DAB 02 JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY September 3, 2002 Ann Luchini Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 Re: Notice of Agency Action in Mary Jane Dowling, Florida Hospital Orlando, Florida Preferred Care Facilities II, Inc. d/b/a West Gables Health Care Center, and Hebrew Home of North Dade, Inc., d/b/a Hebrew Home for the Aged North Dade Dear Ms. Luchini: Enclosed are the various notices of agency action that should have accompanied the above petitions for hearings. I will be sure in the future that these accompany requests for hearings submitted to DOAH. Please let me know if you need anything more for these cases. Thank you. Lealand L. McCharen, Agency Clerk Visit AHCA online at www.fdhe. state. fl.us 2727 Mahan Drive « Mail Stop #1 Tallahassee, FL 32308 Rg SEP-G3-2802 16:61 AHCA LEGAL DEPARTMENT Lo te ™ on STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.; 2002040261 - AHCA No.: 2002040271 v. Return Receipt Requested: 7000 1670 0011 4847 2376 HEBREW HOME OF NORTH DADE, INC. 7000 1670 0011 4847 2383 d/b/a HEBREW HOME FOR THE AGED NORTH 7000 1670 0011 4847 2390 DADE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Hebrew Home of North Dade, Inc. d/b/a Hebrew Home for the Aged North Dade, (hereinafter “Hebrew Home for the Aged North Dade”), pursuant to Chapter 400, Part II, Florida Statutes (“Fla. Stat.”) and Chapter 59n-4, Florida Administrative Code (“Fla. Admin. Code”) and alleges: NATURE OF THE ACTION 1, This is an action to impose an administrative fine of $2,500.00 pursuant to § 400.23(8), Fla. Stat. (2001), and an action of Notice of Intent to Assign aa RE SEP-O3-2882 16:@1 AHCA LEGAL DEPARTMENT o™N oN Conditional Licensure Status to Hebrew Home for the Aged North Dade pursuant to § 400.23(7), Fle. Stat. (2001), for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part II, Fla. Stat., (2001). 3. Venue lies in Miami-Dade County, pursuant to § 400.121 (1) (e), Fla. Stat. And Rule 26.106.207, Fla. Admin. Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Fla. Stat. (2001), and Chapter 590-4 Fla. Admin. Code. 5. Hebrew Home for the Aged North Dade operates a 75-bed skilled nursing facility located at 1800 N. E. 168 Street, North Miami Beach, Florida 33162. Hebrew Home for the Aged North Dade is licensed as a skilled nursing facility, license number SNF1218095; certificate number a701, effective May 5, 2002 through December 31, 2002. Hebrew Home for the Aged North Dade was at all times ee SEP-B3-2082 16:61 AHCA LEGAL DEPARTMENT o™ material hereto 2 licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I HEBREW HOME FOR THE AGED NORTH DADE FAILED TO PROVIDE APPROPRIATE CARE TO A DIABETIC RESIDENT TITLE 42 § 483.25, CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLA. ADMIN, CODE SECTION 400.23, FLORIDA STATUTES (QUALITY OF CARE) CLASS II 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Hebrew Home for the Aged North Dade was cited with one (1) Class Il deficiency based on the annual survey of May 6 and May 8, 2002. 8. Because Hebrew Home for the Aged North Dade participates in Title XVIII or XIX it must follow certification rules and regulations found in 42 Code of Federal Regulation 483. 9. Based on the annual survey conducted on May 6 and May 8, 2002 and based on observation, review of documentation and interview, facility staff did not provide appropriate care to a diabetic resident by not managing the resident's persistent bounds of hyperglycemia increasing the risk of developing complications and did not provide 3 SEP-G3-2002 16:01 AHCA LEGAL DEPARTMENT P.O5 f™ oN well-fitting shoes in order to prevent the resident from developing a foot callus of one (1) of twelve (12) sampled resident, i.e. sampled resident # 4. Findings include the following. 10. Review of sampled resident #4's medical record on 5/6/02 revealed that the resident was diagnosed with urosepsis, coronary vascular disease (CVA), hypothyroidism, insulin dependent diabetes mellitus (IDDM) and hypertension. ll. Review of the treatment records on 5/6/02, for the months of March and April 2002, revealed that the resident was experiencing very high blood sugars. The residents' blood sugar was being tested twice a day, before breakfast and before dinner. In the month of March, there were approximately ten blood sugar values over 400 mg/dl (mermal being 110 mg/dl) and approximately 15 values over 300 mg/dl. In the month of April, there were approximately 6 blood sugar values over 400 mg/dl and approximately 14 values over 300 mg/dl. In the month of May (May 12 thru May 6) there were 4 blood sugars over 300 mg/dl and 2 over 400 mg/dl. 12. Further review of the record revealed that nursing had noted a blackened or dark callus on the right heel of the resident on 05/07/02 and had requested that a SEP-@3-2002 16:@1 AHCA LEGAL DEPARTMENT oN podiatrist examine the resident. Observation was made of this callus in the presence of the resident's podiatrist on 05/07/02. The podiatrist stated that the callus was related to pressure, The podiatrist was then informed of the resident's hyperglycemia and he determined to evaluate the resident's circulation to the feet. Review of the weekly skin record revealed that on 05/06/02, there were "no open areas noted", but did not mention the presence of the dark callus, Consistent inspection of the resident's feet was not apparent although careful inspection of the feet is required for individuals diagnosed with diabetes to prevent complications. 13. Review of the Medication Administration Record (MAR) for March and April 2002, as well as review of the nurses’ notes for that time period, revealed that nursing had not notified the physician whenever the blood sugar was found to be over 300 mg/dl, although there was an order written on the MAR to do so. This order directed nursing staff to administer 10 units of insulin if the resident's blood sugar was over 300 mg/dl and to notify the physician about the high level. 14. After surveyor's enquiry, the Director of Nursing Services notified the physician of the sustained high blood Sugars on 05/07/02. Adjustments were made to the insulin P.65 SEP-@3-2882 16°@1 AHCA LEGAL DEPARTMENT coverage and the resident was given an appointment to see the physician. 15. Interview with the resident determined that family and friends brought sugar-free snacks when they visited and he/she enjoyed them very much. Observation of one of these snacks revealed that it was not Sugar free. The cookies were sugar wafers. Interview with staff revealed that the resident consumes foods brought in by family and friends. Discussion with the resident revealed a lack of knowledge pertaining to blood sugar management and the complications of hyperglycemia. The care plans developed for high blood sugar and pressure sores did not address measures to educate the resident or the family and friends about food and its impact on the residents well being. 16. Review of the care plans revealed that a care plan had been developed to address the resident's risk of pressure sore development on 01/23/02 and another was developed on 5/7/02 to addressed the pre-existing ulcer. However, these care plans did not address measures to improve glycemic control. Another care plan developed on 12/05/01 for the resident's low hemoglobin, low hematocrit, low albumin and high blood Sugar was reviewed. This care plan was not revised in a timely manner as it became SEP-G3-2082 16:42 AHCA LEGAL DEPARTMENT P.e8 coN ™ evident that the residents’ hyperglycemia was not improving. The last revision of the care plan was on 03/15/02. 17. Observation of the resident during 05/06 and 05/07/02 revealed that the resident occasionally wore tightly fitting shoes. She was observed on 05/07 wearing flat pumps. The shoes did not fit properly as the flesh of the foot came out of the sides. It was also noted that the resident had mild edema of the feet, which was another reason why the resident should have been wearing better fitting shoes. The nurse was asked to see the ill-fitting shoes, which the resident was wearing. Shortly after the observation, the nurse changed the shoes to sneakers. Placement of socks on resident's feet before putting the shoes on was mentioned to the nurse. However, the nurse stated that if the resident wore socks, the sneakers would not fit. 18. The podiatrist, later in the day on 5/7/02, observed that the resident was not wearing socks and reported that socks should be placed on the feet. Diabetics are encouraged to wear socks in order to provide a more comfortable fit and to prevent pressure and friction and to allow for the absorption of sweat. SEP-G3-2882 16:82 AHCA LEGAL DEPARTMENT P.@9 19. Uncontrolled hyperglycemia (high blood sugars) is considered a high risk factor in the development of foot ulcers as well as blindness, renal insufficiency and nerve damage. These complications arise from the negative impact that sustained hyperglycemia has on blood vessels. 20. Based on the foregoing, Hebrew Home for the Aged North Dade violated § 483.25, Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, and § 400.23, Fla. Stat., herein classified as a Class II violation pursuant to $400.23, which carries, in this case, a fine or $2,500.00 and gives rise to a conditional rating pursuant to §400.23(7). DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Hebrew Home for the Aged North Dade shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit NAY SEP-83-2082 16:82 AHCA LEGAL DEPARTMENT oon CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Hebrew Home for the Aged North Dade on Count I. 2. Assess against Hebrew Home for the Aged North Dade an administrative fine of $2,500.00 on Count I for violation of § 400.23, Fla. Stat., and § 483.25, Code of Federal Regulations as incorporated by Rule 59A-4,1288, Fla. Admin, Code. 3. Uphold the conditional rating on the license of Hebrew Home for the Aged North Dade pursuant to §400.23(7) 4. Assess costs related to the investigation and prosecution of this matter, if applicable 5. Grant such other relief as the court deems is just and proper on Count I, 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 .16 SEP-83-2882 16:62 ABHCA LEGAL DEPARTMENT om Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Manchester Building, First Floor, 8355 N. W. 53rd Street, Miami, Florida, 33166; Attn: Alba M. Rodriguez. 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, (Aites 2). Radios Alba M. Rodrigvez O Assistant General Counsel Agency for Health Care Administration 8355 N. W, 53 Street Miami, Florida 33166 Copies furnished to: Diane Castillo Field Office Manager Agency for Health Care Administration 8355 N. W. 53 Street Miami, Florida 33166 (Interoffice Mail) Gloria Collins Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) edt SEP-@3-2082 16:82 AHCA LEGAL DEPARTMENT aN Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 1! 12 SEP-@3-2682 16:2 AHCA LEGAL DEPARTMENT oN EXHIBIT “A” Conditional License License # SNF 1218095; Certificate No.: Effective date: 05-08-2002 Expiration date: 12-31-2002 12 8701 SEP-G3-2082 16:2 AHCA LEGAL DEPARTMENT CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Ira Siev, Administrator, Hebrew Home for the Aged North Dade, 1800 N. EB. 168 Street, North Miami Beach, Florida 33162; Hebrew Home of North Dade, Inc., 300 71 Street, Miami Beach, Florida 33141; William Zubkoff, 300 71 Street ~ Suite 445, Miami Beach, Florida 33141 on this 16” day of July 2002. z 2. Alba M. EEO / q 5 .i4 SEP-@3-2082 16:83 AHCA LEGAL DEPARTMENT STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION EXP! ANATION OF RIGHTS LINDER SEC. 120.569 Fl ORIDA STATUTES (To be used with Election of Rights for Administrative Complaint form — attached) In rasponse to the allegations set forth in the Administrative Complaint issued by the Agency for Health Care Administration C-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 da not 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 da_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. OPTION 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. 15 SEP-G3-2082 16:23 AHCA LEGAL DEPARTMENT STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: HEBREW HOME OF NORTH DADE, INC. dib/a AHCA No.: 2002040261 HEBREW HOME FOR THE AGED NORTH DADE AHCANo.: 2002040271 ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT PLEASE SELECT ONLY 14 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) 8 ! do not dispute the allegations of fact contained in the Administrative Complaint and waive my right fo 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) 0 ! 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) @ / 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. Rodriquez, Assistant General Counsel, Agency for Health Care Administration, 8355 N. W. 53 Street, Miami, Florida 33166. AHCA LEGAL DEPARTMENT ‘Armaiag Aindaq COTNE/ZT ‘ALVC NOIWLVUIdXa ASNAON 007/80/S0 ‘ALVC HALLOdASA NOLLOV STYEIS Uy odueyD ‘spaq CL AA @S1€€ Td “HOVEE INVIN HLYON LASULS HL89! @ N 008T advd HIYON GaDY ABL YOd AWOH MANET “BuTAO][0J BY) aJeI0d0 0} paztioyne st aasuadt] OU) SB pur “saIMeIS EPLOLY “T] Wed ‘OO JaideyD ur pazuoyjne ‘uoneAsMUpYy aes wleay Jog Aouady ‘epioyy jo ae au Aq paydope suonemngar pue sey ayy gyi porjduioo sey “Nj “ddVC HIYON dO SWORN ASNaaH 1 wTC9 01 ST SUD, TVNOLLIGNOD ALVYTOVA ONISUON GHTILIS ALITVNO HLIVaH GNV Fav GADVNVW AO NOISIAIC NOILVULSININGYV FaVD HLTVAH YOA AONADV BPLIOL] JO 33eI¢ iW A Mi Hy vi =. 1048 # ALVOMILaO a i TOTAL P.17

Docket for Case No: 02-003475