident’s 11% weight loss to 113 pounds, over 6 18 months, was noted, but no recommendations resulted from this meeting, except a request for Hospice consult on 7/17/01. No documentation was found to evidence that the increase nutritional risk of this resident’s severe weight loss was assessed as a result of this meeting. 96. Minutes of the Standards of Care meeting, held on 7/17/01, reflect the weight of 7/01/01, as no more current weight had been obtained, and these minutes recorded the recommendation to increase the supplement and review of physician's orders on 7/26/01 failed to uncover any order for an increase in the supplement, as had been recommended nine days earlier. 97. Review of a 7/01/01 facility form titled "Referral For Dietitian", confirmed that this resident had not been referred to the RD, despite facility policy that all residents with significant weight loss and abnormal lab values were to be assessed by the RD. 98. Several of the resident’s medications, Lanoxin, Dilantin, Levothroid, and Norvasc depress appetite and the resident’s Dilantin dosage had been increased from 100 mg. three times daily to 100 mg. twice daily and 200 mg at bedtime on 5/13/01. No documentation was found in the clinical record that the effects of these medications on appetite had been considered. 99, This resident was taking 500 mg. of Glucophage twice daily and yet the most current glucose level was recorded on 5/13/01, with no accuchecks being performed, a failure ‘that was confirmed on 7/26/01, in an interview with nursing staff. 100. Observation of the resident at the breakfast meal on 7/25/01, confirmed the resident’s poor oral intake. One staff member stated to surveyor that this resident had, "stopped eating for probably a year". At the evening meal on the same day, the resident refused to eat. 101. Another sampled resident, Resident #4 developed an avoidable pressure sore and the RD based this resident’s nutritional support, at least partly, on inaccurate weights. 19 102. Resident #4 was admitted to the facility on 5/13/01, with multiple diagnoses including pneumonia, dysphasia, cerebral vascular accident, gastrostomy tube placement, and hypertension. 103. Review of the resident’s initial nursing assessment, dated 5/13/01, noted the resident to be free from skin problems, i.e., no open areas and the last page of this document, the Braden Scale, was dated 7/18/01, a day after the stage II pressure sore was documented on the daily nurses’ notes. The DON, ADON, and the facility's we nurse, when interviewed, on 7/25/01, could not give an explanation as to why this had not previously been completed, even though the facility's policies and procedure entitled -Use of Braden Risk Assessment Tool- reads: "All patients will be evaluated using the Braden Scale Risk Assessment upon admission to an JHS facility, and prn (as necessary) as patient activity changes. Re-assessment will occur when clinically driven by change in patient status." 104. The 5/25/01 MDS on this resident, noted one Stage I pressure sore but the 5/18/01 RAP on the same resident noted the Stage I as resolved. 105. Nursing progress notes from 6/3/- 7/17/01, concerning the resident, are unremarkable for pressure sores yet, a nursing progress note dated 7/17/01, reads, "Duoderm applied to buttocks” without an explanation as to why Duoderm was applied, what type of wound is present or measurements of the covered area. 106. On 7/18/01, the we nurse charted, in the nursing progress notes, that this resident had a necrotic area on the right buttock, measuring 2.0 x 2.5 cm, and completed the Branden Scale on the same day, indicating on the wound treatment and progress record that she had assessed the wound on 7/17/01, at a time when the pressure area was unstagable due to necrotic tissue. 20 107. Record review of the CNA daily skin inspection sheets revealed the following: from June 4 - June — 11, June 25, June 28 and June 29, the resident was marked for having redness to the buttocks, as noted by a sketch drawing on which the CNA marked the area, but all other June dates are blank on this sheet including the "clear" column, indicating that a skin check was not documented on those days; on July 10 and 11, the skin was marked as clear, but July 12 and 13 both the clear and the red skin columns were checked while, "redness buttocks" was marked July 14 - 16, July 18 - 21 and July 23, with all other July dates and columns left blank. 108. Review of the nursing progress notes that correspond to the CNA daily skin inspection, failed to reveal any mention to the reported redness to the buttocks. The nursing daily flow sheets, beginning with the 6/6/01 night shift and ending with the 7/23/01 night shift, are marked - N (none) - for Dermal Uleer, yet the 7/23/01 day shift marked Y (yes) on the dermal ulcer category. 109. Conflicting information is also found in the Nutritional Assessment, dated 5/16/01, where, under comments, the RD writes “- 3m on coccyx stage I - Resident has stage I on coccyx per nursing note.” On 7/6/01, RD Dietary Progress note reads, " Right Buttock Necrotic" while the 7/6/01 nurses’ notes, do not reveal that the resident had any skin break down. Interview with RD on 7/25/01, revealed that the information would have been obtained through the wound tracking sheet and that sheet did not reveal the resident to have a necrotic area. 110. Resident #4’s 5/12/01 care plan, noted a history of Stage I pressure sores to the coccyx and stated, as approaches, weekly skin assessments. 111. The 5/16/O1care plan, revealed that the resident had a Stage I open area to the 21 3 coccyx and as goal, that the resident will have improved skin integrity by next review on 6/16/01. However, there is no further documentation related to this breakdown on 6/16/01. Review of the Treatment record for this resident reveals that the only dated weekly skin check noted in July was done on the 4th. 112. Resident #19, admitted to the facility on 4/27/01, with diagnoses, which included neurogenic bladder, hypothyroidism, peripheral vascular disease, congestive heart disease, pain, diabetes, and depression, had a 4.88% weight loss in 30 days, while under the facility’s care. 113. The resident's most recent MDS, dated 4//19/01, noted the resident's weight at 137 pounds, at that time, and also coded the resident as not having had any weight change and as not having any staged pressure ulcers or statis ulcer. 114. Review of, facility records shows resident's weight to be 135 pounds on 6/5/01 and 128.4 pounds on 7/1/01, showing a 4.88 % loss in less than 30 days. 115. Review of the resident's nutritional management record for June and July, revealed that the resident consumed nearly 100% of his breakfast, generally refused lunch and consumed 0 - 25% of dinner. 116. Laboratory results on this resident obtained on 6/1/01, revealed a mildly low Calcium level at 8.2 (8.4 - 10.2 MG/DL) and mildly low Albumin level at 2.7 (3.0 - 5.0 G/DL), but neither the CDM nor the RD suggested any dietary interventions to address the resident's protein needs, as required by facility policies. 117, On 7/2/01, the CDM wrote a note that: "Resident had a 6 4 # weight loss past month. Wife had been bringing ensure for him to drink at lunchtime because he refuses his lunch tray. Will try a diabetic resource drink to offer at lunch. (Name Omitted) refused to try the Resource diabetic fr van (french Vanila) or the Resource Fruit Beverage. He stated he likes 22 iN Ensure vanilla or strawberry. Rec (recommend) to get a doctors order for Ensure BID (twice a day). Monitor closely, weigh weekly till weight w/in (with in) stable range." An order was then obtained for the resident to start on Ensure twice a day, the only dietary intervention noted. There was also no evaluation by the RD, of the resident. 118. A nurses’ note, dated 7/2 states "sent fax to Dr re (regarding) 6# wt loss. Received orders for ensure BID. Spoke with OT (Occupational Therapy) and PT (Physical Therapy) about evaluating him due to recent declines with ADLs and ambulation”. 119. Areview of the facility's Braden Scale, completed for this resident on 7/3/01, rated the resident at 21; indicated that the resident had no limitations in walking, changing or controlling body position; noted the resident’s inadequate food consumption; and failed to reflect the observations noted in the nurses’ notes on 7/2/01, regarding the resident’s decline in ADLs and ambulation. 120. On 7/18/01, the facility discovered a stage II pressure ulcer on the resident's thoracic spine, but no additional nutritional approaches were instituted by the CDM and the resident was not referred to the RD. 121. On7/19/01, a request was made for anew Albumin level yet, during surveyor’s record review, on 7/24/01, no results were found in the resident's record. When the surveyor asked a nurse where the results could be located, she was informed that the results were not back from the laboratory. The results were finally sent in by facsimile on 7/25/01 and they revealed that the resident’s Albumin level was still low at 2.8 G/DL. 122. Arreview of the resident's care plan revealed that the facility had failed to care plan treatment for the resident's pressure ulcer, since such a care plan was not instituted until 7/25/01, after surveyor intervention. 23 6 cae fg 123. The resident was also not referred to the facility's RD until after surveyor intervention, on 7/25/01. On 7/26/01, the RD requested: Resource Protein powder 2 scoops twice a day to increase protein intake by 24 grams per day, multivitamins with minerals, vitamin C 500 mg twice a day, and Zinc 50 mg once a day for this resident. 124. Based on the foregoing, IHS of Venice violated 59A-4.1288 F.A.C., herein classified as a class I violation, and carrying, in this case, an assessed fine of $15,000.00. COUNT IV IHS OF VENICE FAILED TO ENSURE COMPLETE COMPREHENSIVE ASSESMENTS OF RESIDENTS.NEEDS. 59A-4.109(1)(c) F.A.C. (Tag F272 - RESIDENT ASSESSMENT) CLASS I 125. AHCA realleges and incorporates (1) through (5) and (27), (35) through (46) and (75) through (76) concerning Resident #9; (112) through (123) concerning Resident #19; (85) through (99) concerning Resident #26; and (102) through (110) concerning Resident #4, as if fully set forth herein. 126. Based on observation, clinical record review, interview with the facility’s DON, ADON, MDS Coordinator, RD, we nurse, CDM and CNA, the facility failed to assure the accurate and complete assessments fora at least 8 of: 27 residents, > resulting i in harm and potential ; harm to them. . 127. The RD, consultant pharmacists and nursing staff s lack of timely assessment for Resident #9 resulted in 2 unidentified, avoidable stage 2 pressure sores; the failure of RD assessment for Resident #19 and #23, resulted in avoidable pressure sores; the lack of assessment for adaptive equipment for Residents #15 and #16, resulted in these residents not having appropriate adaptive equipment, and lack of RD assessment for Resident #26, resulted in weight loss. 24 Sa etal hema bE ee 128. Through interview the ADON and RD and observation of the CNA weighing Resident #4, surveyors noted the facility’s failure to accurately assess the resident and therefore assure appropriate nutrition. 129. Surveyors also noted a lack of initial wound measurements for an in-house acquired pressure sore on Resident #4. 130. Inan interview, Resident #9’s attending Psychiatrist, stated that he had seen the resident on 5/4/01 and again on 6/15/01, but the that the facility had not informed him of the resident's significant weight change. 131. The Consulting Pharmacist report did not address possible drug interactions which might be contributing to the resident's rapid decline in ADLs, falls, weight loss, and possible causes of involuntary muscle movements and tongue thrusting. 132. Resident #20 was admitted to the facility on 6/16/01, with a multiple diagnosis inclading dehydration, cerebral vascular accident, acute change in mental status and peripheral vascular disease. 133. The initial Nursing Assessment noted the resident as having no skin breakdown and the Braden Scale on this resident, rated him 11. 134, Review of the MDS dated 7/12/01, Medicare 5 day assessment, revealed that the resident had had a stage I pressure sore within the last seven days. Since there were no RAPS attached to this MDS, the surveyor requested a copy be regenerated. 135, Interview with the MDS coordinator, revealed that an initial MDS was collected but was never entered into the system concerning this resident and hence, no RAPS was generated. The MDS coordinator stated that she was not responsible for the MDS information for this unit and that the nurse who was responsible, had been out sick for the last 3 weeks and 25 eee eres oe gee crore no one had taken over the duty of this nurse. When asked if a care plan had been completed, the MDS coordinator stated, "No", since the RAPS were not available. 136. Review of the initial care plan on this resident, dated on 6/1/6/01 reads: - at risk for skin breakdown with a goal to prevent skin breakdown. 137. Nursing progress notes, dated 6/25/01, revealed that Resident #20, at that point, had a pressure area to the left heel and a donut was applied to the ankle to prevent friction to the heel. 138. Askin assessment by the we nurse noted: "Bilat (bilateral) heels with a blister on left heel with intact fluid filled area and dark underlying tissue - R (right) heel soft and mushy - new orders read and noted". However, further review of the care plan, revealed that these areas were not reviewed on this date, and there was no documentation of approaches or goals for these wounds on the care plan. 139, On 7/26/01, when the surveyor requested to be present during a skin assessment on Resident #20, the we nurse stated that an assessment had already been performed that morning and handed the surveyor the Pressure Ulcer Report and other Skin Condition Report, which showed that as of 7/26/01, not only did the resident have a left heel ulcer, but also 2 stage IJ pressure sores to the buttocks, which the we nurse acknowledged were new to her. 140. Review of the nurses progress notes, dated 7/11/01, note the skin on the resident's buttocks to be clear and no further nurses’ notes refer to the buttock skin area, but June CNA Daily Skin Inspection forms, indicate a red area to the coccyx. 141. Further, review of the July CNA sheets, revealed that on July 10 and 11, and July 13 —25, a CNA had marked that the resident’s heels and buttocks were red, but the surveyor was unable to distinguish during what shift or which CNA filled in the CNA inspection sheet. 26 142. On 7/23/01, during observation of the supper meal in the dining room, Resident #16 was observed to have a nosey cup listed on her tray ticket, but the nurse's aide was observed giving the resident beverages in a plastic disposable cup. Interview with the nursing assistant revealed that she did not have a nosey cup for the resident's beverages and had to use a disposable plastic cup instead because, "it will bend". She also confirmed that the resident needed the nosey cup to drink the thickened liquids. Observation of the resident at breakfast on 7/25/01, revealed that the resident was able to drink thickened milk out of a nosey cup without difficulty. - 143. Review of the resident's 5/31/01 MDS, revealed that the resident had chewing and swallowing problems, but had not been coded for adaptive eating equipment and had been also coded as being totally dependent for eating. 144. Review of the 5/23/01 Nutritional Status RAP, indicated that the resident was at a risk for decreased oral intake and aspiration, was a dependent diner and was receiving thickened liquids and indicated that the facility would continue the care plan. 145. Review of the 2/26/01 Dietary Progress Notes, completed by the CDM listed, under the Adaptive Devices section, a "nosey cup” for this resident and noted that the resident was receiving a pureed, reduced concentrated sweets diet with small portions and honey thickened liquids. The note also stated that the resident ate in the dependent dining room and was fed by staff. The documentation contained no assessment for the use of the nosey cup. 146. Review of the Nutritional Assessment completed by the CDM on 5/22/01, revealed that the resident had impaired swallowing; was maximum assist with feeding, but failed to have the box for adaptive equipment checked and indicated that the resident remained on the 27 pureed, thickened liquid diet and was dependent on staff for feeding. The note did not address the nosey cup nor contain an assessment for the continued use of the adaptive eating device. 147. Further review of the clinical record, revealed that the Speech Therapist had screened the resident on 5/31/01 and that the reason for the referral was "Nutrition/Feeding”. The screening indicated that the resident had a change in swallowing status and was holding fluids/foods in mouth per the nursing staff but the Adaptive Equipment section of the screening was left blank. The Speech Therapist documented that she spoke with nursing regarding, "yerbal/tactile cues at meals, liquids by tsp (teaspoon) + (and)-keeping pt (patient) upright until oral cavity cleared. "But there was no assessment of the use of the nosey cup. Further review of the therapy section of the clinical record, revealed no assessment of the resident by the OT. 148. Interview with the DON, RD and MDS Coordinator on 7/25/01, revealed that the clinical CDM observes residents in the dining rooms and refers to therapy for evaluation for assistive eating devices. The DON stated that the CDM's referral to therapy and therapy evaluations should have been documented in the clinical record and also stated that residents needing adaptive eating devices are discussed at the SOC meetings. . 149. Review of the SOC meeting forms for 2/6/01, 2/20/01, 4/24/01, 5/15/01, 6/5/01, 7/3/01 and 7/17/01 revealed that Resident #16 was discussed at these meetings but review of the documentation revealed no indication in the Therapy, Restorative Nursing or Recommendation boxes that the resident's nosey cup was discussed or assessed, for the continued need for this assistive eating device 150. Resident #23 was admitted to the facility on 5/11/01, with diagnoses including cellulitis of the right elbow, type II Diabetes, dehydration, spinal stenosis with back pain and a 28 5 history of prostate and colon cancer and was admitted to the facility on intravenous antibiotics for his infection. 151. Review of the Nursing Assessment, completed, on admission, on 5/1 1/01, revealed under the Skin Condition section, that the resident had no wounds on admission, the right elbow was reddened and swollen with the skin intact and the resident's skin was warm and dry, with bilateral skin on heels dry and calloused and the Braden Scale rated the resident at 19. 152. Inthe Gastrointestinal section, the resident's measured height was documented as 71 inches and measured weight as 160.6 pounds, with a 30 pound weight loss since 3/22/01 noted. 153. A nurse also partially completed 4 Skin Risk Analysis and Interventions form where she/he listed the resident’s clinical conditions of Diabetes and Limited Mobility as primary risk factors for developing pressure sores, but did not include the risk factor for underweight, nor did she/he complete the nutrition section to include the risk factors for the resident's severe weight loss, current low body weight, and low serum albumin and hemoglobin levels. The Skin Condition and Hydration section was also left blank, even though the resident was admitted with dehydration. In the problem section, the nurse wrote, "Potential for skin breakdown R/AT (related to) decreased mobility." with a goal documented as, "Remain free of - skin breakdown." 154. Review of the 5/15/01 MDS on the resident, revealed that the resident had no documented pressure ulcers and the 5/16/01 RAP Summary, indicated that pressure ulcers were a triggered area, but the care plan decision column was blank. 155. Review of the 5/16/01 Pressure Ulcers RAP, revealed that the facility would not proceed to care plan for the risk for pressure sores because the resident needed limited assist with 29 “4 bed mobility; was continent of bowel and bladder; and had no open areas. There was no documentation that the resident's compromised nutritional status had been considered as a risk factor for the development of pressure sores. . 156. Review of the 5/23/01 MDS 14 day assessment, revealed that the resident continued to have no documented pressures ulcers and noted the resident’s weight at 145 pounds, showing a 9.3% weight loss in 11 days. The weight change of 5% or more in the last 30 days was coded but there was no documentation in the clinical record to indicate that the facility had assessed that the resident's further decline in nutritional status placed the resident at increased risk for skin breakdown. 157. On6/7/O1, a significant change assessment was completed which indicated that the resident had 1 stage I pressure ulcer and 1 stage IV pressure ulcer. 158. Review of the RAP Summary indicated that nutritional status and pressure ulcers had triggered and that the facility was going to care plan in these areas, but there were no RAP in the closed record to indicate that RAP had been completed in the triggered areas. 159, Review of the 6/8/01 resident's care plan, indicated that the resident had a stage I pressure sore on the right heel and a Stage IV pressure on the left heel that measured .5 cm. X .5 cm. - necrotic tissue. 160. Review of the Nursing Daily Flow Records, revealed that the nursing staff had first documented the resident's pressure ulcers on 6/8/01 and review of the nursing progress notes from 6/8/01 through 6/22/01 revealed that the nursing staff had documented the pressure sores on three occasions during this time period but from 6/12/01 through 6/22/01, when the resident was discharged but, no other notations were found to indicate that the facility conducted further assessment of the resident's pressure areas. 30 161. Review of the CNA Daily Skin Inspection record for 6/01, revealed that from 6/8/01 through 6/22/01, when the resident had the bilateral heel ulcers, the CNAs had documented that the resident's skin was clear, except for documentation on 6/13/01, when the CNA documented that the skin was clear and had open areas. 162. Further review of the clinical record revealed that there was no Wound Treatment and Progress Record completed for this resident's pressure sores. 163. Interview with the DON, revealed that she could find no Wound Treatment and Progress Record for this resident or any further data that was not in the closed record. 164. Interview with the we nurse, DON, ADON and Care Plan Coordinator, on 7/26/01, revealed that the we nurse had been working as a staff nurse on the 3 to 11 PM shift during the time of the resident's admission. She stated that she remembered that the resident's heel wounds were blisters and the left heel wound was blackened and not a stage IV, but could not remember whether she had documented this assessment of the resident's wound and admitted that the assessment of the resident's wounds that had been documented on the Care Plan, was incorrect. . 165. On 7/26/01, the Corporate Clinical Services Director confirmed that there was no further documentation regarding measurements of the resident's pressures sores and stated that, although the resident was on the "ound list", there was no assessment of the resident's wounds documented on these forms. 166. Review of the Nutritional Assessment completed by RD on 5/16/01, revealed that the RD had documented that the resident had no pressure sores and the Braden Scale was, "19, or within normal limits potential." No documentation was found to indicate that the RD assessed the resident to be at high risk for skin breakdown, even though she documented that the resident 31 rot g had lost 30 pounds in 2 months, was 84 °% of usual body weight on admission and had a very low albumin level of 2.2 g/dl in the hospital, something indicative of moderate protein malnutrition. Review of the RD's assessment of calorie needs revealed that she did not add additional calories to account for the resident's infection and need to regain his lost weight. 167. Review of the RD's 30 day note, dated 6/7/01, revealed that she had documented that the resident's laboratory data was normal, except for his hemoglobin and hematocrit, even though laboratory data, dated 5/24/01, indicated that the resident had an albumin level 2.8 g/dl (reference range - 3.0-5.0 g/dl) which was still indicative of moderate depletion of protein stores and that on 5//30/01, a 2 hour post-prandial blood glucose level of 213 mg/dl (reference range — 75-110 mg/dl) had been registered. There was nd documentation that the RD assessed the resident's elevated blood sugars or was monitoring the resident's protein parameters. 168. Further review of the Dietary Progress Notes revealed that there was no documentation after 6/7/01, to indicate that the RD had reassessed the resident's nutritional needs after the stage IV pressure sore was identified on 6/8/01. 169. At the breakfast meal on 7/24/01, Resident #15 was observed to have the following adaptive equipment: divided plate, plate guard, sippy cup, and soup spoon and review of the resident's clinical record revealed that the adaptive equipment resulted from a recommendation of the CDM as an approach to promote independence in eating. But further review revealed that OT did not evaluate this resident for appropriate adaptive equipment. | 170. Surveyor also noted at this time, that the resident might possibly benefit from a nosey cup and when the staff member feeding the resident was asked if the resident had ever utilized a nosey cup, the staff member obtained one from the kitchen. However, no nosey cup was provided to the resident at subsequent meals and the resident was not referred to OT. 32 171. Based on the foregoing, IHS of Venice violated 59A-4.109 (1)(c) F.A.C. herein © classified as a class I violation, and carrying, in this case, an assessed fine of $12,500.00. COUNT V IHS OF VENICE FAILED TO DEVELOP COMPREHENSIVE CARE PLANS FOR RESIDENTS RESULTING IN SEVERE WEIGHT LOSS AND IN HOUSE ACQUIRED PRESSURE SORES. 59A-4,109 (2) AND 59A-4.106 (4) F.A.C. (Tag F279 - RESIDENT ASSESSMENT) CLASS I 172. | AHCA realleges and incorporates (1) through (5); (27), (48) through (52) conceming Resident #9; (102) through (111) concerning Resident #4; (132) through (141) concerning Resident #20; and (85) through (100) concerning Resident #26, as if fully set forth herein. 173. Based on observation, clinical record review, interviews with the facility’s DON, ADON, RD and MDS Coordinator, the facility failed to develop comprehensive care plans on at least 5 of 27 resident, resulting in severe weight loss and/or in house acquired pressure sores. 174. Review of the nutritional care plan for Resident #28, dated 7/16/01, listed as a problem: “weight is above usual/ideal body weight — some fluctuation” and as the goal, that resident would maintain adequate nutritional intake and weight to remain within 10% of usual (160 #) through next review date. Approaches, included in the plan, were to provide diet as ordered, monitor intake and document percentage of meals consumed every day, and weigh per protocol. 175. Review of resident's weight record revealed that the resident weighed 166.6 pounds on admission, on 1/3/00, and 162.6 pounds a year later on 1/2/01, with a slow gradual weight loss over the next six months to a weight of 153 pounds on 7/26/01. 33 176. Observation of Resident #28 at breakfast, on 7/24/01 and on 7/25/01, revealed that the resident was not taken to the dining room for breakfast as per the care plan, but was fed in bed on both days. 177. Observation of the resident, at supper, in the dining room, on 7/25/01, revealed that the resident was not served ice cream, as per the care plan. 178. Observation of the resident, on 7/26/01, at breakfast revealed that the resident was in bed in a hospital gown lying on her left side, with a clothing protector on and her breakfast tray was open and untouched at the bedside. The tray contained a regular portion of scrambled eggs, 1 slice toast with margarine, 2 slices of bacon, 4 ounces of cream of wheat, 4 ounces of orange juice and 8 ounces of whole milk, but there was no hot beverage on the tray and no one was in the room assisting the resident to eat. 179. A nurse's aide, observed in the hall outside the resident's room at the food cart, was heard to state that, " all residents have been fed" and when questioned regarding the status of Resident #28, she replied that she didn’t know this resident had not been fed because she had been busy feeding two other residents. At this point, the aide entered the room, assisted the resident into a sitting position on the bed and began to give her sips of orange juice. The aide then decided that the food on the tray was cold stated that she would have to go get the resident a new tray and left the room, returning later with a new tray. 180. The CNA assigned to Resident #28 that day, stated that she left the resident in bed on shower days and fed her in her room instead of bringing her to the dining room. ‘181. The resident's profile record was viewed in the dietary computer, which showed that the resident was to receive 8 ounces of whole milk, 4 ounces of orange juice, 6 ounces of super cereal and large portions at breakfast, and a reprint of the breakfast meal tray ticket for 34 | 7/26/01 revealed that the resident was to receive on her tray that morning, 6 ounces of super cereal, 3 pancakes (large portions), 2 sausage links, 4 ounces of orange juice, 8 ounces of whole milk, 2 margarine, and choice of hot beverage. 182. Interview with the Food Service Director revealed that she had monitored the tray line for accuracy this morning and had seen the resident's tray leave the kitchen, with the pancakes, but stated that she did not know why the resident did not receive this tray. 183. Interview with the CNA revealed that the resident ate 100% of the second tray; a tray, which the CNA stated, had what was on the original tray except for the bacon, which was not available. She stated that she did not have the resident's original tray ticket and did not know she was on super foods and large portions. - 184. Interview with the Food Service Director revealed that the resident was supposed to eat in the dining room, but she was had not been there that morning and that the staff had taken the tray to the room but had delivered it to the wrong resident. She confirmed that Resident #28 received the wrong tray and she did not know who got the resident's original breakfast. . 185. Based on the foregoing, IHS of Venice violated 59A-4.109 (2) and 59A-4.106 (4) F.A.C., herein classified as a class II violation, and carrying, in this case, an assessed fine of $5,000. . COUNT VI THS OF VENICE FAILED TO PREVENT IN HOUSE ACQUIRED PRESSURE SORES. 59A-4.1288 F.A.C. (Tag F314 - QUALITY OF CARE) CLASS I 186. AHCA realleges and incorporates 1 through 5; (27) through (42), (44) through (52), and (75) through (80) concerning Resident #9; (101) through (11 1) concerning Resident #4; 35 (112) through (123) concerning Resident #19; (132) through (148) conceming Resident #20; and (150) through (170) concerning Resident #23, as if fully set forth herein. 187. Based on the foregoing, IHS of Venice violated 59A-4.1288 F.A.C. herein classified as a class I violation, and carrying, in this case, an assessed fine of $12,500. COUNT VII IHS OF VENICE FAILED TO ENSURE THAT RESIDENTS MAINTAIN ACCEPTABLE PARAMETERS OF NUTRITIONAL STATUS. 400.141. (9) F.S. (Tag F325 - QUALITY OF CARE) CLASS I 188. AHCA realleges and incorporates 1 through 5; (34) through (47), and (75) through (79) conceming Resident #9; and (112) through (123) concerning Resident #19; as if fully set forth herein. 189. Based on clinical record review, observations, interview with physician, the facilities DON, ADON and staff, and review of the pertinent facility policy and procedures and processes, the facility failed to prevent unplanned, undesirable severe weight loss and/or failed to address and intervene appropriately to normalize abnormal laboratory values, indicative of malnutrition for at least 2 of 27 residents and failed to appropriately refer weight loss issues to RD and/or to have RD provide appropriate and timely nutritional assessments and interventions for at least 2 of 27 residents. 190. Based on the foregoing, IHS of Venice violated 400.141 (9) F.S. herein classified as aclass I violation, and carrying, in this case, an assessed fine of $10,000. COUNT VIII IHS OF VENICE ADMINISTRATION FAILED TO MONITOR STAFF AND INTERVENE IN A TIMELY MANNER. 59A-4.103 (4)(c) F.A.C. (Tag F490 - ADMINISTRATION) 36 CLASS I 191. AHCA realleges and incorporates 1 through 5 as if fully set forth herein. 192. Based on observations of residents and staff throughout the facility, clinical record review, interview with residents on a individual basis and in the Resident Group Council, interviews with the administrator, DON, ADON, RD, we nurse, MDS Coordinator and staff nurses, the administrator failed to monitor staff and intervene in a timely manner, resulting in harm to at least 6 active residents, as evidenced, among other things, by failure to: follow policies and procedures; to accurately assess residents and initiate changes when a decline in resident condition as occurred; assure that staff develop up to date care plans with specific and progressive interventions; assure that a resident who develops psychosocial, received appropriate care and service; and follow the facility’s Quality Assurance Plan for correction of tag F 353, resulting in a recite of the tag. ’ 193. The Administrator did not require the DON or other facility staff to accurately assess residents and to develop specific and progressive care plans for these residents. The Administrator failed to assure that the Director of Nurses and other facility staff develop specific and progressive care plans for each resident, Refer to 279, this failure by the Administrator to require accurate assessment, specific and progressive care planning on each resident contributed to development of pressure sores and weight loss to residents. Refer to F224, F225, and F226 for evidence regarding abuse of the resident, lack of reporting to the appropriate authorities and failure to implement the facility’s policy and procedures for abuse. Refer to F272 for evidence of the facility’s failure to assess residents in a timely and accurate manner. Refer to F279, F314, and F325 for evidence of the facility’s lack of timely and accurate care planning resulting in weight loss at least 3 residents and pressure sores to at least 5 residents. 37 FR OF AS Seige eee a nar ms acme ma a Seep NEFIEEDUES Irene ce 194. The Administrator failed to assure that staff responsible for accurately assessing residents did so, and this failure to accurately assess residents contributed to residents not having specific and progressive care plans that resulted in pressure sores and weight loss. 195. Based on the foregoing, IHS of Venice violated 59A-4.103 (4)(c) F.A.C. herein classified as a class I violation, and carrying, in this case, an assessed fine of $15,000. PRAYER FOR RELIEF WHEREFORE, the Plaintiff, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: A. Enter a judgment in favor of the Agency for Health Care Administration against HIS of Venice on Counts I through VIII. - B. Asséss against IHS of Venice a total fine.of $75,000 for the violations alleged in Counts I through VIII, in accordance with Section 400.121 F.S. . Cc. Award the Agency for Health Care Administration reasonable attorney’s fees, expenses, and costs. D. Grant such other relief as the court deems is just and proper. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN ANS ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OFA FINAL ORDER BY THE AGENCY. 38 Sts a onan er a a aca: IG Ll easter: a a “Issued this 13rd __ day of fasask , 2001. ALA) lg — Harold D, Williams Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue Room 340 Ft. Myers, Florida 33901 Certificate of Service . I HEREBY CERTIFY that a true and correct copy of the foregoing complaint and election of nghts was sent by U.S. Certified Maik Return Receipt Requested to Anthony O. Brunicardi, Administrator, IHS of Venice, 437 S. Nokomis Avenue, Venice, Florida 34285, and Florida Life Care, Inc. 10065 Red Run Blvd, Owings Mills, MD 21117 and National Corporate Research, LTD., Inc. 1406 Hays Street, Suite #2, Tallahassee, Florida 32301 on thisol4 day of AueyeX , 2001. a Hardee Fatege AOTEE hs : ury Lopez Santiago Copies furnished: Pury Lopez Santiago Assistant General Counsel Agency for Health Care Administration 8355 NW 53™ Street _ Miami, Florida 33166 39 meee Harold D. Williams Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue Room 340 Ft. Myers, Florida 33901 Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Nursing Home Unit Program Agency for Health Care Administration : 2727 Mahan Drive Tallahassee, Florida 32308 40 rmmmromernaemaenaancte sun APES: BEY RASS Aon a RAY RES A COT RRS ATR A anceweeen a fl

Docket for Case No: 01-003865