STATE OF FLORIDA pan aH AGENCY FOR HEALTH CARE ADMINISTRATION Pen 25 02 ; horn “TERK STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No: 2001054521 Return Receipt Requested =: KENDALL HEALTH CARE, INC., d/b/a #7000 1670 0011 4848 0340 PALACE AT KENDALL NURSING & 7000 1670 0011 4848 0357 REHABILITATION CENTER, 7000 1670 0011 4848 0364 Respondent cA en / < ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Kendall Health Care, Inc., d/b/a Palace at Kendall Nursing & Rehabilitation Center (hereinafter “Palace at Kendall”) pursuant to 28-106.111, Florida Administration Code (2000) (F.A.C.), and Chapter 120, Florida Statutes (Fla. Stat.) hereinafter alleges: NATURE OF ACTION 1, This is an action to impose an administrative fine in the amount of $11,500 pursuant to Section 400.121, Fla. Stat. JURISDICTION AND VENUE 2. This court has jurisdiction pursuant to Section 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C. 3. Venue lies in Dade County, pursuant to 120.57, Fla. Stat., and Chapter 28- 106.207, F.A.C. PARTIES 4. AHCA is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Fla. Stat., and Rules 59A-4, F.A.C. 5. Palace at Kendal Nursing & Rehabilitation Center is a nursing home located at 11215 SW 84" Street, Miami, Florida 33173, and is licensed under Chapter 400, Part II, Fla. Stat., and Chapter 59A-4, F.A.C. COUNT I PALACE AT KENDALL FAILED TO IMMEDIATELY NOTIFY RESIDENT’S PHYSICIAN WHEN THE RESIDENT EXPERIENCED A SIGNIFICANT UNPLANNED WEIGHT LOSS 483.10(b)(11), C.F.R., 59A-4,1288, F.A.C. (NOTIFICATION OF RIGHTS AND SERVICES) CLASS II 6. AHCA realleges and incorporates (1) through (5) as if fully set forth herein. 7. During the follow up visit conducted on 7/20/01 and based on record review and interview, the facility failed to immediately notify the resident's physician when a significant change in the residents clinical condition was noted in one (1) of fourteen (14) sampled residents (#13). 8. During clinical record review on 7/20/2001, it was noted that sampled resident #13, was readmitted to the facility on 7/6/2001, weighing 148 pounds. During a review of this resident's weekly weights, it was noted that this resident had lost weight and by the second week after readmission, weighted 142.8 pounds, which was a 5.2- pound weight loss. The facility's Diet Technician was interviewed on 7/20/2001, and reported that this resident had been identified as nutritionally at risk, and was being monitored for weight loss. Further review of this resident's weekly weights revealed that the resident had continued to lose weight and by the third week had lost an additional 9.6 pounds, and was now weighing 133.2 pounds. Although the resident was on a Nutritional Risk program, further interview with the facility's Diet Technician revealed that the resident's physician had not been notified of the residents continued weight loss. The failure of the facility to notify the resident's physician of a significant, unplanned, weight loss and allowing the plan of care to be re-assessed and modified resulted in resident #13 experiencing further unplanned weight loss. 9. Based on the foregoing, Palace at Kendall Nursing & Rehabilitation Center violated 483.10(b)(11), C.F.R., and 59A-4.1288, F.A.C., herein classified as a Class II violation, which carries in this case an assessed fine of $2,500. COUNT II PALACE AT KENDALL NURSING AND REHABILITATION CENTER FAILED TO ENSURE THAT EACH RESIDENT IS FREE FROM PHYSICAL RESTRAINTS NOT REQUIRED TO TREAT A MEDICAL SYMPTOM 483.13(a), C.F.R. and 59A-4.1288, F.A.C. CLASS III 10. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 11. During the survey conducted on 5/17/01 and based on observation, interview, and record review, the facility failed to ensure that each resident is free from physical restraints imposed for purposes of convenience and not required to treat a medical symptom for three (3) #4, 9, 10 of twelve (12) residents sampled for the use of restraints, 12. Resident #9 was observed during the orientation tour in bed with two side rails up. The nurse providing information regarding the resident indicated that the resident did not have any restraints. Review of the residents most current minimum data set (MDS) dated 2/1/01 disclosed the need for % or 1 side rail daily. Review of the facility's 90-Day Rehabilitation Therapy Screen dated 2/28/01, revealed a report that assessed the resident as requiring one side rail up and one side rail down. There was no assessment, care plan or medical indication for the use of the restraint. 13. During the orientation tour, nursing staff stated that resident #4 did not have 2 full side rails up. Review of the resident's most current MDS dated 3/18/01 disclosed the use of % or 1 side rail daily and a chair that prevents rising. Review of the facility's 90-Day Rehabilitation Therapy Screen dated 2/2/01 indicated to discontinue the use of 2 side rails (no seizure activity noted) and to use 1 side rail up as an enabler. On 5/15/01 at 3:00 pm the resident was observed in bed with both side rails up. 14. Review of resident #10's MDS (2/23/01) disclosed that full side rails and a trunk restraint were used daily. The resident was observed throughout the survey restrained either with the side rails or trunk restraints. Interview with the resident's private duty on 5/13/01 revealed that the resident has both side rails up "because he climbs out of bed at night, sometimes he climbs out of bed over the side rails and sometimes scoots down to the end of the bed". There was no documented evidence that the use of the physical restraint was used to treat a medical symptom and not for staff convenience. It was given until 6/16/01 for correction 15. During the revisit conducted on 7/20/01 and based on observation, interview, and clinical record review, it was determined that the facility failed to ensure that each resident is free from physical restraints. Restraints were found to be imposed for purposes of convenience and not required to treat a medical symptom for one (1) of fourteen (14) sampled residents (#6). Findings include: 16. Sampled resident #6 was observed in bed with two (2) side rails up. Review of the resident's minimum data sheet (MDS) dated 7/15/01 was coded "2" for side rails, indicating the use of two (2) side rails. Review of the Physical/Occupational Therapy Screening dated 7/5/01 revealed a recommendation for one (1) side rail up and one (1) side rail down. Review of the clinical record revealed that there was no assessment indicating the need for two side rails, and no care plan or medical indication for the use of the side rails. Interview with the Unit Manager confirmed that there was not a care plan for the use of two (2) side rails. During the interview, the Unit Manager revealed that there was no medical reason for the side rails because the resident does not move about in bed. 17, Based on the foregoing, Palace at Kendall Nursing and Rehabilitation Center violated 483.13(a), C.F.R. and 59A-4.1288, F.A.C. herein classified as a Class III violation, which carries, in this case, an assessed fine of $1,000. COUNT OI PALACE AT KENDALL NURSING AND REHABILITATION CENTER FAILED TO DEVELOP A CARE PLAN THAT MET THE RESIDENTS MEDICAL AND NURSING NEEDS. 59A-4,109(2) and 59A-4.1288, F.A.C. CLASS II 18. | AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 19. During the survey of 5/17/01 and based on record review and interview, the facility failed to meet professional standards of quality based on Professional Practice for Dietetic Professionals for two (2) of nine (9) residents sampled for nutrition, #10 and #26. 20. Review of resident #10's clinical record disclosed Ensure plus HN at 75 cc an hour times 21 hours and a low fat puree with honey consistency diet for pleasure foods. Laboratory values revealed depressed cholesterol, high and low-density lipoproteins and elevated triglycerides. Clinical record review and interview with direct care staff revealed that the resident has problems with constipation. Based on the interview, the resident gets impacted 2, 3, sometime 4 times a year. Review of the medication administration record (MAR) indicates that nursing is to check for fecal impaction daily and describe the resident’s bowel movements during each shift, daily. Review of the dietetic technician’s progress notes for nutrition disclosed no evaluation/assessment/appropriateness of the low fat diet or of the constipation in documented monthly notes, the last note being 5/2/01. Reassessment of the resident due to constipation and abnormal lipid profile was done by the registered dietitian on 5/15/01 after an earlier interview recommended that: (a) the formula be changed to a fiber containing formula, (b) discontinue the low fat restriction (c) that pharmacy evaluate medications for increased triglycerides and (d) that further laboratory studies be completed. 21. Based on the American Dietetic Association (ADA) Standards of Professional Practice for Dietetics Professionals, STANDARD 1: Provision of Services, Provides quality service based on client expectations and needs, 1.3 applies knowledge and skills to determine the most appropriate action plan, the dietetic technician did not identify, evaluate, assess the nutritional problems of constipation and altered laboratory values to determine the most appropriate action plan for the resident. In addition, there was no 1.2 collaboration with other professionals as needed. 22. Resident #26 was receiving a no concentrated sweet (sugar) NCS diet. On 3/9/01 the resident's physician ordered a dietary consultant for the resident's diabetic diet and elevated blood sugar levels. On the same day the dietetic technician wrote the following nutrition note, "Physician ordered a dietary consult due to elevated glucose. Resident is on NCS mech soft diet with diet super snack bid. Resident is also on the nutrition at risk program. Spoke to the resident about the importance of diet adherence. Will continue to monitor resident." The dietetic technician did not assess or evaluate the elevated blood glucose levels as requested by the physician. There was no assessment or collaboration with the pharmacist regarding the medications, nor an assessment or appropriateness of current diet or laboratory studies nor documentation of the blood glucose levels, nor recommendations or plan of care. 23. Based on the ADA Standard of Professional Practice for Dietetics Professionals, STANDARD 1: Provision of Services, Provides quality service based on client expectations and needs, 1.3 applies knowledge and skills to determine the most appropriate action plan, the dietetic technician did not identify, evaluate, assess the elevated blood glucose levels to determine the most appropriate action plan for the resident. In addition, there was no 1.2 collaboration with other professionals as needed. It was given until 6/16/01 for correction. 24. | When a follow up was conducted on 7/20/01 and based on observation, clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet the resident's medical and nursing needs for one (1) of fourteen (14) sampled residents (#6). 25. Cross reference F221. During the initial tour of the facility and random observations, sampled resident #6 was observed to be in bed with both side rails up. Review of the clinical record revealed the resident was not care planned for side rails. Interview with the Unit Manager confirmed that the resident did not have a care plan for the use of side rails. 26. During the initial tour of the facility and random observations, sampled resident #6 was observed to have a Foley catheter in place. Review of the clinical record revealed that the Foley catheter was in place 7/3/01, the date of the resident's admission to the facility. Further review of the clinical record revealed that the resident did not have a care plan for the Foley catheter. Interview with the Unit Manager on 07/20/01 confirmed that the Foley catheter was not care planned. 27. Based on foregoing, Palace at Kendall Nursing & Rehabilitation Center violated 59A-4.109(2), and 59A-4.1288, F.A.C., herein classified as a Class III violation, which carries, in this case, an assessed fine of $1.000. COUNT IV PALACE AT KENDALL NURSING AND REHABILITATION CENTER FAILED TO PROMOTE THE DIGNITY OF ONE RESIDENT 483.15(a), C.F.R., and 59A-4.1288, F.A.C. CLASS It 28. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 29, The facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or hers individuality. 30. While on initial tour of the facility at 7:00 am thm 9:00 am on 5/14/01, surveyor observation on the third floor revealed aids walking into the resident's rooms without knocking or asking permission to enter the room. This occurred with four (4) resident's rooms while on tour. The nurse, who was touring with the surveyor, also noticed this happening and proceeded to train the aids in front of the surveyor. They were instructed to knock on the resident's door and ask for permission, from the resident, prior to entering the resident's room. 31. During the initial tour of the facility at 7:50 am, direct care staff was observed entering room 116 by knocking and walking into the resident’s room. The staff member did not slow down to wait for a reply from the resident nor did the staff member identify herself as she entered the room. The staff member was then observed entering room 110, again knocking, entering and not identifying herself. The staff member did not wait for a response to enter or not from the resident in that room. Correction date given as 6/16/01. 32. During the follow up conducted on 7/20/01 and based on observations, the facility did not promote care for residents in a manner and environment that maintains or enhances each resident's dignity and respect by staff's failure to identify themselves and waiting for a response to obtain permission from one (1) of fourteen (14) sampled residents prior to entering the resident's room, resident #7. 33. During a visit to the room of sampled resident #7 at 11:50 a.m. on 07/20/01, a direct care staff was observed entering room #100 by knocking and then continuing to enter the resident's room without slowing down, waiting for a reply from the resident, or identifying herself as she entered the room. The resident was alert, oriented, verbal, and able to respond appropriately. 34. Based on the foregoing, Palace at Kendall Nursing & Rehabilitation Center violated 483.15(a) C.F.R., and 59A-4.1288, F.A.C., herein classified as a Class III violation, which carries, in this case an assessed fine of $1,000. COUNT V PALACE AT KENDAL NURSING & REHABILITATION CENTER FAILED TO MEET THE PROFESSIONAL PRACTICE STANDARDS OF QUALITY FOR DIETETIC PROFESSIONALS 400.141(9), Fla. Stat., and 59A-4.109(2), F.A.C. (RESIDENT ASSESSMENT) CLASS It 35. | AHCA re-alleges and incorporates (1)(through (5) as if fully set forth herein. 36. During the survey conducted on 5/17/01 and based on record review and interview, the facility failed to meet professional standards of quality based on Professional Practice for Dietetic Professionals for two (2), of nine (9) residents sampled for nutrition, residents #10 and 26. 37. Review of resident #10's clinical record disclosed Ensure plus HN at 75 cc an hour times 21 hours and a low fat puree with honey consistency diet for pleasure foods. Laboratory values revealed depressed cholesterol, high and low-density lipoproteins and elevated triglycerides. Clinical record review and interview with direct care staff, the resident has problems with constipation. Based on the interview, the resident gets impacted 2, 3, sometime 4 times a year. Review of the medication administration record (MAR) nursing is to check for fecal impaction daily and describe the resident’s bowel movements each shift daily. Review of the dietetic technicians progress notes for nutrition disclosed no evaluation/assessment/appropriateness of the low fat diet nor of the constipation in document monthly notes, the last being 5/2/01. Reassessment of the resident due to constipation and abnormal lipid profile was done by the registered dietitian on 5/15/01 after an interview earlier recommended that the formula be changed to a fiber containing formula, to discontinue the low fat restriction, that pharmacy evaluate medications for increased triglycerides and further laboratory studies be completed. 38. Based on the American Dietetic Association (ADA) Standards of Professional Practice for Dietetics Professionals, STANDARD 1: Provision of Services, Provides quality service based on client expectations and needs, 1.3 applies knowledge and skills to determine the most appropriate action plan, the dietetic technician did not identify, evaluate, assess the nutritional problems of constipation and altered laboratory 11 values to determine the most appropriate action plan for the resident. In addition, there was no 1.2 collaboration with other professionals as needed. 39. Resident #26 was receiving a no concentrated sweet (sugar) NCS diet. On 3/9/01 the resident's physician ordered a dietary consultant for the resident's diabetic diet and elevated blood sugar levels. On the same day the dietetic technician wrote the following nutrition note, "Physician ordered a dietary consult due to elevated glucose. Resident is on NCS mech soft diet with diet super snack bid. Resident is also on the nutrition at risk program. Spoke to the resident about the importance of diet adherence. Will continue to monitor resident." The dietetic technician did not assess or evaluate the elevated blood glucose levels as requested by the physician. There was no assessment or collaboration with the pharmacist regarding the medications, nor an assessment or appropriateness of current diet or laboratory studies nor documentation of the blood glucose levels, nor recommendations or plan of care. 40. Based on the ADA Standard of Professional Practice for Dietetics Professionals, STANDARD 1: Provision of Services, Provides quality service based on client expectations and needs, 1.3 applies knowledge and skills to determine the most appropriate action plan, the dietetic technician did not identify, evaluate, assess the elevated blood glucose levels to determine the most appropriate action plan for the resident. In addition, there was no 1.2 collaboration with other professionals as needed. Correction date given was 6/16/01. 41. During the follow up conducted on 7/20/01 and based on observation, staff interview and record review, the facility failed to meet Professional Practice Standards of quality for dietetic professionals for one (1) of three (3) residents sampled for weight/nutrition, resident #7. 42. Review of the clinical record of sampled resident #7 revealed that the findings of a video fluoroscopic swallowing assessment done on 7/13/01 indicated the resident to be at very high risk of aspiration. Clinical record review and interview with the Speech Pathologist on 07/20/01 regarding the findings revealed that the resident's best route of nutritional support is tube feeding since the resident has shown persistent aspiration following ingestion of food and beverages. However, the resident's family did not agree to the insertion of a G-tube. The Speech Pathologist stated that the resident does not accept the thickened beverages and the facility food well, except for the thickened soups. Interview with the Unit nurse revealed the same observations. 43. Review of the resident's Food Intake documentation for 7/1 through 7/19/01 revealed the resident's daily intake was 25-50% for the majority of meals. During interview, the Diet ‘1 echnician indicated that the resident eats 50-75% of meals and had no knowledge of the resident's food acceptance as described by other interdisciplinary team members. 44. Review of the clinical record revealed that the resident lost approximately 8 pounds in a three (3) month period (May to July). Interview with the Diet Technician revealed that she had no knowledge of this weight loss. 45. Based on the American Dietetic Association (ADA) Standards of Professional Practice for Dietetics Professionals, Standard 1: Provisions of Services, Provide quality services based on client expectations and needs, 1.1 collaborates with client to assess needs, background and resources and to establish mutual goals, 1.3 applies knowledge and skills to determine the most appropriate action plan), the Diet Technician failed to identify, evaluate, and assess the nutritional problems of food acceptance, oral intake and weight loss to determine the most appropriate action plan for the resident which resulted in an unplanned weight loss of 8 pounds in a three month period. 46. Based on the foregoing, Place at Kendall Nursing & Rehabilitation Center violated 400.141(9), Fla. Stat., and 59A-4.109(2), F.A.C., herein classified as a Class III deficiency, which carries in this case an assessed fine of $1,000. COUNT VI PALACE AT KENDALL NURSING & REHABILITATION CENTER FAILED TO ENSURE THAT FOOD SERVICE EQUIPMENT WAS PROPERLY SANITIZED 400.141(8), Fla. Stat. and 59A-4.110(4), F.A.C. (DIETARY SERVICES) CLASS III 47, | AHCAre-alleges and incorporates (1) through (5), as if fully set forth herein. 48. Based on observation, interview and record review, the facility failed to reduce those practices which result in food contamination and compromised food safety in nursing homes. 49. During the tour of the kitchen on 5/16/01 at approximately 12:30 pm, the porter was asked to demonstrate how he tests the sanitizing section of the 3-compartment sink which was filled with water and iodine solution. At the first attempt, the porter held the test strip used to check for safety of the solution for 2 seconds in the sanitizing solution. The porter held the strip against the reference color and indicated that the solution was at the correct dilution. Observation of the test strip revealed that there was no color change in the test strip, indicating that the solution was not safe to sanitize food service equipment. (The correct amount of time for immersion of the test strip based on the manufacturer’s instructions on the container of test strips is 5 seconds with the iodine being in the range of 12.5 ppm (faintly blue) to 25 ppm (blue). 50. A second attempt was made by the porter to test the solution. This time, the porter was observed to immerse the test strip for over 50 seconds, as another staff member told the porter to keep it immersed for 30 seconds. The porter again indicated that the sanitizing solution was at a safe dilution. Observation of the strip indicated a blue color, Observation of instruction posted on the wall indicated that the strip should be immersed for 30 seconds. Interview with food service administrative staff revealed that the posted instructions were not correct and the instructions on the container were correct and that the staff was in-serviced on the correct procedures for sanitizing equipment on numerous occasions. 51. A third attempt was made by the porter to check for the accuracy of the iodine solution. The porter immersed the test strip for approximately 20 seconds. Inadequate sanitizing of food service equipment may lead to the growth of disease carrying organisms. 52. Observation of the facility cutting boards (blue, white, yellow, and brick color) in the storage rack on May 16, 2001 at approximately 12:30 pm showed numerous deep scratches throughout. The boards had a light dotted black color where the grooves and scratches were, indicative of mold growth. Interview with the food service manager disclosed that the facility has brand new cutting boards that have not been utilized. 53. Observation of the resident trays, dome covers and based for the dishes were noted throughout the first three days of the survey as being chipped, cracked and scratched, thereby not allowing for adequate cleaning, and thus, unable to be properly sanitized. 54. Observation on 5/15/01 at 10:35 am of the cooks preparation sink revealed the second compartment of sink filled with chicken parts and water. Interview with the cook disclosed he was squeezing lemon over the chicken to ‘wash it’. The sink was filled ¥, of the way with the water covering the chicken completely, not draining as per the cook because a piece of chicken was blocking the drain holes. This showed improper handling of a potentially hazardous food by not allowing for adequate drainage of water that may lead to the rapid and progressive growth of infectious or toxigenic micro- organisms such as Salmonella. 55. Observation of the freezer on 5/15/01 at 2:00 pm disclosed several sections of tiles missing in the entrance of the walk in freezer. The areas that the tiles were missing were filled with ice and debris. Correction time given was 6/16/01. 56. During the kitchen tour at 10:00 a.m. on 7/20/01, the Food Service Administrative Staff (FSAS) was asked about the corrective action for the Annual Survey completed 5/17/01, regarding the proper usage of the 3-compartment sink for ensuring adequate sanitation of all cooking equipment used to prepare, distribute and serve food to the facility's residents. The FSAS stated that all Food Services Staff (FSS) were in- serviced on the proper usage of the sanitizing iodine solution and were able to demonstrate the correct procedure. In addition, the FSAS stated that proper instructions 16 were now posted on the wall in front of the 3-compartment sink, which stated the correct length of time for holding the test strip in the iodine solution as 30 seconds. One of the FSS, in the presence of the FSAS, demonstrated how to test the sanitizing section of the 3-compartment sink, which had been filled with water and the iodine solution added. This section had been reported to be at proper concentration and ready for use. The FSS removed one (1) of the test strips, dipped it in the sanitizing section of the 3-compartment sink, and held it for 30 seconds. Upon removal of the strip, the FSS compared the color of the strip to the color chart printed on the small container and stated that the color matched the 50 ppm strength which indicated that the solution was too strong. The manufacture’s instructions posted on the wall in front of the 3-compartment sink indicated the strip was to be held in the sanitizing section of the sink for 30 seconds, and that the correct strength of the sanitizing solution was to be between 12.5-25.0 ppm. Upon reviewing the instructions on the container holding the test strips, the amount of time for immersing the strip in the iodine solution was 5 seconds. Interview with the manufacture’s representative at 4:45 p.m. on 7/20/01, revealed that the information on the test strips container (hold for 5 seconds) is the correct length of time and must be followed. The facility failed to post the correct manufacture’s instructions and ensure that correct procedures were being followed for proper sanitation of cooking equipment. Inadequate sanitizing of food service equipment used in food preparation may lead to growth of disease carrying organisms. 57. Based on the foregoing, Palace at Kendall Nursing & Rehabilitation Center violated 400.141(8), Fla. Stat., and 59A-4.110(4), F.A.C., herein classified as a Class II violation, which carries, in this case, an assessed fine of $3,000. 17 CLASS VII PALACE AT KENDALL NURSING & REHABILITATION CENTER FAILED TO LABEL DRUGS IN ACCORDANCE WITH ACCEPTED PROFESSIONAL STANDARDS 59A-4,112(5)(6), F.A.C. (PHARMACY SERVICES) CLASS II 58. | AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 59. Based on observations and interviews, the facility did not ensure the labeling of drugs in accordance with acceptable professional principles. 60. During inspection of the “brown refrigerator" located in the second floor medication room on 5/17/01 at 10:00 a.m., it was observed that the label on an opened vial of insulin did nut contain the date the medication was first used. The Charge Nurse who accompanied the surveyor during the inspection of the medication room concurred that the vial was not dated. Facility staff's failure to write the date on the label placed the resident at risk for being administered an expired medication. Correction date given was 6/16/01. 61. Based on observations and interviews, the facility did not ensure the labeling of drugs in accordance with acceptable professional principles. 62. During inspection of the refrigerator located in the third floor medication room at 10:30 a.m. on 07/20/01, it was observed that two (2) vials of Novolin R insulin did not contain the date the insulin was first used. The Unit Manager who accompanied 18 the surveyor during the medication room inspection concurred that the vials were not dated. 63. Based on the foregoing, Palace at Kendall Nursing & Rehabilitation Center violated 59A-112(5)(6), F.A.C., herein classified as a Class III violation, which carries, in the case, an assessed fine of $1,000. COUNT VHI PALACE AT KENDAL NURSING & REHABILITATION CENTER FAILED TO MAINTAIN CLINICAL RECORDS THAT WERE COMPLETE AND ACCURATE FOR THREE RESIDENTS. 59A-4.118(1)(2), F.A.C. (MEDICAL RECORDS) CLASS Il 64. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 65. Based on clinical record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional practices that are complete and accurately documented. 66. Review of the clinical record of sampled resident #3 revealed a diagnosis of chronic constipation and physician's orders to, “Record bowel movements every shift" and "Check for fecal impaction weekly." Review of the clinical record revealed the resident's bowel movement were not recorded in April 2001, 13 times on the 7:00 a.m.- 3:00 p.m. shift, three (3) times on the 3:00 p.m.- 11:00 p.m. shift, and three (3) times on the 11:00 - 7:00 a.m. shift. Further review of the clinical record revealed lack of 19 documentation on the April 2001 Treatment Record that the resident was checked for fecal impaction. 67. Review of the clinical record of sampled resident # 20 revealed Physician's Orders dated 4/27/00, to "Check for fecal impaction weekly" and "Record bowel movements every shift - size and consistency." Review of the resident's Treatment Record for April 2001, revealed lack of documentation that the resident was checked for fecal impaction weekly or bowel movements were recorded every shift as ordered. 68. Review of clinical records on 5/16/01 at approximately 2:30 p.m. of sampled resident #16 revealed a Risk of Falling Assessment dated 4/13/01. The Scoring Evaluation at the bottom of the form states, "3 or more check marks indicate a resident is at high risk". The resident's assessment was checked in three areas: Use of assistive devises, vitamins & iron, and diuretics & hypotensives. In addition the clinical record indicated that the resident was coded as moderately impaired on the Minimum Data Set (MDS) assessment Section B. #4 on 4/17/01 and 4/25/01 and also carried a diagnosis of depression. These areas were not checked on the assessment. An Initial Restraint assessment also completed by the licensed nurse on 4/13/01 did not identify the resident to be at high risk for a fall. The nurse’s notes documented that the resident had slipped and fallen on 5/14/01 at 8:30 p.m. and on at 12: 35 a.m. on 5/16/01 both necessitating hospital follow up. 69. Review of clinical records on 5/14/01 of sampled resident #7 revealed a Risk of Falling Assessment dated 5/5/01. The Scoring Evaluation at the bottom of the form states, "3 or more check marks indicate a resident is at high risk". The resident's assessment was checked in four areas: Use of assistive devises, diuretics & hypotensives, 20 cognitive impairment and cerebral vascular accident. An Initial Restraint assessment also completed by the licensed nurse on 5/5/01 did not identify the resident to be at high risk for a fall. 70. Review of the clinical record of sampled resident #] on 5/14/01 revealed a resident receiving enteral nutritional therapy and an indwelling catheter. Resident #1's climactical record revealed a care plan dated 1/12/01 for an indwelling catheter which included an approach to observe I&O (intake and output). The resident's record also contained a care plan dated 2/9//01 for altered nutrition/PEG tube with an approach to monitor I&O. In addition, review of the Policy and Procedure for Intake and Output states that residents receiving these treatments require measurement and documentation of intake and output every eight hours including a 24-hour total. Review of the residents Intake and Output Sheet revealed that the I&O was not totaled from 4/1/01 through 4/21/01, from 4/26/01 through 4/30/01, from 5/1/01 through 5/12/01, and on 5/14/01. In addition, no 1&O was recorded for the 3:00- 11:00 p.m. shift on 4/20/01, 4/29/01, 5/1/01, 5/2/01, 5/3/01, 5/6/01, 5/7/01, and 5/12/01. No I&O was recorded for the 7:00 a.m. to 3:00 p.m. shift on 5/2/01, 5/6/01 and 5/10/01. No I&O was recorded for the 11:00 p.m. to 7:00 a.m. shift on 5/7/01, 5/10/01, 5/11/01, and 5/13/01, No I&O was recorded for the entire 24 hour period on 4/21/01, 4/30/01 an 5/5/01. The facility's failure to monitor and record the [&O could put the resident at risk for dehydration, altered nutrition, weight loss and urinary tract infection. 71. Review of the clinical record of sampled resident # 1 on 5/14/01 through 5/16/01 revealed a care plan for altered nutrition/PEG tube with an approach to monitor weight weekly. In addition the Physician Order Sheet revealed an order dated 3/1/01 to 21 weigh weekly. The monthly/weekly weight record revealed no weight documented for the 4th week of April or the first and second week of May. The facility's failure to monitor and record weights in a resident with altered nutrition may put the resident at risk for uncorrected weight loss, nutritional deficiency and poor wound healing. 72. Review of the clinical record of sampled resident # 8 on 5/14/01 through 5/16/01 revealed a physician's order to encourage fluids dated 4/5/01 as well as an in dwelling catheter. Resident #8's clinical record revealed a care plan dated 4/9//01 for an indwelling catheter, which included an approach to observe 1&O. In addition, review of the Policy and Procedure for Intake and Output states that residents receiving these treatments require measurement and documentation of intake and output every eight hours including a 24-hour total. Review of the residents Intake and Output Sheet revealed that the I&O was not recorded on the 7:00 a.m. - 3:00 p.m. shift on 5/1/01 through 5/7/01, on the 3:00 p.m.-11:00 p.m. shift on 5/3/01, or on the 11:00 p.m.-7:00 a.m. shift on 5/5/01 through 5/7/01. No intake was recorded from 5/8/01 through 5/14/01. Output was not recorded on the 11:00 p.m. -7:00 a.m. shift on 5/8/01, 5/13/01 and 5/14/01 or the 7:00 a.m. -3:00 p.m. shift on 5/11/01. The facility's failure to monitor and record the I&O of a resident with an indwelling catheter and an order to encourage fluids could put the resident at risk for dehydration or urinary tract infection. Correction time given was 6/16/01. 73. On the follow up conducted on 7/20/01 and based on observation, staff interviews and clinical record review, the facility failed to maintain clinical records in accordance with accepted professional practices that are complete and accurately 22 documented relating to dietary notes, dietary assessments and weights for three (3) of fourteen (14) sampled residents (#6, #7, #12). 74. During the initial tour of the facility, sampled resident #6 was observed to be receiving Jevity Plus via G-tube at 40 cc per hour. Review of the clinical record revealed a physician's order for Jevity Plus at 40 cc per hour. Review of the Dietary Progress Note dated 7/19/01 revealed documentation, "Physician notified of recommendation and ordered Jevity 70 cc per hour x 22 hours." During the interview with the Diet Technician regarding the discrepancy in her note and the physician's order that was written 7/10/01, she stated that she had made a mistake in documentation. The Diet Technician confirmed that the resident was receiving Jevity Plus 40 cc per hour and the physician had not ordered a change in the rate amount. 75. Review of the clinical record of sampled resident #7 revealed the resident had skin tears on both legs. Review of the Nutritional Risk Assessment dated 7/6/01, indicated the resident had Stage I and II pressure ulcers on both legs. Interview with the Unit Nurse regarding this discrepancy revealed that the resident did not have and never had pressure ulcers, but does have skin tears on both legs due to edema. During interview, the Diet Technician indicated that the assessment as based on assumption since “no one was available that day to ask when writing the assessment." 76. Review of the clinical record of sampled resident #12 revealed a care plan dated 5/22/00 for weekly weight due to the resident having a G-tube and a physician's order dated 6/11/01 to weight the resident weekly for eight (8) weeks. Review of the monthly/weekly weight record revealed that for the period 6/11-6/30/01 weights were documented for one week and for the period 7/1-7/20/01, no weights were documented. 23 The facility's failure to adequately monitor and record weights for a resident with altered nutrition may further compromise the resident's nutritional status. 77. Based on the foregoing, Palace at Kendall Nursing & Rehabilitation Center violated 59A-4.118(1)(2), F.A.C., herein classified as a Class III violation, which carries, in this case, an assessed fine of $1,000. PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the Court to order the following relief: A. Enter a Recommended Order in favor of the Agency for Health Care Administration against Palace at Kendall Nursing and Rehabilitation Center on Counts I through VIII. B. Assess against Palace at Kendall an Administrative fine of $11,500, in accordance with §400.23(8)(b)(c), Fla. Stat. C. Award the Agency for Health Care Administration reasonable attorney’s fees, expenses, and costs pursuant to §400.121, Fla. Stat. D. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 NW 53"! Street, Miami, Florida 33166; Lourdes F. Roberts, Assistant General Counsel. 24 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 AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Return Receipt Requested to Jeff Aaron Nusbaum, Administrator, Palace at Kendall Nursing & Rehabilitation Center, 11215 SW 34h Street, Miami, Florida 33173, Kendall Health Care, Inc. 11355 SW 84" Street, Miami, Florida 33173, and to Joseph I. Zumpano, Esquire, Registered Agent, FERRELL, SCHULTZ, CARTER, ZUMPANO & FERTEL, P.A., 201 South Biscayne Blvd., 34" Floor. Miami, Florida 33131 on D da ich / q , , 2002. ssistant General Counsel Agency’for Health Zare Administration NW 53" Street, First Floor Miami, Florida 33166 (305) 499-2165 Copy to: Lourdes F. Roberts, Assistant General Counsel Agency for Health Care Administration Manchester Building 8355 NW 53” Street Miami, Florida 33166 25 Elizabeth Dudek, Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive, MS#9 Tallahassee, Florida 26 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Palace at Kendall Nursing & Rehabilitation Center AHCANo.: 2001054521 ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) 0 ! do not dispute the allegations of fact contained in the Administrative Complaint and waive my right to object or to be heard. | understand that by waiving my rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) 6 ! do not dispute and | admit the allegations of fact in the Administrative Complaint, but do wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time | will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3) 6 / do dispute the allegations of fact contained in the Administrative Complaint and request a formal hearing, pursuant to Section 120.57(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. If you choose OPTION THREE (3), in order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve your right to any hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty-one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint. If you have elected either OPTION TWO (2) or THREE (3) above and you are interested in discussing a settlement of this matter with the Agency, please also mark this block. 6 Mediation under Section 120.573, Florida Statutes, is not available in this matter. SEND NO PAYMENT NOW - REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL YOU RECEIVE A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (Please sign and fill in your current address. ) Respondent (Licensee) Address: License. No. and facility type: Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: Alba M. Rodriguez, Assistant General Counsel, Agency for Health Care Administration, 8355 N. W. 53 Street, Miami, Florida 33166. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES (To be used with Election of Rights for Administrative Complaint form — attached) In response to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration (“AHCA" or “Agency”), you must make one of the following elections within twenty- one (21) days from the date of receipt of the Administrative Complaint. Please make your election of the attached Election of Rights form and retum it fully executed to the address listed on the form. OPTION 1. If you do nat dispute the allegations in the Administrative Complaint and waive your right to be heard, you should select OPTION 1 on the election of rights form. A final order will be entered finding you guilty of the violations charged and imposing the penalty sought in the Complaint. You will be provided a copy of the final order. OPTION 2. If you do not dispute any material fact alleged in the Administrative Complaint (you admit each of them), you may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, you will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, you should select OPTION 2 on the Election of Rights form. QPTION 3. If you dispute the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. in order to preserve your right to a hearing, your Election of Rights in this matter must be directed to the Agency by filing within twenty-one (21) days from the date you receive the Administrative Complaint. If you do not respond at all within twenty- one (21) days from receipt of the Administrative Complaint, a final order will be issued finding you guilty of the violations charged and imposing the penalty sought in the Complaint.

Docket for Case No: 02-001789