_ Certified Articte Number . 7106 4575 1254 2049 agi) SENDERS RECORD STATE OF FLORIDA bd-He3. 3, AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA vs. NO.2002043121/2002043111 HP/ST.CLOUD, INC D/B/A ST.CLOUD HEALTHCARE & REHABILITATION 4 O02 a7 an iy L F Respondent. / ree ory JG) ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION, hereinafter referred to as Petitioner), by and through its undersigned counsel, and files this Administrative Complaint against HP/ST. CLOUD, INC., D/B/A ST. CLOUD HEALTHCARE & REHABILITATION (hereinafter referred to as Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This is an action filed pursuant to section 400.23 (7)(b) Fla. Stat. (2001) relative to the assignment of a conditional ticense as well as an action to impose an administrative fine, interest and costs, related to the investigation and prosecution of this case, pursuant to Section 400 Fla. Stat (2001) JURISDICTION AND VENUE 2. This tribunal has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, (2001). 3. Venue shall be determined pursuant to Rule 28-106.27, Florida Administrative Code. 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, Florida Statutes, (2001), and; Chapter 59A-4 Fla. Admin. Code, respectively. 5. Respondent is a nursing facility whose 131-bed nursing home is located at 1301 Kansas Avenue, St. Cloud, Florida 34769. Respondent is licensed to operate a nursing facility license with facility license number designated as #1518096 and Respondent was required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA at all times material. COUNT I EFFECTIVE JUNE 12, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO HP/ST. CLOUD, INC., D/B/A ST. CLOUD HEALTHCARE & REHABILITATION UPON THE DETERMINATION THAT HP/ST. CLOUD, INC., D/B/A ST. CLOUD HEALTHCARE & REHABILITATION WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF TWO (2) CLASS ONE (I) DEFICIENCIES AT THE MOST RECENT SURVEY OF JUNE 12, 2002 Ss. 400.23(7) Fla. Stat. (2001); Rule 59A-4.1288 F.A.C; 42 CFR 483.13(1); 42 CFR 483.75; s.400.147(2) Fla.Stat. (2001); s.400.022 Fla.Stat.(2001);s.400.23 Fla.Stat.(2001); s.400.19 Fla.Stat. (2001) 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. AHCA conducted a survey of Respondent facility on or about June 12, 2002, and the investigation revealed two (2) Class (I) deficiencies as the Respondent failed to provide care and services to protect the residents, failed to develop and operationalize policies for the protection of residents and for the prevention of neglect and mistreatment and as the Respondent failed to administer effectively to ensure resident safety and well being. 8. Based on observation, staff interview and record review the findings are delineated as follows: FINDINGS AS TO THE FIRST CLASS ONE DEFICIENCY: Based on observation, record review and interview, it was determined that the facility neglected to provide cares and services to protect 4 of 4 sampled residents. (#1, #2, #3, & #4) Findings: 1. On the morning of Monday 6/10/02, resident #1 left the facility and went to a liquor store. Resident #1 is in an electric wheelchair and is known to frequently leave the facility. This liquor store is over 3 miles from the facility. The resident would have to cross over a busy 4 lane divided highway to reach the liquor store. There are no side walks for the last 2 miles of the trip therefore the resident would have to maneuver the electric wheelchair on the side of the road or on the shoulder of the road. Resident #1 purchased a bottle of vodka and as he/she crossing back over the highway the resident was hit by a bus. The resident expired on 6/10/02. Interview with the Liquor Store Manager on 6/11/02, revealed that resident #1 is a frequent customer that would visit every 2-3 days and a times every other day. The Manager stated that resident buys vodka in a plastic container. The Manager confirmed that the resident purchased a bottle of vodka shortly after 10:00 AM on 6/10/02. The manager stated he/she heard the accident and described the sound of a motorcycle being hit. The Manager also added that he/she has observed resident #1 crossing the highway into the median on previous visits. The manager stated that he/she did not think resident #1 was an alcoholic. Resident #1 was originally admitted the facility on 7/21/00. The resident had current diagnosis of CVA, hemiplegia and was noted to have a history of alcohol abuse. There was no indication that the facility effectively managed the resident's alcohol addiction. This resident was allowed to freely leave the facility unattended and without Physician's orders. There was no evidence the the facility's interdisciplinary care plan team had assessed the resident for safety and deemed the resident as appropriate for unattended leave of absence(LOA), The Minimum Data Sets (MDS) indicated that this resident did not have any behavorial or psychosocial issues. Interview with the facility's Social Worker revealed that the MDS should have been coded for some of the behaviors that the resident had been displaying. The physician wrote an order for the resident not to have alcohol. A review of psychiatric evaluation done on 8/19/00 revealed a recommendation for ReVia to help reduce alcohol craving. The resident's record revealed no evidence that Re Via had been administered. Review of nurses notes from 6/01 through 6/02 revealed that there existed a minimum of 39 documented entries evidencing use of alcohol by resident #1. The following are some of the entries found in the nursing notes: 4/24/02 speech slurred face flushed wandering around in wheelchair 4/19/02 Resident smells of alcohol, noted to have slurred speech....drinking from a glass with ‘liquid' and ice. 4/16/02 resident #1 found on ground, unresponsive with slight frothing from mouth lasting approximately 30 seconds. Another resident reported that resident #1 had been drinking and fell over. Resident #1 refused to go to hospital for CT scan to rule out seizure activity due to alcohol abuse. 4/11/02 2 PM resident's behavior sluggish. Refuses assistance with ADL's. Noted a glass of liquid...resident resting between trips to ice chest. At 4:15 PM Eckerd Drugs called to inform the facility that resident #1 had fallen out of the wheelchair. The DON left the facility and found the resident at Walgreens Liquor Store. The resident was intoxicated. The DON instructed Walgreens not to sell to the resident anymore. 3/31/02 10:45 PM resident intoxicated and smoking in room. After being reminded of the facility policy the resident gave the cigarette to the nurse. 1/20/02 12:30 AM resident fell in bathroom. There were no visible injuries. The staff encouraged resident to stop drinking and go back to bed but the resident refused. At 2:45 AM resident found on floor in front of bed -continues to smell of alcoho! with speech slurred. 2 PM resident incontinent of urine cloths are saturated but the resident refuses to change cloths. Strong smell of alcohol in roam and on resident noted. 1/19/02 3 AM resident continuous to go out to porch via electric wheelchair. Continues to smell of alcohol. At 9:45 (AM or PM not documented) resident in room with slurred speech, completely out of it. Usually intoxicated on the weekends. Refused to be helped, smokes on the porch. Aggressive when reprimanded, can hardly control his/her electric wheelchair. Smokes behind curtains in his/her room. 7/21/01 at 2:30 AM while CNA in room attending roommate, resident #1 lit a cigarette in room. The cigarette was taken away and put out. The facility smoking policy was explained...resident refused to leave cigarettes at nurses station. Continues to smell of alcohol with slurred speech. At 11 PM the police department called facility and they stated resident out on LOA and needed assistance back to the facility. At 11:15 the police called 2 more times. The nurse stated to the police that the resident is able to sign himself/herself out on LOA via electric wheelchair and can return by himself/herself. The police stated that the battery on the electric wheelchair was low. 2 CNA's were dispatched to assist the resident. CNA stated resident uncooperative. Observed resident in chair and the officers were following slowly behind resident. Officers left when CNA's arrived. The resident took off in chair in opposite direction and got stuck in the mud. Eventually the resident returned to the facility with the CNA's. 6/6/01 at 10:50 resident #1 was on the porch and got into an altercation with another resident. Resident #1 threatened to push the other resident into traffic using the electric wheelchair. Resident #1 stated "I wish I could punch you instead of push you." Resident #1 did sustain a scratch for this altercation. Eyewitness indicated that resident #1 did push the other resident 2-3 times with the electric wheelchair. Resident #1 had slurred speech, red face and a smell of liquor to his/her. There was no evidence that facility was providing services such as supervision to ensure resident #1's safety and the safety of other residents. Staff did not enure the resident wheelchair was properly charged prior to leaving the facility. No evidence that staff prevented the resident from drinking in the facility. Interview with CNA revealed that the resident gets some assistance with showers. The CNA stated that the resident doesn't request help with anything else. The last CARES assessment for appropriateness of care was done 12/15/02. 2. Resident #2 was admitted on 2/08/00 from a local area hospital brain injury rehabilitation center, where he/she was rehabilitating from a bilateral thalamic infarction with secondary confusion. He/she had the additional diagnoses of diabetes mellitus, cerebro-vascular disease, hypertension and functional/behavioral impairment. The resident's 2/11/02 and 5/05/02 minimum data sets (MDS) reflected a short term memory problem, some difficulty with decision making in new situations and a mental function that varies over the course of a day. Upon interview on 6/11/02, resident #2 stated that he/she left the facility almost daily without signing out. He/she said that he/she walked to the "Dollar Store", which is in a large shopping plaza across the street from the facility, and to the “Cumberland Farms", which is approximately two blocks east of the facility on State Route 192. The resident admitted that it was dangerous to walk on the unpaved shoulder of the road, but further stated that in his/her pocket, he/she kept a note with his/her name and the name of the residence on it in case he/she gets "hit with a car." Facility administration and staff revealed in an interview on 6/12/02 that they were unaware that the resident was leaving the premises. The resident was not assessed for the cognitive or physical ability to leave the facility unaccompanied. There was no physician's note or order indicating that the practitioner was aware of and approved of the resident's outings into the community. His/her solo departures and returns were not monitored. There was no supervision of the outings and no assessment of his/her condition upon return. The plan of care developed for the resident's risk for falis and injury related to "walks outside the facility around building" was not implemented. 3. Resident #3 was a quadriplegic with diabetes mellitus, peripheral vascular disease, anemia, cerebral vascular accident (late effect), depression, and psychosis with a history of stasis ulcers and pressure ulcers. The resident was noted on interview to be alert and well oriented, but difficult to understand due to expressive aphasia. He/she was wheelchair-bound with minimal movement of all extremities. The resident was wearing shorts, which he/she described as normal attire. His/her lower extremities were edematous and scarred. The resident identified the scars as former blisters. The resident's skin was dry and deeply tanned from the sun. At the time of the survey, he/she was undergoing 90 days of daily treatment with Mentax 1% cream to "all" and daily Lachydrin 12% applications to "both lower legs until resolved." The resident's legs were elevated slightly in the wheelchair to prevent swelling, which promoted increased exposure of the lower legs to the sun. The resident routinely left the facility for periods of time spanning from 5 to 12 hours, with no indication of where he/she is going or when he/she will return. He/she had not been assessed for the ability to travel outside the boundaries of the facility for long periods, unaccompanied. There was no physician's note or order indicating that the practitioner was aware of and approved of the resident's outings into the community. The resident often left in the afternoon and returned after dark, sometimes as late as 3:24 AM. There were no lights on the resident's wheelchair. In an interview with the resident on 6/11/02, the resident stated that he/she spends the late hours in local bars, but does not drink alcohol. The interview further revealed that he/she traveled “all over", going as far west as a hospital in Kissimmee. His/her reason for leaving the facility was that he/she wanted to socialize with more compatible acquaintances than those available in the nursing home. The resident's Blood Urea Nitrogen (BUN) on 5/10/02 was elevated at 22. An elevated BUN is one indicator of possible dehydration. The resident was identified as being at risk for dehydration due to long periods outside. When notified of the BUN results, the physician ordered that fluid intake be increased to 8 glasses of 8 ounces of water daily. No documentation of this intake could be provided. The resident was on a therapeutic diet of measured carbohydrates and no added sugar. The nurses’ progress notes consistently stated that the resident refused facility food and ate outside of the facility. As a diabetic, the resident was to be given a bedtime snack with 8 ounces of milk nightly. The resident's record indicated that he had not received the snack or the milk for at least the month of June. On 5/17/02 high protein was added to the resident's diet to help heal maintain skin integrity,as the resident was at risk for pressure ulcers due to extended periods of sitting the wheelchair. The resident medication administration record indicated that, for at least the month of June, the resident had not received his/her evening medication which included the diabetic medication, Glucophage 850 mg, as well as Os-calc 500, and Feosol 325 mg. Interview with the evening medication nurse on 6/12/02 revealed that the resident was not receiving the medication or the evening snack because [he/she] was out." The facility policy stated, "The facility will provide for the resident the number of doses of physician ordered medication to cover the period of time that the resident would be absent from the facility.". No medication was provided. On 6/09/02, the resident required 2 units of Novolin R insulin coverage for a high fingerstick glucose of 208. No plan of care for the resident's daily outings was developed and related care plans were not implemented. 4. Resident #4 frequently left the facility. This resident is quadriplegic with a motorized wheelchair. During an interview, the resident stated he/she often returned to the facility late in the evening, many times after 12 AM. This resident often left the facility without signing out. The staff were not always aware when resident #4 left the facility, his/her destination and expected time of return. The resident did not have a physician's order for LOA and the the facility did not assess the resident to ensure he/she did not require an attendant when he/she was away from the facility. There was no evidence that the resident's motorized wheelchair had been inspected to ensure safety. FINDINGS AS TO THE SECOND CLASS ONE DEFICIENCY 42 CFR 483.75 Based on observation, record review and interview it was determined the the facility failed to be administer effectively to ensure resident safety and well being. Findings: 1. Based on the extent of noncompliance identified in F-224, the facility did not effectively implement policies and procedures to ensure resident safety and well- being. A policy existed, entitled "Residents, Off Premises", but it was not being followed. There was no evidence that a sign-out/in logging procedure had been implemented for residents who leave premises, unattended. Occasionally, residents #1, #3 and #4 signed a Release of Responsibility for Voluntary Leave of Absence form, but these forms were usually incomplete or illegible. A policy entitled “Missing Resident/Elopement" was also presented. Since no expected return times were required of the residents who regularly leave the facility alone, it was difficult to assess in a timely manner when the resident was "missing" or had "eloped." With regard to the two above-mentioned policies, an interview with the social services director stated that she had not seen the policies prior to 6/11/02. The residents were not assessed to determine if they were able to safely leave the premises unaccompanied. Administrative staff stated that we need to get CARES in here to do those assessments. The facility was also under renovation. This presented a barrier to the visible monitoring of residents who leave the building through the front door. No one was observed monitoring access to and from the facility during the two days of the survey. 9. AHCA assigned a conditional licensure status to Respondent based upon these determinations and because Respondent, due to the presence of two (2) Class (I) deficiencies, was not in substantial compliance at the time of the survey on or about date of June 12, 2002. 10. Attached hereto as Exhibit “A” and by reference made a part hereof is a copy of the conditional license reflecting certificate #8726 license #SNF1518096, action effective date of June 12, 2002, and license expiration date of June 12, 2003. 11. The original of Exhibit “A” has been attached to the petition forwarded by certified mail return receipt requested to Respondent. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Enter actual and legal findings in favor of the agency. 2) Uphold the issuance of the conditional license with an effective date of June 12, 2002, a copy of which is attached hereto as Exhibit “A”; (original attached to complaint forwarded to Respondent) and 3) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). 4) Grant and enter such other and further relief deemed appropriate in the context of the attendant facts and circumstances. DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florié la Statutes, HP/ST.CLOUD, INC D/B/A ST. CLOUD = HEALTHCARE & REHABILITATION shall post the license in a prominent place that is in clear an@® unobstructed public view at or near the place where residents are being admitted to the facility COUNT II RESPONDENT FAILED TO DEVELOP AND IMPLEMENT WRITTEN POLICIES AND PROCEDURES THAT PROHIBIT MISTREATMENT, NEGLECT AND ABUSE OF RESIDENTS. 42 CFR 483.60; Rule 59A-4.1288, Fla. Admin. Code (2001);s.400.23 Fla.Stat. (2001); s.400.022 Fla.Stat. (2001); 400.23 Fla.Stat. (2001); 5.400.147(2) Fla.Stat. (2001); .400.19 Fla.Stat. (2001) 12. Petitioner repeats and realleges paragraphs numbered (1) through (5) as if fully set forth herein. 13. Petitioner conducted a survey of Respondent’s facility on or about June 12. 2002, and the investigation revealed a Class I deficiency more specifically delineated as follows: Based on observation, record review and interview, it was determined that the facility neglected to provide cares and services to protect 4 of 4 sampled residents. (#1, #2, #3, & #4) Findings: 1. On the morning of Monday 6/10/02, resident #1 left the facility and went to a liquor store. Resident #1 is in an electric wheelchair and is known to frequently leave the facility. This liquor store is over 3 miles from the facility. The resident would have to cross over a busy 4 lane divided highway to reach the liquor store. There are no side walks for the last 2 miles of the trip therefore the resident would have to maneuver the electric wheelchair on the side of the road or on the shoulder of the road. Resident #1 purchased a bottle of vodka and as he/she crossing back over the highway the resident was hit by a bus. The resident expired on 6/10/02. Interview with the Liquor Store Manager on 6/11/02, revealed that resident #1 is a frequent customer that would visit every 2-3 days and a times every other day. The Manager stated that resident buys vodka in a plastic container. The Manager confirmed that the resident purchased a bottle of vodka shortly after 10:00 AM on 6/10/02. The manager stated he/she heard the accident and described the sound of a motorcycle being hit. The Manager also added that he/she has observed resident #1 crossing the highway into the median on previous visits. The manager stated. that he/she did not think resident #1 was an alcoholic. Resident #1 was originally admitted the facility on 7/21/00. The resident had current diagnosis of CVA, hemiplegia and was noted to have a history of alcohol abuse. There was no indication that the facility effectively managed the resident's alcohol addiction. This resident was allowed to freely leave the facility unattended and without Physician's orders. There was no evidence the facility's interdisciplinary care plan team had assessed the resident for safety and deemed the resident as appropriate for unattended leave of absence (LOA). The Minimum Data Sets (MDS) indicated that this resident did not have any behavioral or psychosocial issues. Interview with the facility's Social Worker revealed that the MDS should have been coded for some of the behaviors that the resident had been displaying. The physician wrote an order for the resident not to have alcohol. A review of psychiatric evaluation done on 8/19/00 revealed a recommendation for ReVia to help reduce alcohol craving. The resident's record revealed no evidence that Re Via had been administered. Review of nurse's notes from 6/01 through 6/02 revealed that there existed a minimum of 39 documented entries evidencing use of alcohol by resident #1. The following are some of the entries found in the nursing notes: 4/24/02 speech slurred face flushed wandering around in wheelchair 4/19/02 Resident smells of alcohol, noted to have slurred speech....drinking from a glass with ‘liquid’ and ice. 4/16/02 resident #1 found on ground, unresponsive with slight frothing from mouth lasting approximately 30 seconds. Another resident reported that resident #1 had been drinking and fell over. Resident #1 refused to go to hospital for CT scan to rule out seizure activity due to alcohol abuse. 4/11/02 2 PM resident’s behavior sluggish. Refuses assistance with ADL's. Noted a glass of liquid...resident resting between trips to ice chest. At 4:15 PM Eckerd Drugs called to inform the facility that resident #1 had fallen out of the wheelchair. The DON left the facility and found the resident at Walgreen’s Liquor Store. The resident was intoxicated. The DON instructed Walgreen's not to sell to the resident anymore. 3/31/02 10:45 PM resident intoxicated and smoking in room. After being reminded of the facility policy the resident gave the cigarette to the nurse. 1/20/02 12:30 AM resident fell in bathroom. There were no visible injuries. The staff encouraged resident to stop drinking and go back to bed but the resident refused. At 2:45 AM resident found on floor in front of bed -continues to smell of alcohol with speech slurred. 2 PM resident incontinent of urine cloths are saturated but the resident refuses to change cloths. Strong smell of alcohol in room and on resident noted. 1/19/02 3 AM resident continuous to go out to porch via electric wheelchair. Continues to smell of alcohol. At 9:45 (AM or PM not documented) resident in room with slurred speech, completely out of it. Usually intoxicated on the weekends. Refused to be helped, smokes on the porch. Aggressive when reprimanded, can hardly control his/her electric wheelchair. Smokes behind curtains in his/her room. 7/21/01 at 2:30 AM while CNA in room attending roommate, resident #1 lit a cigarette in room. The cigarette was taken away and put out. The facility smoking policy was explained...resident refused to leave cigarettes at nurse’s station. Continues to smell of alcohol with slurred speech. At 11 PM the police department called facility and they stated resident out on LOA and needed assistance back to the facility. At 11:15 the police called 2 more times. The nurse stated to the police that the resident is able to sign himself/herself out on LOA via electric wheelchair and can return by himself/herself. The police stated that the battery on the electric wheelchair was low. 2 CNA's were dispatched to assist the resident. CNA stated resident uncooperative. Observed resident in chair and the officers were following slowly behind resident. Officers left when CNA's arrived. The resident took off in chair in opposite direction and got stuck in the mud. Eventually the resident returned to the facility with the CNA's. 6/6/01 at 10:50 resident #1 was on the porch and got into an altercation with another resident. Resident #1 threatened to push the other resident into traffic using the electric wheelchair. Resident #1 stated "I wish I could punch you instead of push you." Resident #1 did sustain a scratch for this altercation. Eyewitness indicated that resident #1 did push the other resident 2-3 times with the electric wheelchair. Resident #1 had slurred speech, red face and a smell of liquor to his/her. There was no evidence that facility was providing services such as supervision to ensure resident #1's safety and the safety of other residents. Staff did not ensure the resident wheelchair was properly charged prior to leaving the facility. No evidence that staff prevented the resident from drinking in the facility. Interview with CNA revealed that the resident gets some assistance with showers. The CNA stated that the resident doesn't request help with anything else. The last CARES assessment for appropriateness of care was done 12/15/02. 2. Resident #2 was admitted on 2/08/00 from a local area hospital brain injury rehabilitation center, where he/she was rehabilitating from a bilateral thalamic infarction with secondary confusion. He/she had the additional diagnoses of diabetes mellitus, cerebro-vascular disease, hypertension and functional/behavioral impairment. The resident's 2/11/02 and 5/05/02 minimum data sets (MDS) reflected a short-term memory problem, some difficulty with decision-making in new situations and a mental function that varies over the course of a day. Upon interview on 6/11/02, resident #2 stated that he/she left the facility almost daily without signing out. He/she said that he/she walked to the "Dollar Store", which is in a large shopping plaza across the street from the facility, and to the "Cumberland Farms", which is approximately two blocks east of the facility on State Route 192. The resident admitted that it was dangerous to walk on the unpaved shoulder of the road, but further stated that in his/her pocket, he/she kept a note with his/her name and the name of the residence on it in case he/she gets “hit with a car." Facility administration and staff revealed in an interview on 6/12/02 that they were unaware that the resident was leaving the premises. The resident was not assessed for the cognitive or physical ability to leave the facility unaccompanied. There was no physician's note or order indicating that the practitioner was aware of and approved of the resident's outings into the community. His/her solo departures and returns were not monitored. There was no supervision of the outings and no assessment of his/her condition upon return. The plan of care developed for the resident's risk for falls and injury related to "walks outside the facility around building" was not implemented. 3. Resident #3 was a quadriplegic with diabetes mellitus, peripheral vascular disease, anemia, cerebral vascular accident (late effect), depression, and psychosis with a history of stasis ulcers and pressure ulcers. The resident was noted on interview to be alert and well oriented, but difficult to understand due to expressive aphasia. He/she was wheelchair-bound with minimal movement of all extremities. The resident was wearing shorts, which he/she described as normal attire. His/her lower extremities were edematous and scarred. The resident identified the scars as former blisters. The resident's skin was dry and deeply tanned from the sun. At the time of the survey, he/she was undergoing 90 days of daily treatment with Mentax 1% cream to "all" and daily Lachydrin 12% applications to "both lower legs until resolved." The resident's legs were elevated slightly in the wheelchair to prevent swelling, which promoted increased exposure of the lower legs to the sun. The resident routinely left the facility for periods of time spanning from 5 to 12 hours, with no indication of where he/she is going or when he/she will return. He/she had not been assessed for the ability to travel outside the boundaries of the facility for long periods, unaccompanied. There was no physician's note or order indicating that the practitioner was aware of and approved of the resident's outings into the community. The resident often left in the afternoon and returned after dark, sometimes as late as 3:24 AM. There were no lights on the resident's wheelchair. In an interview with the resident on 6/11/02, the resident stated that he/she spends the late hours in local bars, but does not drink alcohol. The interview further revealed that he/she traveled "all over", going as far west as a hospital in Kissimmee. His/her reason for leaving the facility was that he/she wanted to socialize with more compatible acquaintances than those available in the nursing home. The resident's Blood Urea Nitrogen (BUN) on 5/10/02 was elevated at 22. An elevated BUN is one indicator of possible dehydration. The resident was identified as being at risk for dehydration due to long periods outside. When notified of the BUN results, the physician ordered that fluid intake be increased to 8 glasses of 8 ounces of water daily. No documentation of this intake could be provided. The resident was on a therapeutic diet of measured carbohydrates and no added sugar. The nurses’ progress notes consistently stated that the resident refused facility food and ate outside of the facility. As a diabetic, the resident was to be given a bedtime snack with 8 ounces of milk nightly. The resident's record indicated that he had not received the snack or the milk for at least the month of June. On 5/17/02 high protein was added to the resident's diet to help heal maintain skin integrity, as the resident was at risk for pressure ulcers due to extended periods of sitting the wheelchair. The resident medication administration record indicated that, for at least the month of June, the resident had not received his/her evening medication, which included the diabetic medication, Glucophage 850 mg, as well as Os-calc 500, and Feosol 325 mg. Interview with the evening medication nurse on 6/12/02 revealed that the resident was not receiving the medication or the evening snack because "[he/she] was out." The facility policy stated, "The facility will provide for the resident the number of doses of physician ordered medication to cover the period of time that the resident would be absent from the facility." No medication was provided. On 6/09/02, the resident required 2 units of Novolin R insulin coverage for a high fingerstick glucose of 208. No plan of care for the resident's daily outings was developed and related care plans were not implemented. 4. Resident #4 frequently left the facility. This resident is quadriplegic with a motorized wheelchair. During an interview, the resident stated he/she often returned to the facility late in the evening, many times after 12 AM. This resident often left the facility without signing out. The staff was not always aware when resident #4 left the facility, his/her destination and expected time of return. The resident did not have a physician's order for LOA and the facility did not assess the resident to ensure he/she did not require an attendant when he/she was away from the facility. There was no evidence that the resident's motorized wheelchair had been inspected to ensure safety. 14. The foregoing violation constitutes a pattern Class I deficiency. A Class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care ina facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. 15. The Respondent was given a mandated correction date of June 13, 2002. 16. That as a result of the failure of the Respondent to provide care and services as required by law, as a result of the failure of the Respondent to develop and operationalize policies for the protection of residents and for the prevention of neglect and mistreatment and the failure of the Respondent to ensure resident safety and well being the Respondent has violated 42 CFR 483.60; Rule 59A-4.1288, Fla. Admin. Code (2001); Section 400.23 Fla.Stat;(2001);Section 400.022 Fla.Stat. (2001) and a fine is warranted in the minimum amount of $12,500. 17. That pursuant to s. 400.19 Fla.Stat. (2001) a survey fee in the amount of $6,000 is authorized, warranted and assessable. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: 1)Enter actual and tegal findings in favor of AHCA 2) Impose a $12,500 fine which constitutes the minimum amount as authorized by law; 3) Assess a survey fee in the amount of $6,000 as authorized by law; costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). 4) Enter order awarding interest, fees and costs as allowed by law and; 5) Grant any other general and equitable relief as deemed appropriate. COUNT III RESPONDENT FAILED TO ADMINISTER EFFECTIVELY TO ENSURE RESIDENT SAFETY AND WELL BEING AND FAILED TO FOLLOW IT’S OWN IMPLEMENTED POLICIES. 42 CFR 483.75; Rule 59A-4.1288, Fla. Admin. Code (2001); s. 400.23 Fla.Stat. (2001); $.400.022 Fla.Stat. (2001); s.400.147(2) Fla.Stat. (2001) 18. Petitioner repeats and realleges paragraphs numbered (1) through (5) as if fully set forth herein. 19. Petitioner conducted a survey of Respondent on or about June 12. 2002, and the investigation revealed a Class I deficiency. as more specifically delineated as follows: Based on observation, record review and interview it was determined the facility failed to be administer effectively to ensure resident safety and well- being. Findings: Based on the extent of noncompliance identified in F-224, the facility did not effectively implement policies and procedures to ensure resident safety and well-being. A policy existed, entitled "Residents, Off Premises", but it was not being followed. There was no evidence that a sign-out/in logging procedure had been implemented for residents who leave premises, unattended. Occasionally, residents #1, #3 and #4 signed a Release of Responsibility for Voluntary Leave of Absence form, but these forms were usually incomplete or illegible. A policy entitled "Missing Resident/Elopement" was also presented. Since no expected return times were required of the residents who regularly leave the facility alone, it was difficult to assess in a timely manner when the resident was “missing" or had "eloped." With regard to the two above-mentioned policies, an interview with the social services director stated that she had not seen the policies prior to 6/11/02. 20. The foregoing violation constitutes a pattern Class I deficiency. A Class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine must be levied notwithstanding the correction of the deficiency. 21. The Respondent was given a correction date of June 13, 2002. 22. That as a result of the failure of the Respondent to administer effectively to ensure resident safety and well-being and to follow and implement it’s own procedures the Respondent has violated 42 CFR 483.75; Rule 59A-4.1288, Fla. Admin. Code (2001); s 400.23 Fla.Stat. (2001); s.400.022 Fla.Stat. (2001) and a fine is warranted in the minimum amount of $12,500, as authorized by law. 23. That pursuant to s. 400.19 Fla.Stat. (2001) a survey fee in the amount of $6,000 is warranted and assessable. CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: 1)Enter actual and legal findings in favor of AHCA 2) Impose a $12,500 fine in the minimum amount as authorized by law; 3) Assess a survey fee in the amount of $6,000 as authorized by law; costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). 4) Enter order awarding interest, fees and costs as allowed by law and; 5) Grant any other general and equitable relief as deemed appropriate. Dated July 11 2002 Agency for Health Care Administration Richard Joseph Saliba, Esquire, Senior Attorney Fla. Bar. No. 0240389 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5865 (office) (850) 921-0158 (fax) 20 NOTICE Respondent, HP/ST.CLOUD INC., D/B/A ST. CLOUD HEALTH CARE & REHABILITATION, hereby 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 form and explained in the attached Explanation of Rights form. Ali requests for a hearing shall be sent to AHCA, Richard Joseph Saliba, Esquire, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop #3, Tallahassee, Florida, 32308. In order to preserve your right to a hearing, your Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date you receive the Administrative Complaint. If the election of rights form with your selected option is not received by AHCA within twenty-one (21) days from the date of your receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. Dated July 11, 2002 AGENCY FOR HEALTH CARE ADMINISTRATION Richard Joseph Saliba, Esquire, Senior Attorney Fla. Bar. No. 0240389 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-5865 (office) (850) 921-0158 (fax) 21 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint has been sent by U.S. Certified Mail, Return Receipt Requested, (Return Receipt #7106 4575 1294 2049 8811 to HP/ST.CLOUD, INC, D/B/A ST. CLOUD HEALTHCARE & REHABILITATION, 1301 KANSAS AVENUE, ST ’ CLOUD, FLORIDA 32769-5999 , this 11" day of July, 2002. AGENCY FOR HEALTH CARE ADMINISTRATION Richard Joseph Saliba, Esquire, Senior Attorney Fla. Bar. No. 0240389 Counsel for Petitioner Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 921-0071 (office) (850) 921-0158 (fax) 22 CERTIFICATE #: LICENSE #: _SNF1518096 State of Florida AGENCY FOR HEALTH CARE ADMINISTRATION DIVISION OF MANAGED CARE AND HEALTH QUALITY SKILLED NURSING FACILITY CONDITIONAL - beh = Dea tate nies Mtns i in Y q h This is to confirm that HP/ST. CLOUD,INC._ has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part If, Florida Statutes, and as the licensee is authorized to operate the following: ST CLOUD HEALTH CARE & REHABILITATION 1301 KANSAS AVENUE ST CLOUD, FL 32769-5999 with 131. beds. Ran RTTITH Ebina Peon Change In Status i ACTION EFFECTIVE DATE: 06/12/2002 HTT 44 rein HY 4, LICENSE EXPIRATION DATE: _06/12/2003

Docket for Case No: 02-003632