‘ STATE OF FLORIDA 7 “ny, & Ep | AGENCY FOR HEALTH CARE ADMINISTRATION 4ohly) § 4 » OM, . Megs os “ STATE OF FLORIDA NE ye AGENCY FOR HEALTH CARE S ADMINISTRATION, epithet pete : Petitioner, re fe O |-Y U } 2. vs. AHCA NO: 09-01-0040 NH DARCY HALL, INC., d/b/a DARCY HALL OF LIFE CARE, Respondent. y 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 Six Thousand Four Hundred ($6,400) Dollars upon Darcy Hall, Inc., d/b/a Darcy Hall of Life Care (hereinafter referred to as "Respondent"). Ags 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 2170 Palm Beach Lakes Boulevard, West Palm Beach, Florida 33409, as a nursing home in compliance with Chapter 400 Part I Florida Statutes and Rule 59A-4, Florida Administrative Code. 3. The Respondent has violated the provisions of Chapter 400, Part I, Florida Statutes, and the Provisions of Chapter 59A-4, Florida Administrative Code, in that it failed to correct within the mandated time frame of March 2, 2001 (Section 400.23(4)(c), 28-31, These deficiencies, set forth below, were stil] uncorrected when a follow-up visit was made on 3/12-13/0]. . ° (a) Tag F 246. Quality of Life. Facility failed to meet the needs of residents. Provide liquids and not Providing personal care, Findings include: () On January 28, 2001 at 10:00 am dietary services delivered | . - | old. The family member also felt that the staff did not give the resident assistance in drinking the water. This resident had a urinary tract infection and was Supposed to be drinking lots of fluids but there was no monitoring of fluids on this resident’s chart. . (4) Observation of resident 23 on ou29/01, at 10:55 am, revealed that the resident was sitting in the hallway opposite the nursing station. The resident was unshaven, and had dry, white scaly specks in the corner of his/her eyes and on the upper checks just below the eyes. Interview with the nursing assistant caring for this resident (5) Observations conducted during the 4 days of the Tecertification Survey and interviews with staff assigned to the main resident dining room and Certified Nursing Assistants (CNAs) assigned to deliver trays to the resident’s room revealed that water was not served as a standard component of each resident's tray during meal service. The “Dining Services Protocol” states that water is to be served either at the table or on each resident’s tray at the point of meal service, (6) Interviews with a resident that resides on the “D” wing, on 01/29/01, and 01/30/01 revealed that the staff often take 45-60 minutes to answer the call bell. The resident Stated, “I almost wet myself several times, trying to wait for them to help me.” This Tesident was assessed as needing assistance With transfers, and is continent of urine and bowel. A a (7) Observation of the “D” wing and West wing during tour on 01/28/01 at 7 am revealed that the glasses of water in the Tesident rooms were warm to the touch. Some rooms had glasses dated 01/26/01, and some were date 01/27/01. One resident (#29), stated, “I could use a cold glass of water.” The water on this resident’s bedside stand was warm and dated 01/26/01. (2a) This deficiency remains out of compliance during the 3/12/01 revisit based on the following information. Based on observation, record review, and interviews, the facility did not ensure that resident received Services that accommodated their individual needs and preferences, for 4 of 17 residents (#6, 8, 9 and 13). Findings include: (1) During the tour of the east wing on 3/12/01 at 9:30 am sampled resident #6 had put on his/her call bell. The call bell is audible and visual alert that can be seen and heard on the entire East wing. Three facility staff members (dietary, CNA and a nurse) were observed within 6 to 50 feet of the resident’s room. (2) Subsequent interviews with the facility administrator and the director of nursing (DON) on 3/14/01 at approximately 11:00 am revealed all employees are required to answer call bells; the call bel] system can also be heard at the nurses’ station. At the time of the observation there were other facility staff (nurse, therapist, and unit revealed that his/her certified hursing assistant (CNA) was busy with another resident and would be there as soon as Possible. At the time the nurse responded to the call for assistance. The nurse covered the resident and assured him/her that the CNA would be right in. (3) Resident #8 was admitted on 8/22/00, with diagnoses that included diabetes, hypertension, and depression. The Minimum Date Set (MDS), dated 9/04/00 and 12/04/00, for this resident revealed that the resident _was alert and oriented, with no cognitive impairment for daily decision making. He/she was also assessed as being totally incontinent of bowel and bladder, and requiring assistance with transfers and ambulation. Interview with the unit manager and staff nurse revealed that the resident was oriented and “totally able to make his/her needs know wn, make his/her own decisions, and tell you what’s happening.” (4) Interview with resident #8, during the east wing orientation tour, on 3/12/01 at 9:35 am revealed that, “the staff did not answer the call lights when you ring. Often it takes at least 15 minutes, so if you have to 80 to the bathroom, you end up. wetting yourself and then Sitting in it.” He/she also Stated, “T never used to be wet or use diapers before coming in here”. At 9:40 am, the resident stated, “I’m stil] waiting for Someone to give me my morning care. The nurse who was with the Surveyor stated that, “someone will be here shortly.” At 10:20 am the surveyor returned to this resident’s toom. The resident stated, “they usually get me up by 10:00 am, but I’m not up yet. I also moved my bowels and am dirty. I told the nurse at 9:40 am when getting my meds (medications), and I’m still lying here”. Interview in the early afternoon, with the resident revealed that, “they finally got me up in time for lunch”, (5) On 3/13/01, at 8: :25 am, resident #8 was lying in bed with the head of the bed elevated. At 9: 45 am, observation and interview with the resident revealed that he/she remained in the same Position. The resident Stated, “T’ve been waiting an hour to have someone come in and change my diaper, as “I’ve had to wet (urinate) and dirty. I had to move my bowels at approximately 8:25 am. I told the nurse at that time (8:25 am) and she said someone would be is shortly, but no one has come in yet”. At 10:10 am, this was brought to the attention of the unit manager, at which time the resident was given care. ; cso aus (6) Resident #9 was admitted on 12/22/00, and readmitted on 01/04/01, with diagnoses that included hypertension, depression, Osteoarthritis, and primary diagnosis (per the unit manager) of a right total hip arthroscopy. The MDS, dated 01/03/01, revealed that the resident was, “frequently incontinent of urine” and alert and oriented with no cognitive impairment for daily decision making. The MDS, coded as an admission assessment, (with a dated care plan dated )1/19/01), was not dated, but indicated that the resident was now totally continent of bowel and bladder. He/she was assessed as requiring limited assistance with transfer and ambulation, and used a walker. Interview with the resident revealed that he/she quite frequently needs the help of staff to g0 to the bathroom and get out of bed. During the Orientation tour, on 3/12/01, at 10:00 am, the resident stated that, “when I’m in bed and ring the call light for help, it often take up to 10-20 minutes for someone to come, especially on Saturdays and Sundays. He/she State, “I never used to wear diapers, but they put them un me, and if they don’t come, I have to wet it and then they change the diaper.” (7) During tour conducted on March 12, 2001, at 9:00 am, a family member of resident #13 had stated to the surveyor that the facility was lacking the direct care staff, namely nursing assistants, to provide care to the residents, The family member Stated that one night he/she stayed all night with his/her relative, and no staff members came in to check on the resident from 8:00 pm until 8:00 am the next morming. The relative also stated that it often takes as long as one-half of an hour to get help when the call bell is rung, sometimes as long as an hour. The family member stated one time his/her relative soiled him/herself while waiting for assistance from staff, and this hurt his/her dignity. This is in violation of rule 594-4.1288, F.A.C., uncorrected Clas: Meficiency, carrying in this instance an $800 civil penalty. (b) Tag F278. Resident assessment. The assessments did not accurately reflect the resident’s status. Based on record review, interviews and observation, the facility did not ensure that for 4 of 31 sampled residents, the assessments were accurate to reflect the relevant care areas of the resident’s status and needs, and they were signed as complete by a registered nurse (#27,24,28, and 21). Findings include: (1) Resident #27 was admitted to the facility following a hospital stayed on 9/22/00 with diagnoses of urinary tract infection and pneumonia. Further review of the record revealed the resident was transferred to the hospital for an evaluation on 10/04/00. According to the transfer record the resident was, “not responding to antibiotic therapy.” Review of the comprehensive assessment dated 10/06/00 indicated that there had been no hospital Stays in the last 90 days and no visits to the emergency room (ER). . (2) Closed record review of resident #28, revealed that the resident’s Minimum Date Set (MDS) dated 7/28/00 indicated in section “G” Physical Functioning... that this resident is independent or Tequires supervision only, in walking, transferring, locomotion on unit, eating, toilet use, personal hygiene, and bathing. The MDS further indicated this resident has no problems with balance. Review of the nursing progress peep ae ee notes and the Interdisciplinary Care Plans dated 7/28/00, indicted this resident required extensive assistance with dressing, toilet use, personal hygiene, and bathing. The Care Plans indicated in Problem #1, that this resident is at risk for fall due to history of falls, wandering, unsteady gait, and a fall risk of 17. The Rap Summary dated 7/28/00 f indicated the resident had an unsteady gait and required supervision for most Activitie Daily Living. The MDS dated 10/27/00, section “G” Physical Functioning... indicated the resident required extensive assistance in transferring between surfaces, but walks independently in his/her room, corridor, and on the unit. Record review of nursing Progress notes and the facility occurrence log, indicated this resident required supervision ambulating, and sustained several falls and skin tears in the months of July, August, September and October. Section “J”, Health Conditions, indicated this resident had not sustained any falls in the past 180 days. (3) Record review of Resident #21, revealed that this resident was receiving treatments to a skin ulcer on the left mid calf since 9/25/00, and continued to Teceive treatment to this ulcer. Review of the wound care Physician/Podiatrist’s progress notes, revealed that on 9/27/00, the area appeared necrotic, and at one point, was debrided. Review of the Interdisciplinary Care Plans revealed that problem #5 stated, “Resident has a non-healing ulcer on the left leg.” Interview with the wound care nurse on 01/31/00, revealed that this resident was still receiving treatments to the ulcer on his/her left leg. Review of the current MDS dated 12/27/00, and the previous MDS dated 9/27/00, for this resident, revealed that section “M”-Skin Condition, had documented that this resident had no ulcers, no history of ulcers, no other skin problems or lesions, and TOE re Rg rE nn pr ee eee PEN eee pee FETT rome OR BB bee | (4) Resident #24 Was admitted on 8/13/00. The Minimum date set (MDS) assessment dated 11/01/00 was in the record. Interview ‘with the MDS of this assessment revealed that it was not signed or dated, as complete, by the RN Assessment Coordinator. When this was brought to the attention of the MDS Coordinator, he/she signed and dated it on 01/30/01. (2b) This deficiency remained out of compliance during the 3/12-13/01 revisit based on the following information: (1) Resident #9 was admitted on 12/24/00, and readmitted on 01/04/01. An assessment was completed following the original admission, which was coded as “other Medicare Tequested assessment”. The assessment coded as the there is no excuse”. (2) Resident #11 was admitted on 12/20/00. The admission assessment, dated 01/08/01, had assessed the resident as having long and short-term memory loss, and Severely impaired cognitively for daily decision-making, On 02/26/01, Interview with the unit manager, assessment coordinator, and two staff nurses revealed that the resident’s cognitive status remained severely impaired and had not changed from the initial assessment. Further review of the clinical record revealed that the resident recently (01/25/01 had a gastrostomy tube inserted and he/she was unable to make this decision, so the family made the decision. The resident assessment Protocol (RAP) revealed on 01/08/01, that the staff must anticipate all the resident’ s care needs. The assessment for this resident was inaccurate. a 6) Resident #17 was observed on 3/12/01 to have 2 full side rails. This resident’s Minimum Data Standard (MDS) done on 02/23/01 under section (P)(4) Restraints indicated 0 meaning no side rails. This resident did not have a physician’s order for 2 side rails. This is in violation of tule 59A-4,109(1)(c), FAC, uncorrected Class I] deficiency, carrying in this instance an $800 civil penalty. (c) Tag F 279. Resident Assessment. Facility failed to have a plan of care for triple lumen catheter (TLC). During the survey of 01-28-30/01, review of clinical records, interviews with staff, and observations of residents revealed that Care Plans were not developed that were resident Specific, identifying the services to be furnished and with measurable objectives and established timetables to meet a Tesident’s medical, nursing, mental and Psychosocial needs as identified in the Comprehensive assessments, for 3 of 31 sampled resident (#1 ,6,19). The findings include: (1) Resident #1 was observed during the initial tour of the facility conducted at 6:50 am on 01/28/01, to reside in a room that was found to be unsafe and a hazard to both the resident and the roommate due to the cluttered state of personal 10 the kk belongings. A Care Plan established for this resident note the problem as, “Resident continues to hoard or collect things in the room until it becomes overbearing and hazardous.” A short-term goal is, “Resident will maintain an organized, uncluttered room by next review.” As observed during the tour, the surveyor and nursing staff could not enter the resident’s room without moving a silk tree and wheelchair from in front of the entrance to the room. The roommate would not have been able to utilize the bathroom without assistance from staff to remove belongings from in front of the bathroom door and pathways. Social Services was noted as an approach to, “provide organizational options for resident to utilize room Space more efficiently; facilitate efforts to clean out and store unnecessary clutter from room; will initiate assistance from resident’s family to help provide Storage space and/or organizers for room; allow resident to participate in discarding items and storing items which were important; and offer to set up a daily cleaning and sorting schedule to do on own.” (2) The Care Plan as written had not been successful and additional interventions beyond those noted were not being planned, attempted or evident as determined through interview with staff on “C” wings. The room was found to be extensively cluttered, and staff reported that that is the way the resident wants in, contrary to the hazard it poses to the resident, roommate and others in the building. When staff CNAs was asked about the cleaning and sorting schedule, 3 CNAs knew nothing of one. (3) Resident #6 was admitted to the facility on 02/15/99 with current diagnoses of arterio sclerotic heart disease; Cognitive heart failure; atrial fib.; Alzheimer’s disease; abnormal gait and depressive disorder. The resident was assessed with a cognitive status of 2 (moderately impaired for decision making). The resident was 11 observed during the 4 days of the survey to spend most of the day in the resident’s room with little organized activity participation, however the “resident was assescod on the Minimum Data Set assessment (MDS) of 11/15/00 as having an activity level of 1, “some” (1/3 to 2/3 of time when awake and not receiving treatments or ADL cate). The Director of Activities was interviewed and it was determined through the interview and medical record review to include the resident’s Care Plan that there was only, “encourage food related group activities,” as an Activity based Care Plan program of care S for this resident. The Care Plan did not provide for an Activity Program deve Toped specifically for a resident with decreased cognitive ability. (4) The resident was Care Planned to have, “meals in so th west dining room for encouragement with meals.” Observation of this resident during 7 meals consumed from 01/28/01 through 01/31/01 revealed that the resident remained i in the bedroom for these meals. It was determined through observation of the passing of trays and staff interaction with this resident that the resident was s not t encouraged to dine i in the Dining Room but was automatically set up for service in the bedroom, _The resident ¥ was also observed to lie down throughout the meal and recei ve lit from staff to complete the meal. An observation made during the lunch meal on 01/28/01 revealed a resident from another room wheeled into Resident #6’s room and took a slice of bread from the resident’s tray and wheel out of the room with it in hand. The’surveyor notified nearby staff of the incident and the slice of bread was replaced. The Care Plan for dining services was not followed as witnessed during 7 meals. (5) The resident was also assessed as needing 1800 cc’s of fluid daily. Review of the Hydration monitoring sheets reveals inaccurate and inconsistent 12 Mg crete peer creer - pee’ a ae a eed We twee oe monitoring for this resident that was assessed as being at risk for Dehydration per Care Plan #3. This resident is documented to consistently leave 25% or more at meals and was observed with food and fluid consumption less than 50% during the 4 days of the survey and the 7 observed meals. This resident has Hydration Protocol risk factors to include a history with poor intake; diuretic therapy; low albumin level (2.9), Alzheimer’s disease and decreased cognitive status (2) and needing assistance with meals. The Care Plan did not have appropriate interventions approaches and proactive measures to meet this resident’s Hydration risk status nor provide for accurate and consistent fluid consumption monitoring. | (6) Resident #19 was admitted to the facility on 6/21/99 and has current diagnoses to include hypertension; organic brain syndrome; and joint difficulty. The resident was assessed with a cognitive status of 3 (severely impaired for decision making) on the most recent MDS assessment of 12/15/00. The resident was observed throughout the 4 days of the survey to be in a meri-walker, able to self propel throughout the halls of the West Wing. The resident was assessed by Nutrition Services to require 1530-1890 cc’s of fluid daily. Review of the facility’s Hydration monitoring tecords revealed that the records were not maintained consistently and could not be accurately calculated for daily fluid consumption. The resident was noted on Care Plan #5 to be at tisk for dehydration with risk factors of impaired mental function related to organic brain syndrome, risk of pressure ulcers, and declining cognitive status and ADL ability relating to Eating (2/2), needing assistance or supervision with eating, to include drinking. (7) The resident was observed during the 4 days of the survey to participate in no organized activity program. The resident was observed wandering in the 13 poner oy pW mre ge geese ana... ake atest ed ee eres hei ec ee ee eas i A meri-walker as the Care Plan indicates. There was no Activities Care Plan for this — resident who was cognitively impaired, however the (MDS) assessment for Activities indicated a | (1/3 to 2/3 of time) in activity. As observed during the survey, this activity level was inaccurate and confirmed with the Activities Director. (2c) This deficiency remained out of compliance during the 3/12-13/01 re-visit based on observation, staff interview and record review. The facility ¢ did not ot develop : a plan of care to meet the medical, nursing, mental and psychosocial needs for 1 of ae ee sampled residents. Findings include: soles LS eol Sw tse OR (1) Resident #15 was admitted to the Facility, on 1 02/09/01 with a diagnosis of debridement/closure of foot wound. The Tesident also. had | order: on admission to receive Vancomycin 1 gram via intravenous TV) e every 2B hous Claforan 1 gram IV every 8 hours. A Plan of care was not available i in the medical record to address care and services for this subclavian (Iv) catheter. Inte iew with the Tegistered nurse revealed that she was unable to aspirate blood from the subclavian TV __ 7 catheter at 1:55 pm on 3/12/01, and the resident was unable to receive his Vancomycin antibiotic that was ordered for 9:00 am, because she was unable to draw the blood for the trough levels. Review of the nurse’s notes for 3/12/01 at 8:00 pm revealed that redness (a sign of infection) was noted around the subclavian (IV) site. This is in violation of rule 59A-4.109(2), F.A.C., uncorrected Class DI deficiency, carrying in this instance an $800 civil penalty. (d) Tag F 281. Resident Assessment. The facility did not ensure that services being provided met professional standards of quality, by administering 14 ial dahil ioe ae eee ee a a Sree a medication without a physician’s order, and not following physician’s orders, in one (1) of the 31 sampled residents (#R3). Findings include: (1) Review of the clinical record for R#3, on 01/13/01, at approximately 9:30 am, revealed that there was no written order by the physician for the resident to be administered Tylenol. Review of the medication administration record (MAR) for this resident revealed that it was not documented on the MAR to be given. Further review of this MAR revealed that there an order for two other pain medications if the resident should need them for pain. Interview with the resident revealed that he/she was given “two Tylenol” for a headache just before breakfast that moming. He/she stated that he/she would like something else, as the Tylenol did not help. Interview with the nurse on the unit revealed that the night nurse had verbally told him/her that she had given the resident two Tylenols in the morning. There was no documentation of this on the MAR orin the nursing notes, (2) Further interview with the nurse on unit and the staff development coordinator revealed that the facility has a “standing order” for the use of Tylenol, and “any resident can get this without an order.” Review of the standing order revealed that it was not signed by the physician, and it did not specify any particular residents that could have the medications. . (3) Further interview with the staff development coordinator, and review of the physician order form revealed that she had written an order for the Tylenol on the form. When asked if she had called the physician to obtain the order, she stated no”. The “facility standings orders” included the following medications: Colace, Milk of Magnesia, Tylenol, Glycerin suppositories, Robitussin and Mylanta. 15 rower Tw ron ET IRE PE ETE Tee ee RR a (4) Administering medication to residents without a physician’s order, and ordering a medication without receiving an order from the physician, did not met professional standards for nursing. _ (2d) This deficiency remained out of compliance during the 3/12-13/01 revisit based on observation, interview, and record review. It was determined that the facility did not ensure that the services provided to the resident met professional standards of quality for 3 sampled residents (#6, 8 & 11) and 1 randomly observed resident t(D Findings include: 69) Clinical record review of resident #8 revealed that on 9/12/01, there was an order from the physician for “Vitamin C one tablet daily”. This medication had no dosage ordered since this date, and there were various dosages that this medication comes in. The physician was not notified of this, and the ect g gave the resident 500mg. (milligrams) on a daily basis for six months. ‘The uni manager Stated ‘ that this dosage of 500mg is the amount that is given routinely according to to the facility policy. This is not a physician’s order. (2) Further review of this record revealed that the physician ordered Glyburide (diabeta) 2. Smg to be given at 7:30 am, n, according to the monthly order sheet. On the first day of the survey, this medication was administered to the resident at 9:40 am. The nurse was not following the physician’s order. Interview with the pharmacy consultant revealed that this medication should be given with a meal. “() Clinical record review of resident #11 revealed that on 03/07/01, the physician ordered “Procel 2 scoops twice a day” to be given to the resident. Review of the medication administration record (MAR) for this resident revealed that the resident 16 ie tO AT ew had been receiving the medication three times a day. The nurse was : not following the physician’s order. (4) During medication pass observation conducted on March 12, 2001, at 12: 37 pm, it was observed that random resident #1 was receiving medication through his/her Gastrostomy Tube. The nurse providing the care did not check for placement of the tube prior to administering medications. Facility policy dictates for staff to verify tube placement before administering medications. | (5) The physician ordered Zantac 150mg in liquid form for resident #6. The resident had been receiving Zantac 150mg in capsules. At the time of the revisit the record lacked documentation of physician notification by the pharmacist that the medication was being dispensed in solid form because it was more cost effective. This is in violation of rule 59A-4.1288, F.A.C., uncorrected Class III deficiency, . carrying in this instance an $800 civil penalty. cos (e) Tag F323. Quality of Care. Facility did n not ensure that the resident environment was free of accident hazards as is possible. Findings include (dd) Observation of Resident #1’s room n during the initial facility tour at 6:50 am on 01/28/01 revealed an environment with extensive clutter, and personal belongings arranged in a manner that entrance into the room could not be made without moving a silk tree and a wheelchair holding multiple pieces of clothing from in front of the doorway. After entrance to the room was made, the resident was observed in bed asleep. On the bed next to the sleeping resident were 2 food trays, one with a partially eaten sandwich and fruit salad, and another with a dinner plate and dome lid covering the place. There were an assortment of books, magazines, clothing and a purse on the bed.’ 17 PEE roe ere Renee SR Senet er TRI ERE REE” At the foot of the bed were 2 rolling bed tables, 1 with 5 boxes of cereal, fruit, juice, books and other personal belongings. The second rolling table contained other personal belongings. Next to the resident’s bed were an oxygen machine, a stand with a television set, a stand with a word processor and printer on it. The room is a 2-person room and the 2™ resident was observed asleep. The area that the 2™ resident would have had to walk to utilize the bathroom facilities was cluttered with Resident #1’s personal belongings. The door to the resident’s bathroom was completely blocked. (2) Interview with staff revealed that this had been an ongoing problem with this resident. A Care Plan intervention was noted, however the problem continued to exist as observed by the surveyor during the survey of 01/28/01. The resident’s extensive clutter constitutes a hazard for the roommate. Immediate and unabated access to the room for an emergency situation would be extremely difficut, as well as the clutter constitutes a fire hazard as well as placing both residents ata tisk of falls due to cluttered pathways. . (3) During a tour of the facility on the first day of the survey, the fire exit to the patio on B wing was blocked by furniture. In the corridor there was a bed, and a geri-chair. Beyond the door on the patio there was a bed, and a geri-chair. Beyond the door on the patio, was a truckload of new nightstands, and some older furniture such as wheelchairs, geri chairs and merry walkers, which were being stored on the walkway of the patio. The other exit door on the opposite side of B wing had a hoyer lift in front of the door. Staff was notified of this danger. 18 AV RWET Wear vy oo Ct SSR creme oR pee ee PCT RET ORR TCO rR CORTE ERR RETR er ge oe (4) During the tour of the west wing on the first day of the survey, a large (about 8 ft. tall) fake tree was blocking the fire exit at the end of the hallway on the Alzheimer’s unit. (2e) This deficiency remained out of compliance at the time of the 3/12-13/01 revisit. Findings include: (1) During the first day of the survey, a 6ft. weight table was stored all day in the corridor of wet wing just inside the entrance/exit doors. When a staff member was asked why the weight table was there, a staff member replied that it was being stored there because there was no place to put it. No staff was observed using the weight table all day on 3/12/01. There was a storage room on the west wing and observation by the surveyor showed it to be already full with trash and other items. In case of a fire this weight table presented a hazard obstructing access to this wing. (2) On the first day of the survey, there was no sign on room 294 indicating that oxygen was in use. This was pointed out to the staff and a sign was put in place. On the second day of the visit, the sign was again missing. (3) On 3/12/01 room 294 was observed to have “too much furniture,” mainly too many chairs. The furniture was so arranged that they prevented the three residents from having access to the hallway without considerable amount of re-arranging of bedside tables, TV’s, tray tables, gerichairs, wheel chairs and extra chairs, this was also a hazard in case of a fire. This is in violation of rule 59A-1288, F.A.C., uncorrected Class III deficiency, carrying in this instance an $800 civil penalty. 19 Oe Ae i ce en oe EEE AEE (f) Tag F329. Quality of Care. The facility did not ensure monitoring for behavior and side effects for the use of antipsychotic medications. Findings include: qd) During review of the clinical record for resident #25, it was revealed that the resident was admitted to the facility 0 on o1/15/01 with the following diagnoses; congestive heart failure, failure to thrive, manic- -depression, bipolar disorder, difficulty walking and myocardial infarction. Review of the medication administration record (MAR) revealed that the resident was receiving Haldol 0.5mg twice daily, for bipolar disorder. In addition, there was no behavior monitoring sheets for the use of this drug. Interview with nursing staff on 01/30/01 confirmed that there was not a proper diagnoses for the use of Haldol, nor were there any behavior monitoring records. (2f) This deficiency remained out of compliance during the 3/12/01 Tevisit based on the following information: cent (1) Resident #13, admitted on 3/07/01 with the following diagnoses: dehydration, Alzheimer disease, arteriosclerotic heart disease, and pacemaker. He/she was prescribed Haldol 1 mg. by mouth or intramuscularly injection every eight hours as needed for sedation. Review of the medical record revealed that the resident received this medication as follows: March 8 (2 doses were given), March 11, March 12, and March 13, 2001. The indication for this drugs use listed on the medication administration record is sedation. Documentation in the nurse’s notes revealed that the medication was administered for agitation on March 8, at 10:00 pm, and 4:00 am; anxiety on March ll, 2001, and agitation on March 12, and March 13. There was no documentation that explains what behaviors the resident was displaying or attempts at redirecting the 20 PE ITE RTE RT TET RES RR SE SERRE mer Re rene ger OPPO MORE Prmrerste nem oer epreeeescee: ees peer ere oe e ~ resident. At the time of the revisit, the record lacked documentation of the facility’s monitoring for the significant side effects associated with the use of this drug. This is in violation of rule 59A-4.1288, F.A.C., uncorrected Class UI deficiency, carrying in this instance an $800 civil penalty. (g) Tag 325. Quality of Care. The facility failed to ensure that is free of medication errors rates of five percent or greater. Based on observation, clinical record review, and staff interview during the annual recertification survey conducted 01/28- 31/01, it was determined that the facility had a medication error rate of 15.25%. This was based on 59 opportunities for error and nine medication errors. Findings include: (1) On 01/28/01, at 9:20 am, on the “D” wing, resident #RS, in room 44, was administered K-Dur milliequivalent (mEq) one tab. The physician s order was for K-Dur 20 mEq. This error was verified with the nurse administering the medication and the Director of Nursing. (DON). (2) On 01/28/01, at 9:45 am, on the “ce wing, FRO, in room 35, had la physician order for Xalatan 0.005% eye drops to be administered at “9 am. This medication was not available to be ad ini surveyor inquiry at I 30 pm; the medicati This was verified with the nurse administering medication to this resident. (3) On 01/28/01, at 10 am, on the “C” wing, room 35, #R7 had a physician order for a Multiple vitamin with minerals. The nurse took the pill out of a bottle labeled “Multiple vitamins with Iron.” Further investigation of this bottle of vitamins revealed that there were two different types of pills in this bottle. This was verified with the DON, who then disposed of this bottle of pills. 21 eer Tremere rpg cee (4) On 01/28/01, at 10:05 am, on the “C” wings #R7 had a physician order for Paxil 10mg. at 9 am. The nurse administered Paxil 20 mg. (whole tablet). This was verified by the nurse administering medication, and the DON. _ (5) During the extended medication pass, conducted on the east wing, for the morning medication on 01/28/01, the nurse prepared resident #8’s medication, and stated that he/she gets all his/her medications crushed. One of the medications crushed was a “ferro-sequel” tablet, which is a time-released medication. Review of the bottle of ferro-sequel tablets revealed that this was written on the label of the bottle. Review of the facility “Do Not Crush” medication form revealed that “time release” medication cannot be crushed. The nurse stated that this “Do Not Crush” form is usually located at the front of each MAR on the units. . (6) During the same extended medication ass #8 . was ordered “Xalatan ere drops to each eye every morning”. This was s identified on the MAR to be given at 9:00 am. After the nurse administered the resident his/her oral medications, and had gone to the next resident to give him/her their medications, the surveyor inquired about the eye drops that resident #8 was to have gotten. The nurse stated she “gives the eye drops when the resident gets back to bed.” The surveyor asked to be notified when she gave these eye drops to the resident, At 1:00 pm, the nurse stated to the surveyor and the unit manager, “they are getting resident #8 back to bed now, so I'll give the eye drops.” This was three hours after the window for administering the 9:00 am medications. (7) During the medication pass conducted on the east wing of the facility, on 01/28/01, at approximately 8:50 am, the nurse was attempting to locate the’ 22 eee pee tree * [Prmewee eer | k betpron medication “Prilosec”, in medication cart, for the resident. This medication was ordered to be given every moming to resident #R1. The facility time to administer this was 9:00 am (with a window of one hour before or one hour after). The nurse could not locate the medication, so she continued to give the resident the other ordered medications, and stated she would call pharmacy later. The surveyor asked to be notified when she received the medication and was ready to administer it to the resident. At approximately 1:30 pm, the surveyor was still not notified, and the resident did not receive the medication as ordered. This was an omission error. (8) During the same medication pass, while the surveyor was reconciling the medications given to resident #R1 with the physician’s orders, it was noted that on 01/22/01, an order was written for this resident to get “Vitamin C 500mg daily”. The facility time for giving “daily” medication is 9:00am. "Review of the medication administration record (MAR) for #R1 ‘Tevealed that it was not there, | The resident did not receive Vitamin C during the medication " Pass, and had | not received it since it was ordered on the 22". This was an omission error. (9) The 9: 00 am dose of Plavix 75 mg. was | mitted for resident R2. The medication was not available for (2g) This « deficiency remained out of compliance at the time of the 3/12/01. revisit based on observations, staff interviews and record reviews conducted. It was determined that the facility failed to ensure that it was free of a medication error rate of 5% or greater. Findings include: (1) The medication error rate was 13.5%. This was based on 45 opportunities for error and 6 medication errors. 23 Dodd del wore “See Se RI ome peer errr ae Ra ter o (2) The following medication errors were observed on 3/12/01 between 9:35 am and 10:00 am on the East Wing. (3) The physician ordered Zantac 150mg by mouth in liquid form for resident #6. The nurse gave a Zantac 150mg in capsule form. The nurse stated that the resident has been receiving only the capsule form of Zantac because that is what the pharmacy has been sending. The record lacked documentation of an order by the physician to change to the capsule form. The pharmacist stated that it had been communicated to the staff that the capsule could be opened and mixed with food if the resident had difficulty swallowing. He further stated on 3/12/01 that it is more cost’ effective to give the capsule form. (4) The physician ordered Prevacid 30 mg. by mouth every morning and Paxil 10mg by mouth everyday for a randomly observed resident (R3). The medications were to be administered at 9:00 am according to the medication administration record (MAR). The medications were not given at the time of the 9:00 am medication pass. The medications were not available. The nurse stated that she ordered the Prevacid YS ago. Interview with the nurse on 3/13/01 revealed that the pharmacy sent the liquid form on 3/12/01. OO (5) During medication pass conducted on March 12, 2001, at 12:37 pm, the following medication error occurred. Random resident #1 had a physician’s order to flush the resident’s Gastrostomy tube with 30cc of water before and after medication administration. It was determined during observation that the resident’s nurse did not flush the tube with water before administration of Vitamin C liquid 500 mg. Five 24 SOT I RENEE ERE RE ROR aS PFW

, uncorrected Class sant deficiency, carrying in this instance an $800 civil penalty. (h) Tag F426. Pharmacy Services. The facility failed to provide medications as ordered. During the 01/28-30/01 survey and based on observation, record review and it was determined the facility failed to provide pharmaceutical services that assured the accurate administration of all drugs and biologicals to 4 residents during the medication pass observations (#R1, R2, R6, R7) sampled 31 and 4 non sampled residents. Findings include: 26 Ee TE STR RR TREE TET OSE PO Ee RE ME I RRR np aR “aE EEE oes renee anes oneree (1) During the medication pass observation on 01/28/01, at 10:00 am, resident #R7, in room C35, was administered K-Dur 10 milliequivalents (mEq), (one — tab). The label on this medication read, “give two © tabs=20 mEq. ” “The physician’ s order — is for K-Dur 10 mEq.; not 20 mEq., as the label read. | (2) During the medication observation pass on 01/28/01, it was revealed that resident #R7, had a physician’s order for Paxil 10mg by mouth each am. The medication was package with a whole 20 mg tablet for each dose. The label did not state to give one half of this tablet. (3) Review of the physician’s orders for resident #R1 revealed that there was an order for Prilosec 30 mg every morning. This was also on the medication administration record (MAR). When it was time to administer this medication, the nurse was unable to locate it in the medication cart. The nurse called the pharmacy, and by 1:30 pm, the medication was still not available. (4) Resident #R6 was ordered Xalatan 0.005%, eye drops to be administered at 9:00 am. On 01/28/01, this dedication was not available for 9: am availability. - S 6) While observing mg to resident #R2. Interview with the nurse revealec available for administration. (2h) This deficiency remained out of compliance at the time of the 3/12/01 revisit based on observations, interviews and record reviews. The facility failed to 27 Tre ree ar Seo eres mes peepee: provide pharmaceutical services that assured accurate acquiring, receiving, dispensing and administering of drugs to meet the needs of 4 sampled residents (#6, 8, 13 & 15) and 3 randomly observed residents (R1, R2 and R3). Findings include: medications due to a cerebral vascular accident (CVA). The physician ordered Zantac 150 mg. in liquid form to be given at 9:00 am each morning. “Observation of the 3/12/01 medication pass on the East Wing between 9:35 am and 10:00 am revealed the nurse administered Zantac 150 mg in capsule form. The nurse stated that the capsules have been administered because that is the form that is sent by the pharmacy. Subsequent interview with the pharmacist later that day at approximately 12:30 pm revealed that the capsule form is more cost effective. The pharmacist further stated that nursing x staff had been informed that the capsules could be opened and mixed with food. At the time of the survey, the medical record lacked documentation of the following: physician notification of the change in the form of medication and notification of nursing staff by the pharmacist that the capsule could be opened and mixed with food. The resident was observed to fay ty swallowing the Zantac Capsule a as s well as a Darvocet tablet given during the medication pass on 3/. 12/01. Sie sine - o “Observation of ‘the. East Wing medication. pass on D3 12101 between 9:30 and 10: 00 am revealed the following medications were not administered as ordered to random yi given ¢ at 9: 00 “am each day. The medications were not available for the nurse to "administer during the morning medication pass. The medication nurse stated that she had 7: ordered the Prevacid two days ago (Saturday). The Paxil was ordered after the last dose’ 28 (1) Sampled resident #6 has difficulty swallowing pockets of food and g were ordered to be SPRETTTNe” ~ 7 -cNEREEUReer” © Rees BRT EET fr FRNRIE'TEeT BORER? Bo pe ernest coe ORE -Imermmeremmeerer eer ranma rere: ge ‘neers OP RECT RE Re NON ee opera Tar rr OO SRR RRR = OPT NR TR REE per Trem Teer was given on 3/11/01. Subsequent interviews with the pharmacist on 3/12/01 following the medication pass confirmed the medications had not been delivered as of 12:30 pm. (3) During medication administration pass conducted on March 12. 2001, observation was made of random resident #1. The resident had a physician’s order to flush gastrostomy tube with 30cc of water before and after medications are administered. Observation of the medication pass revealed that the nurse did not flush thirty ces of water prior to the administration of Vitamin C 500mg/Scc. (4) During the medication pass on the East wing on 3/ 12/01, and review of resident #8’s record, it was revealed that “Vitamin C one tablet daily” was ordered on 9/12/00. There was no specific dosage ordered by the physician, so the facility administered 500 mg without receiving a complete order from the physician. This was not picked up by the pharmacist, and there was no complete doctor’s order for 6 months. } (5) _ Based on observation during the medication pass on the / A Hall on 3/12/01 the nurse observed administering medications late to the following x residents as follows: sampled resident #15 at 10:30 am, unsampled resident #R2 at 10:55 a am, and resident #13 at 11 am. The medications were ordered to be administered at 9:00 am for all of these residents. ) (6) During the medication pass at 10:30 am on 3/12/01, resident #15 asked the nurse which IV medication should be getting now? The nurse stated the trough need to be drawn first before the Vancomycin was given. Resident #15 had a physician order to receive Vancomycin 1 gram intravenously every 24 hours and an order to obtain Vancomycin peak and trough every Monday and Thursday. Review of the medication 29 SC PRMERIE r mere one mre erage Ri i dR ee ee ee ee ger - record, revealed that the Vancomycin was scheduled for 9:00 am. At 10:55 am the nurse stated that the Vancomycin could be given at anytime during the day after the peak and trough were drawn. There was no physician order available in the medical record to support giving the Vancomycin at anytime during the day. At 12:10 pm the nurse was questioned by the surveyor about the resident receiving the Vancomycin, the registered nurse stated that the blood was not drawn as yet because the resident was eating lunch in the dining room. At 1:55 pm the registered nurse was questioned again by the surveyor about the administration of the Vancomycin, she stated that she was unable to obtain the blood from the subclavian line due to no blood return and the resident refuse to be “stuck” peripherally therefore the resident did not receive the Vancomycin. Review of the medication record on 3/13/01 revealed that the Vancomycin was given at 3:00 pm on 3/12/01, after the trough was obtained. "Further review of the nurse’s notes on 3/12/01 revealed that a “call was placed to the doctor “regarding stitches opening at the medial aspect of the incision on the right foot”. but there was no mention that the physician was notified of the resident not receiving the Vancomycin as ordered. This is in violation of rule 59A-4.112(1), F.AC., d Class il deficiency, carrying in this instance an $800 civil the operation of a nursinghome. 5. Notice was given in writing to the respondent of each of the above violations and the time frame for correction. 30 i | ' ; } ELECTION AND EXPLANATION OF RIGHTS FORMS ATTACHED 7. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO REQUEST A HEARING WITHIN TWENTY ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY, I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Retum Receipt Requested to Brian Tenney, Administrator, Darcy Hall of Life Center, 2170 Palm Beach Lakes Blvd., West Palm Beach, Florida 33409, Darcy Hall, Inc., 3570 Keith Street, NW, Cleveland, TN 37312, and to CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on , 2001. ND , Field Office Manager - Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, Florida 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 31 tere i A. ae i ood ERE EE CR ET TERE SRR NR PRET RRP REE = CER Se 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. 32 RO Ee ee ee ERP yer

Docket for Case No: 01-004412