STATE OF FLORIDA i, | AM a, AGENCY FOR HEALTH CARE ADAENTSTERSTOH, Ae ° AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA NO. 2001070431 MADISON HEALTH INVESTORS, LLC d/b/a LAKE PARK OF MADISON, Respondent. / _ ADMINISTRATIVE COMPLAINT COMES NOW the Agency For Health Care Administration (hereinafter AHCA), by and through the undersigned counsel, and files this Administrative Complaint against the Madison Health Investors, LLC, d/b/a Lake Park of Madison (hereinafter Lake Park), pursuant to §§ 120.569, 120.57 and Chapter 400, Part II, Fla. Stat., and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $2,500.00 against Lake Park, pursuant to Section 400.102, Florida Statutes, and assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Fla. Stat. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part II, Fla. Stat. 3. Venue shall be determined pursuant to Fla. Admin. Code 28- 106.27. PARTIES 4, AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Fla. Stat., and; Fla. Admin. Code R. 59A-4, respectively. 5. Lake Park is a skilled nursing facility, licensed (number 16360961, certificate number 7904, effective through 08/31/02), for 120 beds and is located at 1900 Country Club Drive, Madison, FL 32340. At all relevant times hereto, Lake Park was a licensed facility required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA. COUNT I LAKE PARK FAILED TO IMMEDIATELY CONSULT WITH A RESIDENT'S PHYSICIAN FOLLOWING A SIGNIFICANT CHANGE IN THE HEALTH STATUS OF THAT RESIDENT. 42 CFR 483.10(B) (11) §§ 400.23(8) (b) and 400.102(1), Fla. Stat. Fla. Admin. Code R. 59A-4.1288 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. AHCA conducted a complaint investigation on 11/19/2001. The investigation revealed that on 10/31/2001, a resident was admitted to the facility with diagnosis of severe closed head injury, respiratory failure, dysphagia, blunt chest trauma with left pneumothorax and pulmonary contusion. 8. The resident's clinical record revealed that on 11/02/2001, in the a.m., the resident's temperature was elevated. The resident's physician was paged at 11:55 a.m. for consultation. The physician had not responded by 3:30 p.m. At 7:30 p.m. the facility nursing staff assessed the resident as having no respirations or pulse. At 7:35 p.m. emergency medical services were called and arrived at the facility at 7:40 p.m. and pronounced the resident anastolic. At 7:55 p.m. the resident's physician responded to the 11:55 a.m. page for consultation. 9. Surveyor interviews conducted on 11/19/2001 revealed that various facility staff had attended the resident at various times during the afternoon of 11/02/2001, however they were not aware whether additional attempts were made to contact the resident's physician for consultation. 10. Lake Park's failure to immediately consult with the resident's physician compromised the resident’s ability to maintain or reach the highest practicable level of physical well-being; an isolated Class II violation subject to a civil penalty of $2,500.00 under § 400.23(8) (b), Fla. Stat. 11. AHCA’s assessment of costs related to the investigation and prosecution of this case is proper, pursuant to Section 400.121(10), Fla. Stat. WHEREFORE, AHCA intends to impose an administrative fine in the amount of $2,500.00 against Lake Park, a skilled nursing facility in the State of Florida, pursuant to §§ 400.102 and 400.23(8) (b) Fla. Stat. and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, 525 Mirror Lake Drive, North, Sebring Building, Suite 310H, Saint Petersburg, Florida, 33701; Attention Gerald L. Pickett, Senior Attorney. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Dated April 25, 2002. Gerald L. Pickett AHCA - Senior Attorney Florida Bar No. 559334 525 Mirror Lake Drive, North Sebring Building, Suite 310H (727) 552-1436 (office) (727) 552-1440 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U. S. Postal Service Certified Mail (receipt No. 7099 3400 0002 2450 8351) on April 25', 2002 to: Karen Goldsmith, Esquire, with Goldsmith, Grout & Lewis, P.A., located at 2180 North Park Avenue, Suite 100, Post Office Box 2011, Winter Park, Florida 32790-2011. Gerald L. Pickett Copies furnished to: Molly McKinstry Fort Knox # 1 Mail Stop # 33 Room 220 Tallahassee, Florida (via Interoffice Mail) Donah Heiberg Fort Knox # 2 Mail Stop # 46 Room 1213 Tallahassee, Florida (via Interoffice Mail) Gerald L Pickett AHCA — Senior Attorney 525 Mirror Lake Drive, North Sebring Building, Suite 310H Saint Petersburg, Florida 33701

Docket for Case No: 02-002739