Petitioner: AGENCY FOR HEALTH CARE ADMINISTRATION
Respondent: IHS AT CENTRAL PARK VILLAGE, INC., D/B/A INTEGRATED HEALTH SERVICES AT CENTRAL PARK VILLAGE
Judges: JEFF B. CLARK
Agency: Agency for Health Care Administration
Locations: Orlando, Florida
Filed: Sep. 18, 2002
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Tuesday, November 5, 2002.
Latest Update: Dec. 25, 2024
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CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 4918
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STATE OF FLORIDA, AGENCY FOR HEALTH Certified Article Number
CARE ADMINISTRATION, 7U0b 4575 1294 2050 yal
Petitioner, SENDERS RECORD
Enc)
vs. AHCA NO: 200283142 “i 4
ee Enews
IHS AT CENTRAL PARK VILLAGE, INC.,
d/b/a INTEGRATED HEALTH SERVICES
AT CENTRAL PARK VILLAGE,
Res ondent . ae =
Pp Fas) =
/
ADMINISTRATIVE COMPLAINT
COMES NOW the Agency for Health Care Administration (hereinafter
“AHCA”), by and through the undersigned counsel, and files this
Administrative Complaint, against IHS AT CENTRAL PARK VILLAGE, INC.,
d/b/a INTEGRATED HEALTH SERVICES AT CENTRAL PARK VILLAGE, (hereinafter
“Respondent”) and alleges:
NATURE OF THE ACTION
1. This is an action to impose an administrative fine in the
amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) pursuant to $$
400.022 (1) (¢), 400.102 (1) (a) and 400.102(1) (d), 400.121(2), and
400.23(8)(b), Fla. Stat (2001) and to assess costs related to the
investigation and prosecution of this case, pursuant to § 400.121(10),
Fla. Stat. (2001).
2. The Respondent was cited for the deficiencies set forth
below as a result of a complaint survey conducted on or about March
22, 2002.
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CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 4918
JURISDICTION
3. The Agency has jurisdiction over the Respondent pursuant to
Chapter 400, Part II, Florida Statutes.
4. Venue lies in Orange County, Division of Administrative
Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-
106.207 F.A.C.
PARTIES
S. AHCA is the enforcing authority with regard to nursing home
licensure law pursuant to Chapter 400, Part II, Florida Statutes and
Rules 59A-4, Florida Administrative Code.
6. Respondent is a skilled nursing facility located at 9311 S.
Orange Blossom Trail, Orlando, Florida 32837. The facility is
licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-
4, Florida Administrative Code. Its license number is 1089096,
effective 07/25/2002 through 07/31/2003; its certificate number is
8847.
COUNT I
RESPONDENT FAILED TO DEVELOP AND IMPLEMENT WRITTEN POLICIES AND
PROCEDURES THAT PROHIBIT MISTREATMENT, NEGLECT, AND ABUSE OF
RESIDENTS. 42 CFR 483.13(c) (INCORPORATED BY REFERENCE IN FLA. ADMIN
CODE R. 59A-4.1288), §$§ 400.102, 400.121(2), 400.23, 400.022(1) (f) Fla.
Stat. (2001).
CLASS II DEFICIENCY
7. AHCA re-alleges and incorporates (1) through (6) as if fully
set forth herein.
8. Based on resident record reviews and interviews the
Respondent failed to neglected to obtain necessary care and service of
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CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 4918
one sampled resident. Specifically, based on observation, staff and
confidential interviews, clinical record reviews, review of emergency
medical service records and hospital emergency room admission records,
the Respondent failed to ensure that services or care was provided to
prevent physical harm for Resident (#1) who was hospitalized with
severe heat stroke (hyperthermia) , respiratory failure requiring
intubation, intravenous fluids for hydration, and blisters due to
exposure to high environmental heat temperatures and sun exposure for
an extended period of time. The findings include the following:
A. Clinical record review on 3/22/02 at approximately 3:00 PM for Resident #1 revealed the resident
was originally admitted to the facility on 4/17/98 with diagnoses of Multiple Sclerosis, Osteoarthrosis,
Debility, and Dementia.
B. Review of the resident's Minimum Data Set (MDS) dated 1/19/02 identified the resident as having
a short term memory deficit and cognitive skills coded at "I" indicating the resident had difficulty with
decision making skills in new situations. Activities of daily living revealed the resident was unable to
ambulate and was wheelchair bound.
Cc. Review of the resident's care plans identified the resident's Needs/Problem/Concerms as follows:
a. Safety R/T smoking dated 10/10/01 and updated on 1/17/02. Approaches were identified as
follows:
i. Staff member to be with resident when smoking.
il. Smoking smock to be used.
iii. Cigarettes/lighter held at nurses’ station.
b. Alteration in thought process R/T Dx. Dementia as evidenced by short-term memory loss
and impaired daily decision-making dated 10/10/01 and updated on 1/17/02. Approaches
as follows:
i. Ask yes/no questions.
D. A review of a Safety Evaluation for Unsupervised Smoking assessment form dated 6/19/01
identified that the resident was assessed by the interdisciplinary team as "is able to smoke unsupervised.”
E. Review of the scoring system "severe impairment". The form also indicated “evaluation is done
quarterly and with significant change in condition."
F. Further record review revealed no other evaluations were available in the clinical record. Interview
with the Care Plan Coordinator on 3/22/02 at approximately 5:45 PM revealed, "We don't do the form
quarterly."
G. Review of physician’s notes dated 2/13/02 revealed the following: "Multiple Sclerosis with
gradual decline in function- more falls recently- increased memory loss."
H. Review of Social Service Progress Notes dated 2/13/02 revealed the following: "Late entry review
of quarterly assessment (1/19/02) alert and oriented x 2 with periods of confusion. Continues to display
impaired decision-making skills. Resident found on floor several times over past quarter."
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CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 4918
L A review of the physician's orders revealed the resident was administered 10 milligrams of
Ditropan XL every day for urinary incontinence while at the facility. According to Saunders Nursing
Drug Handbook (W.B. Saunders, Publisher, 1998), Ditropan "should not be taken in high environmental
temperatures (heat prostration may occur due to decreased sweating)." A "frequent" side effect of
Ditropan is noted to be "decreased sweating” according to the drug handbook.
H. A review of the local Orlando newspaper revealed that on 3/21/02, afternoon temperatures in
Orlando on 3/20/02 reached 87 degrees with the Ultraviolet index 7-9 indicating " 15 minutes in the sun
before skin damage occurs." The "feel like" temperature was 88 degrees due to the humidity.
I. Observation of the southeast patio on 3/22/02 at 4 PM where Resident #1 was found on 3/20/02,
revealed this patio to be uncovered by any type of awning or shade trees. The concrete patio received the
direct rays of the sun at this time of day. A water fountain or other source of fluids such as a soft drink
machine was not observed in the area of the patio.
J. On 3/22/02 at 4:15 PM, a small lady was observed with a washcloth resting on her forehead
shading her eyes from the sun. Another cognitively aware resident on the patio at 4:15 PM on 3/22/02
was asked if staff checked residents periodically when they were out on the patio. The resident stated,
"No one ever checks on us .. . they (facility) don’t have the staff to take care of residents who they need to
care for."
L. Interview with the nurse manager in her office on the West Wing at 4:45 PM on 3/22/02 revealed
that the resident ate lunch in his room at 12 Noon on 3/20/02. At 12:15 PM, the resident propelled
him/her self in a wheelchair to the southeast outdoor patio to smoke cigarettes.
J. The nurse manager stated that the resident remained on the southeast patio, which does not have
an awning or any other cover, from 12:15 PM until 2:45 PM.
K. When staff went to check on the resident and called his name, the resident did not respond. The
nurse manager admitted during the interview, "it was hot out there." The staff observed cigarette ashes on
the clothes of the resident and the resident was not wearing a smoking smock. The resident was retumed
to the facility and administered oxygen. A 911 call was placed to transport the resident to the hospital.
L. Interview with a 3-11 nursing assistant took place at 5:30 PM on 3/22/02 in the nurse manager's
office on West Wing. She stated that she observed the resident in bed at 3:15 PM on 3/20/02. She stated
that the resident appeared to be in a lot of pain. According to the nursing assistant, the resident had a
"stroke" as the resident could not talk at that time.
M. Review of the nurse's notes on 3/22/02 at approximately 3:00 PM revealed the following:
a. 3/20/02 3:00 PM - "Resident was not in his room at the time of the changing of shift. CNA
(certified nursing assistant) went looking for resident. He was sitting on the patio
unresponsive. Nurse was called to the patio, resident was brought back to room and placed
in bed by staff. Resident remained unresponsive, respiratory difficulty noted, resident was
placed on O2 at 2liters via nasal cannula. Unable to obtain blood pressure in both arms.
Temp.107.0. Respirations 34. 911 called.
N. Review of the Emergency Medical Service report revealed the following: 3/20/02 1520 - "Blood
Pressure 151/121, Pulse 190, Temperature 107.9. Pt. unresponsive at nursing home. Upon arrival pt. was
in bed unresponsive. Initial contact with pt. felt hot. Temp. verified 107.9. Staff at facility states pt. came
to room and collapsed into bed. Nursing home staff states pt. is usually responsive. Doctor states pt. had
been outside smoking. Doctor states pt. is wheelchair bound and believes pt. had been outside for quite a
while. Doctor also states, pt. has had decreasing fluid intake. Ice packs applied to pt. Transported to ER
for tx.”
O. Review of the Emergency Records revealed the following:
b. 3/20/02 1525 - Emergency Physician Record. " Arrived in ED in unresponsive state from
NH. Just prior to arrival pt. allegedly collapsed at NH in unresponsive state. Found outside
in smoking area fell out of w/c. Unknown downtime. Agonal respirations with vomiting,
depressed gag reflex, Tachycardia, Respiratory Failure, Sepsis, and Hyperthermia. Ice pack
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CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 4918
to neck, axilla, groin, Cooling blanket from OR. Critical care 45 minutes, pt. intubated,
lumber puncture, NGT all done by MD. “Item on the form revealed "if either question #4,
6, or 8 is answered as yes, the resident is evaluated as not able to smoke unsupervised.”
Review of question #4 stated "does the resident need assistance entering the smoking
area,” the facility documented yes. Other questions on the sheet evaluating the resident's
cognitive/memory status identified the resident scored "8" indicating
c. Emergency Procedure Note. " Respiratory Failure requiring intubation. Agonal respirations
and vomiting. Pt intubated and placed on respiratory support. Admitted and ventilated."
d. Critical Care Continuation Record. " Coma, severe distress. Pt. intubated by MD under
conscious sedation because of respiratory failure.
e. 4:15 PM: " Pt. is oxygenating adequately, B/P stable after fluid challenge. NG tube
inserted by MD."
f. Nursing Skin Assessment. "Open blisters on right hand and near elbow, left chest with
several unopened blisters and red mark on left upper back."
g. Caregiver Observation, Assessment, Interventions and Response to Interventions: " On
arrival to ER, pt intubated. Temp 106.3 rectally. Foley inserted. IV's x2 fluids infusing
without complications. 17:45 Temp 99.5. Awaits bed. Blistering sunburn noted to right
arm.
h. Nursing Assessment Continuation: 19:30 "Assumed care of pt at 19:00- NG noted to low
suction returning dark brown fluid in small amounts- Foley in place 100cc in bag
concentrated dark urine. [V NS infusing Iliter/800 infused. Intubated with 7.5 ET tube on
vent. VS 97/48, Heart rate 110, resp.16. Abdomen noted to be hard. Blisters noted to R
arm areas: 2” x 1.5" opened area below elbow, 1.5" x .75 at elbow open, .75" x .5" open on
elbow. Right forearm unopened blisters: 0.25" round, 1" x 1.25", 1" x .75" above elbow, 1"
x 0.75" elbow, 2.5" reddened skin above R elbow with described blisters above, 9.5" area
below shoulder R arm noted 4 unopened blisters." 20:00 VS B/P 90/49, Pulse 103. 20:30
B/P 102/61, Pulse 104. 21:00 B/P 100/54, Pulse 104. Output 250ce dark concentrated
urine."
P. Observation of Resident #1 on 3/22/02 at approximately 1:45 PM, in the Intensive Care Unit at the
hospital identified the resident to be on a ventilator for assistance with breathing, a naso-gastric tube was
attached to suctioning and intravenous fluids were infusing. The resident's right arm was bandaged and
interview with the resident's nurse revealed "the resident has many opened and unopened blisters to
various areas." The resident was unable to be interviewed.
9. Based upon the forgoing, the Respondent violated 42 CFR
483.13(c), which requires the Respondent to develop and implement
written policies and procedures that prohibit mistreatment, neglect,
and abuse of residents and misappropriation of resident property.
Fla. Admin Code R. 59A-4.1288 implements §§ 400.102, 400.121(2),
400.23, 400.022(1) (2) Fla. Stat. (2001), and incorporates by reference
42 CFR 483.13. In addition, based upon the forgoing findings, the
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CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 4918
Respondent violated the resident’s “right to receive adequate and
appropriate health care and protective and support services
consistent with the resident care plan, with established and
recognized practice standards within the community, and with rules as
adopted by the agency.” § 400.022(1) (@) Fla. Stat. (2001).
10. The above referenced violation constitutes the grounds for
the imposed Class II deficiency and for which a fine of TWO THOUSAND
FIVE HUNDRED DOLLARS ($2,500) is authorized under §§ 400.022(3),
400.102(1) (a), 400.102(1)(d), 400.121(2), and 400.23(8)(b), Fla. Stat.
(2001).
11. This violation also constitutes the grounds for the
assessment for costs related to the investigation and prosecution of
this case, pursuant to § 400.121(10), Fla. Stat. (2001).
CLAIM FOR RELIEF
WHEREFORE, AHCA requests this Court to order the following
relief:
A. Make factual and legal findings in favor of the Agency on
Count I,
B. Impose a fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500)
for the violation cited in Count I against the Respondent under §§
400.102(1) (a), 400.102(1)(d), 400.121(2), and 400.23(8)(b), Fla. Stat.
(2001),
Cc. Assess costs related to the investigation and prosecution of
this case, pursuant to § 400.121(10), Fla. Stat. (2001).
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CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 4918
NOTICE
The 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
Explanation of Rights (one page) and Election of Rights (one page).
All requests for hearing shall be made to the attention of Joanna
Daniels, Assistant General Counsel, Agency for Health Care
Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, FL 32308.
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.
Respectfully submitted,
FL Bar #0118321
Assistant General Counsel
Agency for Health Care Administration
2727 Mahan Dr., MS #3
Tallahassee, FL 32301
(850) 922-5873 Fax (850) 413-9313
CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 4918
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a copy hereof has been furnished to
Administrator, Integrated Health Services At Central Park Village,
9311 South Orange Blossom Trail, Orlando, Florida 32837, Return
Receipt No. 7106 4575 1294 2050 4918 by U.S. Certified Mail, on August
/ , 2002,
C4 (LE,
J na Daniels
Copies furnished to:
Eloise Abrahams, Administrator
Integrated Health Services
At Central Park Village
9311 South Orange Blossom Trail
Orlando, Florida 32837
(U.S. Certified Mail)
Wendy Adams Joanna Daniels
Agency for Health Care Agency for Health Care
Administration Administration
2727 Mahan Drive, MS #3 2727 Mahan Drive, MS #3
Tallahassee, FL 32308 Tallahassee, FL 32308
(Interoffice Mail) (File Copy)
JD/sr
Page 8 of 8
Docket for Case No: 02-003606
Issue Date |
Proceedings |
Jun. 05, 2003 |
Final Order filed.
|
Nov. 05, 2002 |
Order Closing File issued. CASE CLOSED.
|
Nov. 01, 2002 |
Motion to Remand (filed by Respondent via facsimile).
|
Oct. 09, 2002 |
Respondent`s First Request to Produce to Petitioner (filed via facsimile).
|
Oct. 02, 2002 |
Order of Pre-hearing Instructions issued.
|
Oct. 02, 2002 |
Notice of Hearing issued (hearing set for November 8, 2002; 9:00 a.m.; Orlando, FL).
|
Sep. 23, 2002 |
Response to Initial Order (filed by Respondent via facsimile).
|
Sep. 18, 2002 |
Administrative Complaint filed.
|
Sep. 18, 2002 |
Petition for Formal Administrative Hearing and Answer to Administrative Complaint filed.
|
Sep. 18, 2002 |
Notice (of Agency referral) filed.
|
Sep. 18, 2002 |
Initial Order issued.
|